Clatsop Care Center

The FacilityGÇÖsGÇ»Resident Right to Privacy in CommunicationGÇ»Policy, dated 1/1/26, stated the facility would ensure each resident received any mail addressed to that resident promptly, defined as delivery within 24 hours of delivery by the postal service.-á On 1/28/26-áat 1:45 PM during the Resident Council group interview, residents-ástated-átheir mail was not delivered on Saturdays.-áResident 9-ástated-áshe/he-ácomplained to-áfacility-ástaff-áthree times-áabout not receiving mail on Saturdays and was told-áno staff worked-áon the weekends-áwho delivered-ámail.-áResident 9-ástated-áthis-áwas-áGÇ£very frustrating.GÇ¥-áResident 27 agreed with-áResident 9GÇÖs statement,-áand-áResident 4 nodded-áher/his-áhead-áin agreement.-áResident 25-ástated-áshe/he made-ásure not to have any-ádeliveries-áfor Saturdays due to the lack of mail delivery.-á-á On 1/28/26 at 4:10 PM, Staff 9 (CNA) stated she was responsible for delivering resident mail. Staff 9 stated she worked Monday through Friday, and any resident mail received over the weekend was placed in a locked office. Staff 9 stated when she arrived at work on Mondays, the mail was delivered to residents.-á-á-á On 1/29/26 at 9:30 AM, Staff 1 (Administrator) was informed of residentsGÇÖ concerns-áregarding-ánot receiving mail on Saturdays. Staff 1 acknowledged the facility did not have a system in place to ensure residents received-átimely-áwritten communication.-á -á -á

F576: Right to forms of communication. Address how corrective action will be accomplished for those residents to have been affected by the deficient practice .  A weekend mail distribution schedule/process has been implemented. Address how the facility will identify other residents having the potential to be affected by the same deficient practice .  All residents have the potential to be affected. Review confirmed no systemic backlog; however, weekend distribution procedures were inconsistent and have been corrected. Address how measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.  A designated staff member/and or designee is assigned responsibility for Saturday distribution. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting.   The Administrator or designee will review all mail for proper distribution weekly x4 weeks and then monthly x3 months. Any concerns noted will be addressed immediately. Results of the audit will be taken to monthly QAPI meeting. Include dates when corrective action will be completed.    The Administrator or designee is responsible for ensuring compliance by 1/30/2026.

The facilityGÇÖs Trauma Informed Care Policy dated 1/1/26 indicated: -The facility will use a multi-pronged approach to identifying a residentGÇÖs history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), Admission Assessment, the history and physical, the social/history assessment, and others. -The facility will collaborate with resident trauma survivors, and as appropriate, the residentGÇÖs family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plans. -á Resident 6 was admitted to the facility in 8/2024 with diagnoses including PTSD (Post-Traumatic Stress Disorder) and depression. Resident 6GÇÖs 11/6/25 Quarterly MDS indicated the resident was cognitively intact. Resident 6GÇÖs 8/5/24 Social Services & Initial Assessment indicated Resident 6 had a diagnosis of depression; however, there was no mention of the residentGÇÖs documented PTSD or related triggers. No evidence was found in Resident 6GÇÖs clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers.-á Record review revealed Resident 6 had an open PTSD claim with the Veterans Administration (disability compensation application in review process), which was discussed during the care conference on 8/7/25. On 1/28/26 at 8:57 AM Resident 6 was observed in her/his room. Resident 6 stated the facility had not asked her/him about any triggers she/he had. Resident 6 stated she/he had experienced nightmares in the past and seeing news coverage related to the U.S. Coast Guard triggered distressing memories. Resident 6 further stated the facility had not discussed or assessed these triggers with her/him. On 1/29/26 at 9:47 AM Staff 7 (CNA) stated she did not know if Resident 6 had a diagnosis of PTSD. Staff 7 reviewed the residentGÇÖs Kardex (quick-reference bedside care plan), PTSD or trauma-related triggers were not listed. Staff 7 further stated Resident 6 would become upset when her/his requests were not met, would refuse cares and would yell at staff. Staff 7 was unable to identify any trauma-related triggers or interventions in place to address these behaviors. On 1/29/26 at 9:55 AM Staff 8 (CNA) stated she did not know Resident 6 had a diagnosis of PTSD. Staff 8 reviewed the residentGÇÖs Kardex, PTSD or trauma-related triggers were not addressed. Staff 8 stated when Resident 6 became upset she/he would yell at staff. Staff 8 was unable to identify any trauma-related triggers or interventions in place. On 1/29/26 at 10:04 AM Staff 5 (LPN Resident Care Manager) stated she was unaware Resident 6 had a diagnosis of PTSD and could not identify any triggers. Staff 5 confirmed the residentGÇÖs care plan did not include interventions or approaches related to PTSD or known triggers. On 1/29/26 at 10:26 AM Staff 6 (Social Services) stated resident trauma screenings were to be completed at the time of admission. Staff 6 stated a care plan had not been developed related to Resident 6GÇÖs history of trauma or potential triggers. Staff 6 stated she was unaware if Resident 6 had any triggers. On 1/29/26 at 10:53 AM Staff 2 (DNS) and Staff 3 (Nurse Consultant) acknowledged Resident 6 had a diagnosis of PTSD and no interventions were implemented to address the resident's trauma or trauma triggers. Staff 2 stated she expected a care plan to be developed to address Resident 6's potential PTSD triggers and staff were responsible to implement the care plan.-á -á -á -á

F699: Trauma Informed Care Address how corrective action will be accomplished for those residents to have been affected by the deficient practice .  Resident #6 care plan and assessments have been reviewed and updated to ensure we are meeting his needs as well as identifying triggers. Address how the facility will identify other residents having the potential to be affected by the same deficient practice .  All residents with diagnosis of PTSD were reviewed and care plans and assessments updated as needed. Address how measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.   The DNS, SSD or designee will monitor all residents for changes or new residents with diagnosis of PTSD weekly x4 weeks and then monthly x3 months. Any concerns noted will be addressed immediately. Results of the audit will be taken to monthly QAPI meeting. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting.  DNS or designee to ensure all new residents are assessed for PTSD history, have individualized trauma-informed interventions documented in their care plans, and that these plans are reviewed and updated as needed. Include dates when corrective action will be completed.   The DNS or designee is responsible for ensuring compliance by 1/30/2026.

The facilityGÇÖs Insulin Pen Policy dated 1/1/26 specified insulin pens were to be primed with two units of insulin prior to each use to avoid the collection of air in the reservoir.-á Resident 18 was admitted to the facility in 10/2020 with diagnoses including type 2 diabetes mellitus (a chronic condition affecting the bodyGÇÖs ability to control blood sugar levels). Resident 18GÇÖs Physician Orders included the following: - -á -áinsulin glargine (a long-acting mediation for diabetes) 100 units/ml inject 25 units two times daily - -á -áinsulin lispro (a rapid-acting medication for diabetes) 100 units/ml inject 10 units before meals On 1/28/26 at 7:19 AM Staff 10 (LPN) administered insulin glargine and insulin lispro to Resident 18 and did not prime the insulin pens prior to administration.-á On 1/28/26 at 7:19 AM Staff 10 acknowledged they did not prime the insulin pens prior to administration and expressed they were not aware priming was required. On 1/28/26 at 10:39 AM Staff 2 (DNS) stated she expected all nursing staff to prime the insulin pens prior to administering insulin. Staff 2 acknowledged Resident 18's insulin pens had not been primed before insulin administration.

F759: Free of Medication Error Rates of 5 Percent or More Address how corrective action will be accomplished for those residents to have been affected by the deficient practice .  Resident #18 medications were reviewed to ensure the special instructions were included for insulin pen to be primed prior to use. All residents with insulin orders were reviewed for special instructions added to their orders. Education was provided to all licensed nurses on staff related to insulin pens and special instructions. Address how the facility will identify other residents having the potential to be affected by the same deficient practice .  All residents have the potential to be affected. Address how measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.   The DNS or designee will perform audits and review all new orders for proper special instructions weekly x4 weeks and then monthly x3 months. Any concerns noted will be addressed immediately. Results of the audit will be taken to monthly QAPI meeting. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting.   The DNS or designee will in-service/educate the licensed staff regarding medication administration and education on priming insulin pens. Include dates when corrective action will be completed.    The DNS or designee is responsible for ensuring compliance by 1/30/2026.

Based on observation and interview it was determined the facility failed to maintain a homelike environment with window cleanliness for 1 of 1 facility reviewed for a homelike environment. This placed residents at risk for an unclean homelike environment. Findings include: On 9/9/24 at 3:38 PM Resident 22 stated her/his windows were all very dirty and she/he would like them cleaned. Observation of Resident 22's windows and windows throughout the facility determined the majority of windows were dirty and unhomelike. On 9/13/24 at 9:06 AM Staff 8 (Maintenance Director) stated the outside windows in the facility had been cleaned only twice in the last eight years. Staff 8 confirmed the outside windows needed to be cleaned.

• F584 Safe/Clean/Comfortable/Homelike Environment • Address how corrective action will be accomplished for those residents to have been affected by the deficient practice. Resident #20 window was cleaned as well as all other resident and facility windows in the community. • Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected. • Address how measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Weekly cleanliness audits will be completed. • Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. A schedule has been developed to ensure all windows are audited for cleanliness. The maintenance director will do weekly audits to monitor the cleanliness of the windows x4 weeks and then monthly x3 months. Results of the audits will be reported/brought to the QAPI meeting. • Include dates when corrective action will be completed. Compliance completed by 10/18/24

Based on interview and record review it was determined the facility failed to comprehensively assess 3 of 7 sampled residents (#s 8, 25 and 83) reviewed for medications, behavior and mood. This placed residents at risk for inaccurate or incomplete assessments and unmet care needs. Findings include: 1. Resident 83 was admitted to the facility in 8/2024 with diagnoses including recent stroke and delirium. Resident 83's physician orders included the use of scheduled and PRN antipsychotic medication. The 8/29/24 psychotropic CAA did not include a description of the specific behavior necessitating the use of the antipsychotic; causes and contributing factors; or risk factors related to the care area such as increased drowsiness, lethargy or increased risk for falls. On 9/13/24 at approximately 9:50 AM Staff 2 (DNS) confirmed the CAAs lacked an analysis of findings. , 2. Resident 8 was admitted to the facility on 2/2024 with diagnoses including dementia and depression. A review of the 2/12/24 Cognitive Loss/Dementia CAA revealed Resident 8 had dementia. The family was aware and content with care and the plan moving forward. Communicate with Resident 8 and her/his family regarding capabilities and needs. The CAA failed to indicate specifically how dementia was a problem for the resident, how the resident's dementia manifested, the impact on the resident, or a rational for the care planning decision. A review of the 2/15/24 Psychotropic Drug Use CAA revealed Resident 8 was on venlafaxine (an antidepressant) for major depressive disorder, which was effective with no adverse effects noted. The CAA failed to indicate specifically how depression was a problem for the resident, how the resident's depression impacted Resident 8, or a rationale for the care planning decision. On 9/12/24 at 1:26 PM PM Staff 1 (Administrator) stated Staff 4 (LPN) completed the MDS and CAAs for the facility. On 9/12/24 at 4:19 PM Staff 3 (Social Service Director) stated she completed the Cognitive Loss/Dementia CAA for Resident 8. Staff 3 stated she was learning how to better complete the CAAs and acknowledged there was not sufficient information in the CAA section. On 9/12/24 at 6:41 PM Staff 4 (LPN) stated she was training staff to complete the MDS and triggered CAAs. Staff 4 stated she did not complete Resident 8's CAA but confirmed there was not enough "meat and potatoes" in Resident 8's Cognitive Loss/Dementia and Psychotropic CAA. Staff 4 stated The CAAs were important because they helped drive the care plan for each resident. 3. Resident 25 was admitted to the facility on 6/2024 with diagnoses including schizophrenia and cancer of the lung. A review of the 7/2/24 Psychotropic Drug Use CAA revealed the resident received aripiprazole (an antipsychotic) for her/his schizophrenia which had been effective with no adverse effects noted. Medicate the resident per physician order and assess effectiveness of the medication for adverse effects. The CAA failed to include information regarding Resident 25's potential problems, manifested behaviors, precipitating factors, alleviating factors or non-pharmacological interventions. On 9/12/24 at 1:26 PM PM Staff 1 (Administrator) stated Staff 4 (LPN) completed the MDS and CAAs for the facility. On 9/12/24 at 6:41 PM Staff 4 stated she was training staff to complete the MDS and triggered CAAs. Staff 4 stated she did not complete Resident 25's CAA but confirmed there was not enough "meat and potatoes" in Resident 25's Psychotropic CAA. Staff 4 stated the CAAs were important because they helped drive the care plan for each resident.

• F636 Comprehensive Assessments & Timing • Address how corrective action will be accomplished for those residents to have been affected by the deficient practice. Comprehensive CAAs have been completed for resident #8, 25, and 83. • Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Moving forward the MDS Coordinator or designee will review new residents/annual/change in condition comprehensive CAAs for the next 30 days and then will pick random resident charts who have comprehensive CAAs completed for accuracy and to ensure assessments are comprehensive and thorough during monthly visits. • Address how measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The DNS, RCM, and Social Services Director will be trained/re-educated on the process for writing comprehensive CAAs that trigger on the MDS to ensure all needs are being met per the RAI manual. • Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. Results of the CAA audit will be addressed immediately with the IDT and the DNS will take results to the next QAPI meeting weekly x4 weeks then monthly x3 months. • Include dates when corrective action will be completed. The DNS or designee is responsible for ensuring compliance by 10/18/2024.

Based on interview and record review it was determined the facility failed to follow physician orders for medication administration and implement bowel care timely for (1 of 5) sampled residents (# 17) reviewed for medications. This placed residents at risk for adverse side effects and constipation. Findings include: Resident 17 was admitted to the facility in 10/2020 with diagnoses including hypothyroidism (deficiency of hormones used to regulate heart rate, body temperature and digestion) and constipation. a. A physician order from 12/5/23 stated levothyroxine 50 mg was to be given once a day at 8:00 AM to Resident 17 for hypothyroidism. On 9/6/24 the orders for levothyroxine were modified for the medication to be given at 5:00 AM. Review of the 9/2023 MAR revealed Resident 17 did not receive levothyroxine from 9/6/24 through 9/11/24. On 9/12/24 at 1:29 PM Staff 2 (DNS) confirmed Resident 17 did not receive levothyroxine on the dates listed and did not provide any additional information as to why the medication was not administered. b. A physician order from 4/15/23 stated bisocodyl was to be administered as needed for constipation to Resident 17 on the fourth day of no bowel movement A physician order from 4/15/23 stated fleet enema was to be administered as needed for constipation to Resident 17 on the fourth day of no bowel movement. A physician order from 4/28/23 stated milk of magnesia was to be administered as needed for constipation to Resident 17 on the third day of no bowel movement. Review of 8/2024 and 9/2024 bowel care records revealed the following: - Resident 17 had no bowel movements from 8/29/24 through 9/1/24, a total of four days. Review of medication administration records revealed none of the medications listed above were attempted to be administered on day three or day four. - Resident 17 had no bowel movements from 9/3/24 through 9/6/24, a total of four days. Review of medication administration records revealed none of the medications listed above were administered on day three or day four. - Resident 17 had no bowel movements from 9/9/24 through 9/11/24, a total of three days. Review of medication administration records revealed milk of magnesia was not administered on day three. On 9/12/24 at 1:29 PM Staff 2 (DNS) confirmed that based on the 8/2024 and 9/2024 bowel care records, medications used for constipation were not administered as ordered to Resident 17.

" F684 Quality of Care " Address how corrective action will be accomplished for those residents to have been affected by the deficient practice. Resident #17 orders have been reviewed to ensure routine and prn medications are given per physician orders. " Address how the facility will identify others having the potential to be affected by the same deficient practice. The DNS reviewed missed medications and bowel records for the entire community to ensure this did not affect any other residents. " Address how measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The DNS or designee will provide in-service/education to all licensed nurses and CMAs to review the importance of following physician orders. " Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. The DNS will conduct weekly audits to ensure compliance and address immediately with licensed staff any concerns. Audits will be brought to QAPI meeting x4 weeks and then monthly x3 months. " Include dates when corrective action will be completed. The DNS or designee is responsible for ensuring compliance by 10/18/2024.

Based on observation and interview it was determined the facility failed to ensure medications were labeled with administration instructions for 1 of 5 residents (#11) for whom medication administration was observed. This placed residents at risk for decreased medication efficacy. Findings include: On 9/11/24 at 8:43 AM Staff 6 (CMA) was observed to crush the medication pantoprazole 40 mg DR (delayed release) prior to administration to Resident 11. According to the manufacturer's instruction, this medication is enteric coated to pass through the stomach and should not be crushed. The medication was labled as "pantoprazole 40 mg" without the DR. There were no instructions on the MAR or the medication bubble pack from the pharmacy to indicate the medication should not be crushed prior to administration. On 9/12/24 at 10:48 AM Staff 7 (Consultant Pharmacist) confirmed pantoprazole 40 mg should not be crushed and was not labeled with instructions not to crush.

• F761 Label/Store Drugs and Biologicals • Address how corrective action will be accomplished for those residents to have been affected by the deficient practice. The medication record and medication card were updated for resident #11 to ensure the special instructions were included not to be crushed. • Address how the facility will identify other residents having the potential to be affected by the same deficient practice. The pharmacy conducted a community wide audit to ensure medication cards/records were accurate with any special instructions. • Address how measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The DNS or designee will in-service/educate the licensed staff regarding medications that cannot be crushed and the importance of it being in the special instructions on the eMAR and on the medication card. • Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. The Pharmacist or designee will audit to ensure the special instructions are noted during their monthly reviews for compliance. In addition to the Pharmacist audit the DNS will audit weekly x4 weeks and then monthly x3 months for compliance and bring results to the QAPI meeting. • Include dates when corrective action will be completed. The DNS or designee is responsible for ensuring compliance by 10/18/2024.

Based on interview and record review it was determined the facility failed to ensure records were complete and accurate for 1 of 5 residents (#8) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 8 was admitted to the facility in 2/2024 with diagnoses including dementia and depression. A review of Resident 8's Physician Orders dated 8/2024, revealed an order dated 8/15/24, discontinued on 8/16/24, for mirtazapine (an appetite stimulant) 7.5 mg, one tablet for appetite stimulation for three days. The medication was administered on 8/15/24. A review of Resident 8's Physician Orders dated 8/2024, revealed an order dated 8/16/24, for mirtazapine 7.5 mg, one tablet for appetite stimulation for 30 days. A review of Resident 8's clinical record revealed no evidence the resident received her/his mirtazapine from 8/16/24 through 8/25/24. In an interview on 9/12/24 at 1:42 PM, Staff 1 (Administrator) and Staff 5 (RNCM) stated both physician orders for the mirtazapine were incorrectly transcribed. Staff 1 stated facility staff clarified the mirtazapine order with the physician, and the physician clarified the mirtazapine with a new start date of 8/26/24. Staff 1 acknowledged the 8/2024 MARs were incorrectly transcribed.

• F842 Resident Records – Identifiable Information • Address how corrective action will be accomplished for those residents to have been affected by the deficient practice. Resident #8 order was clarified, and medication was given per physician order. • Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All new orders will be reviewed during morning 24-hour clinical review for accuracy. • Address how measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The DNS will provide in-service/education on the process for transcribing new orders to all licensed nurses. • Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. The DNS or designee will review all new orders for proper transcription weekly x4 weeks and then monthly x3 months. Any concerns noted will be addressed immediately. Results of the audit will be taken to monthly QAPI meeting. • Include dates when corrective action will be completed. The DNS or designee is responsible for ensuring compliance by 10/18/2024.

Based on interview and record review it was determined the facility failed to meet the CNA to NA staffing ratio on 13 of 40 days reviewed for sufficient nurse staffing. This placed residents at risk for unmet needs. Findings include: Review of Direct Care Staff Daily Reports from 8/1/24 through 9/9/24 revealed the facility failed to meet NA to CNA staffing ratios on the following dates and shifts: - 8/4/24 Day shift: 2 CNAs, 3 NAs, and Evening shift: 2 CNAs, 2 NAs - 8/5/24 Evening shift: 2 CNAs, 2 NAs - 8/6/24 Evening shift: 2 CNAs, 2 NAs - 8/7/24 Evening shift: 2 CNAs, 2 NAs - 8/10/24 Day shift: 2 CNAs, 3 NAs - 8/11/24 Day shift: 2 CNAs, 3 NAs - 8/13/24 Evening shift: 2 CNAs, 3 NAs - 8/20/24 Evening shift: 2 CNAs, 2 NAs - 8/28/24 Evening shift: 2 CNAs, 2 NAs - 9/1/24 Evening shift: 2 CNAs, 3 NAs - 9/2/24 Evening shift: 2 CNAs, 3 NAs - 9/3/24 Evening shift: 2 CNAs, 3 NAs - 9/5/24 Evening shift: 2 CNAs, 2 NAs On 9/12/24 at 2:04 PM Staff 2 (DNS) stated she had worked as the staffing coordinator for the last few months. Staff 2 acknowledged the CNA to NA ratio exceeded the maximum of 25% allowed on the dates listed above.

• M183 Nursing Services: Minimum CNA Staffing • Address how corrective action will be accomplished for those residents to have been affected by the deficient practice. No residents were identified as being affected. • Address how the facility will identify other residents having the potential to be affected by the same deficient practice. No residents were identified as being affected. • Address how measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. A staffing waiver was obtained and posted. All residents have the potential to be affected by this deficient practice. DNS reviewed and updated the schedule to ensure compliance. Staffing coordinator will be educated on the requirement that no more than 25% of staff during a shift are NA’s unless a waiver is obtained. • Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. Audits of staffing will be conducted by the DNS or designee weekly x 4 weeks then monthly x 3 months to ensure ongoing compliance. Results from the audit will be taken to the QAPI meeting monthly. • Include dates when corrective action will be completed. The DNS or designee is responsible for ensuring compliance by 10/18/2024.

******************** OAR 411-087-0100 Physical Environment: Resident Rights Refer to F584 ******************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F636 ******************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ******************** OAR 411-086-0260 Pharmaceutical Services Refer to F761 ******************** OAR 411-086-0300 Clinical Records Refer to F842 ********************

Based on interview and record review it was determined the facility failed to properly administer anticoagulant medication to 1 of 2 sampled residents (#2) reviewed for medications. As a result, Resident 2 was hospitalized and required Vitamin K infusion (used as reverse the effects of blood thinning medications). Findings include: Resident 2 was admitted to the facility in 5/2021, with diagnosis including paroxysmal atrial fibrillation (irregular heart beat caused by poor blood flow). Resident 2's 5/20/22 Care Plan noted the resident received Coumadin (an anticoagulant medication) related to atrial fibrillation. Resident 2's 5/2022 physician orders indicated Resident 2 was to be administered Coumadin 5 mg daily every Tuesday, Friday, and Sunday at 4:00 PM. A review of Resident 2's 11/2023 MAR revealed the following dates and times the resident's Coumadin was administered: - 5 mg on 11/3/23 at 8:00 AM - 5 mg on 11/3/23 at 4:00 PM - 5 mg on 11/5/23 at 8:00 AM - 5 mg on 11/5/23 at 4:00 PM - 5 mg on 11/7/23 at 8:00 AM - 5 mg on 11/7/23 at 4:00 PM - 5 mg on 11/10/23 at 8:00 AM - 5 mg on 11/10/23 at 4:00 PM - 5 mg on 11/12/23 at 8:00 AM - 5 mg on 11/12/23 at 4:00 PM An 11/14/23 facility investigation revealed Staff 4 (LPN) inputted a duplicate order of Coumadin, which resulted in Resident 2 receiving two doses of Coumadin for six days. The investigation noted Resident 2 was sent to the emergency department after lab test revealed critical lab results. Resident 2's 11/15/23 Progress Note indicated the resident received a Vitamin K infusion while at the hospital. On 7/15/24 at 11:58 AM, Staff 4 (LPN) stated he ordered a duplicate medication of Coumadin, which resulted in Resident 2 receiving extra Coumadin for six days. On 7/11/24 at 12:56 PM, Staff 1 (Administrator) confirmed findings and indicated Resident 2 received a Vitamin K infusion while at the hospital as a result of the medication error. On 11/20/23, the Past Non-Compliance was corrected when the facility completed a root cause analysis of the incident and determined there was medication error. The Plan of Correction included: 1. The effected resident was assessed and sent the emergency department for Vitamin K infusion. 2. An audit of all anticoagulant orders were reviewed for accuracy. 3. All nursing staff were provided education related to administration of Coumadin including warning systems to prevent duplicate orders. 4. Education was received by consultant pharmacist on avoiding medication errors. 5. Anticoagulation orders for residents continued to be monitored and triple checked for accuracy.

******************************** OAR 411-086-0110 - Nursing Services: Resident Care Refer to F760

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/05/2024 and 02/11/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/29/2024 and 02/04/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/18/2023 and 12/24/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/11/2023 and 12/17/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/13/2023 and 11/19/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/09/2023 and 10/15/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/25/2023 and 10/01/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/11/2023 and 09/17/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/12/2023 and 06/18/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to immediately notify a resident's physician of a severe unplanned weight loss for 1 of 3 sampled residents (#30) reviewed for nutrition. This placed residents at risk for unmanaged weight loss. Findings include: Resident 30 was admitted to the facility in 2023 with diagnoses including Multiple Sclerosis (disease of the brain and spinal cord). On 6/11/23 at 10:48 AM Witness 1 (Family) stated Resident 30 lost 17 pounds in about a month. Resident 30's weight record from 5/4/23 through 6/8/23 revealed the resident lost 18 pounds or 6.7% body weight in 35 days. Resident 30's Progress Notes from 5/4/23 through 6/9/23 revealed no evidence to indicate the resident's family and physician were notified regarding the resident's severe weight loss. On 6/12/23 at 11:04 AM Staff 2 (DNS) stated the resident's family and physician were not immediately notified after the resident lost 18 pounds. Refer to F692.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice Resident # 30 MD and family notified of wt loss. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. An audit of resident changes (new meds, change in condition, wt loss, etc) will be complete to ensure notifications have been complete. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education with staff on policy/procedure of notification of resident/representative and MD will be completed. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. Weekly audits will be complete of orders, notes, change in condition using the PCC dashboard to ensure timely notification of residents and/or resident representative and MD. Audit results will be presented at QAPI Include dates when corrective action will be completed. July 27, 2023 DNS or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to ensure a resident's missing personal property was addressed for 1 of 1 sampled resident (#17) reviewed for personal property. This placed residents at risk for loss of personal items. Findings include: The facility's Grievance policy and procedure dated 3/9/16 indicated the following: -Prompt Resolution of Complaint: The staff member who receives the complaint should determine if they can immediately resolve the resident/representative's concern. If they cannot, they must alert their supervisor/charge nurse and a concern/comment form will be completed by staff if it occurs outside of Social Service business hours. During Social Service business hours, staff will contact them directly to aid in completing the form. -The timeframe for follow-up of concern is three days. Resident 17 was admitted to the facility in 2022 with diagnoses including Alzheimer's dementia. 6/11/23 12:41 PM Witness 4 (Family) and Witness 5 (Family) reported Resident 17 was missing a digital picture frame/pictures and hearing aids. Witness 4 and Witness 5 reported Resident 17 had a digital picture frame that displayed numerous pictures of the her/his life over many years which was missing since the resident moved rooms a while ago. They stated they reported the missing items to staff and staff looked for the items but were unable to locate them. A review of the facility's 2023 Grievance notebook revealed no evidence that a grievance form was completed for Resident 17's missing items. On 6/12/23 at 2:05 PM Staff 15 (CNA) reported she recalled seeing Resident 17's digital picture frame/pictures in the resident's previous room but had not seen the digital picture frame/pictures since. Staff 15 stated she did not know if Resident 17 had hearing aids. On 6/13/23 at 10:11 AM Staff 14 (RN) stated approximately one month ago she was informed by Resident 17's family members that the resident's digital picture frame/pictures and hearing aids were missing. Staff 14 stated she looked through the resident's room but was unable to locate the missing items. Staff 14 stated she passed the information to the night shift nurse. On 6/13/23 at 11:41 AM Staff 12 (Social Services Director) stated she was not notified that Resident 17 had any missing items. On 6/13/23 at 12:18 PM Staff 2 (DNS) stated she expected staff to complete a grievance form when residents had missing items and either the items would be located or replaced if they were unable to be located.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice Resident #17 representative to be reimbursed for missing items Address how the facility will identify other residents having the potential to be affected by the same deficient practice. An audit will be done with current residents or representatives to ensure if they have missing items, those items have been addressed. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education will be provided to staff on grievance policy and procedure to ensure staff understand of the process for missing items. Grievances will be discussed at the morning department head meeting until issues are resolved Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. Audits of the grievance log will be complete on a weekly basis X 3 months then monthly for compliance. Results will be presented at QAPI Include dates when corrective action will be completed. July 27, 2023 DNS or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to comprehensively assess a resident's nutritional status for 1 of 3 sampled residents (#30) reviewed for nutrition. This placed residents at risk for unassessed needs. Findings include: Resident 30 was admitted to the facility in 2023 with diagnoses including Multiple Sclerosis (disease of the brain and spinal cord). On 6/11/23 at 10:48 AM Witness 1 (Family) stated Resident 30 lost 17 pounds in about a month. Resident 30's diet order dated 5/4/23 included a general diet with regular texture and thin consistency (for fluids). Resident 30's Nutritional Status CAA dated 5/11/23 did not indicate a nutritional problem, a comprehensive assessment of the resident's nutritional status or the impact on the resident. On 6/12/23 at 11:04 AM Staff 2 (DNS) verified Resident 30's Nutritional Status CAA was not comprehensive and the resident lost 18 pounds over 35 days. Refer to F692.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident # 30 wt loss has been identified, a comprehensive assessment is complete, care plan updated and family and MD aware Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected. Charts will be audited to ensure comprehensive assessments complete and residents needs are met. Address what measure will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education will be provided to nursing staff on policy/procedure of Comprehensive Assessments and Timing. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. Weekly ongoing audits of residents assessments will be conducted with appropriate interventions documented and care plan updated. Results of ongoing audits will be presented at QAPI Include dates when corrective action will be completed. July 27, 2023 DNS or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to ensure nursing professional standards of practice were followed for 1 of 1 sampled resident (#33) reviewed for hospitalization. This resulted in Resident 33 being transported to the hospital and placed in the ICU on a ventilator. This also placed other residents at risk for hospitalization. Findings include: The Oregon Nurse Practice Act included the following: Oregon Administrative Rule 851-045-0050 Scope of Practice Standards for Licensed Practical Nurses - Standards related to the LPN's responsibility for nursing practice. Applying practical nursing knowledge, at the clinical direction and under the clinical supervision of the RN or LIP (Licensed Independent Practitioner), the LPN shall: - Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data discrepancies to the supervising RN or supervising LIP; - Evaluate client responses to nursing interventions, progress toward measurable outcomes, and communicate such to appropriate members of the health care team. Resident 33 was admitted to the facility in 2023 with diagnoses including hip fracture. The facility's Bowel Management Policy and Procedure dated 9/2020 included the following interventions for when a resident did not have a bowel movement: - On day three administer Milk of Magnesia in the evening. - On day four administer a laxative suppository in the evening. - On day five if the resident has not had a bowel movement by after breakfast the nurse will check for impaction, check the abdomen and administer an enema per physician's orders. If the resident has not had a bowel movement by 3:00 PM the nurse will again check for impaction and check the abdomen. If there is no stool in the rectal vault the physician will be called for further orders and alert charting will begin. Resident 33's Care Plan initiated on 3/17/23 included the following interventions related to constipation and pain: - "Follow facility bowel protocol for bowel management." - "Monitor medications for side effects of constipation. Keep physician informed of any problems." - "Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician." Resident 33's 3/2023 Order Summary report included a physician's order for an enema as needed for constipation after five days of no bowel movement. Administer after a bowel assessment. If no results by the afternoon notify the physician for further orders. Resident 33's 3/2023 MAR and Progress Notes revealed the following: - On 3/20/23 at 6:58 PM a Progress Note by Staff 5 (LPN) indicated the resident had not had a bowel movement and an enema was administered (no enema administration was documented on the MAR) after lunch with no bowel movement by the end of the shift. The resident continued with nausea (no nausea was documented prior to this note) and vomited once. The resident's abdomen was hard and bowel tones were sluggish. The note did not indicate Staff 5 contacted an RN or the physician for further instructions. The note indicated "will continue to monitor." - On 3/21/23 at 4:39 AM a Progress Note indicated Resident 33 was transported to the hospital by ambulance at 4:00 AM. The resident woke from her/his sleep with multiple episodes of vomiting which was dark brown in color and appeared to be fecal matter. The resident had not had a bowel movement for several days despite being administered Milk of Magnesia and an enema. - On 3/22/23 at 2:50 AM a Progress Note indicated the resident was in the ICU, intubated and on a ventilator. On 6/14/23 at 9:16 AM Resident 33's Care Plan, physician's orders and Progress Notes were reviewed with Staff 5 (LPN). Staff 5 stated she recalled Resident 33 and the incident on 3/20/23. Staff 5 stated she did not remember notifying anyone, such as Staff 2 (DNS) or the physician on 3/20/23. Staff 5 stated she usually did not contact Staff 2 for bowel issues and faxes were the normal method to contact the physician. Staff 5 stated she did not know how to contact the on-call provider. On 6/13/23 at 2:37 PM and 6/14/23 at 11:04 AM Resident 33's Care Plan, physician's orders and Progress Notes were reviewed with Staff 2. Staff 2 stated the physician should have been informed of the resident's condition on 3/20/23. Staff 2 stated the nurses were aware they could call her to evaluate any questions they had. Staff 2 stated the on-call provider was available by fax, text or phone and the charge nurse had the authority to send resident's out to the hospital based on their nursing judgement. Staff 2 verified the physician was not notified on 3/20/23 about Resident 33's condition. Refer to F684.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident # 33 has discharged Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected. An audit will be complete of resident records to ensure no other residents are affected Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Staff 5 has received one on one education concerning following MD orders and Nursing Standard of Practice. Nursing staff will be educated on Professional Standards, the need to report any data and/or evaluation discrepancies to the supervision RN. Nurse Practice Act will be posted in the nurses stations for easy reference. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. Weekly chart audits times 3 months for compliance then monthly. Results will be reported at QAPI. Include dates when corrective action will be completed. July 13, 2023 DNS or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to provide scheduled showers for 1 of 5 sampled residents (#20) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: Resident 20 was admitted to the facility in 2020 with diagnoses including end stage renal disease. Resident 20's 4/28/21 ADL Care Plan indicated Resident 20 required physical assistance of one staff for showering three times a week and as necessary. Resident 20's 5/17/23 Quarterly MDS indicated the resident was cognitively intact and totally dependent with one person physical assistance for bathing. Resident 20's 4/30/23 through 6/13/23 bathing task logs indicated the following: -5/5: not applicable; -5/9: shower received; -5/11: not applicable; -5/13: not applicable; -5/16: shower received; -5/20: resident refused; -5/23: shower received; -5/25: shower received; -5/27: not applicable; -5/30: not applicable; -6/3: not applicable; -6/8: shower received and -6/10: shower received. A review of Resident 20's Progress Notes from 4/30/23 through 6/13/23 revealed no documentation indicating Resident 20 was provided with additional bathing opportunities if bathing was refused or not provided. On 6/11/23 at 10:52 AM Resident 20 stated she/he was supposed to receive showers three times a week but only received them sporadically. On 6/12/23 at 1:54 PM and 2:22 PM Staff 15 (CNA) and Staff 16 (CNA) stated Resident 20 was supposed to receive showers three times a week and never refused. On 6/13/23 at 12:32 PM Staff 2 (DNS) reviewed Resident 20's bathing task logs and confirmed the resident did not receive showers three times a week and Resident 20 never refused showers unless she/he was ill.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident # 20 will receive showers per schedule and when unable to shower due to any reason a replacement shower will be offered. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents at risk for deficiency. An audit will be complete to ensure all residents are receiving showers per schedule and personal preference. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education will be provided to nursing staff on importance of following bath schedule, documenting bathing and providing replacement showers as needed. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Weekly audits will be complete x 3 months to ensure residents are receiving scheduled showers or replacement showers are being offered. Include dates when corrective action will be completed. July 27, 2023 DNS or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to follow physician's orders and the plan of care for 3 of 8 sampled residents (#s 16, 20 and 33) reviewed for hospitalization, dialysis and medications. This resulted in Resident 33 being transported to the hospital where the resident was placed in the ICU on a ventilator and died three days later. This also placed other residents at risk for hospitalization and unmet needs. Findings include: 1. Resident 33 was admitted to the facility in 2023 with diagnoses including hip fracture. The facility's Bowel Management Policy and Procedure dated 9/2020 included the following interventions for when a resident did not have a bowel movement: - On day three administer Milk of Magnesia in the evening. - On day four administer a laxative suppository in the evening. - On day five if the resident has not had a bowel movement by after breakfast the nurse will check for impaction, check the abdomen and administer an enema per physician's orders. If the resident has not had a bowel movement by 3:00 PM the nurse will again check for impaction and check the abdomen. If there is no stool in the rectal vault the physician will be called for further orders and alert charting will begin. Resident 33's Care Plan initiated on 3/17/23 included the following interventions related to constipation and pain: - "Follow facility bowel protocol for bowel management." - "Monitor medications for side effects of constipation. Keep physician informed of any problems." - "Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician." Resident 33's 3/2023 Order Summary report included the following physician's orders: - Milk of Magnesia as needed for constipation after three days of no bowel movement. - Bisacodyl suppository as needed for constipation after four days of no bowel movement. - Enema as needed for constipation after five days of no bowel movement. Administer after a bowel assessment. If no results by the afternoon notify the physician for further orders. - Hydrocodone(opioid pain medication which may cause constipation)-acetaminophen every four hours PRN for pain. Resident 33's 3/2023 Progress Notes and MAR revealed the following: - hydrocodone-acetaminophen was administered five times from 3/17/23 through 3/19/23. - On 3/18/23 a Progress Note indicated a bisacodyl (laxative) suppository was administered because the resident had not had a bowel movement for four days after Milk of Magnesia (laxative) was administered. - No administration of Milk of Magnesia was charted as being administered on or prior to 3/18/23 either in Progress Notes or the MAR. - On 3/19/20 a Progress Note indicated the resident did not have a bowel movement after the medication was administered. - On 3/20/23 at 3:59 PM a Progress Note indicated Milk of Magnesia was administered for third day with no bowel movement. (Being the third day with no bowel movement is not consistent with charting on 3/18/23 and 3/19/23 which indicated the resident had not had a bowel movement by those dates.) - On 3/20/23 at 6:58 PM a Progress Note by Staff 5 (LPN) indicated the resident had not had a bowel movement and an enema was administered (no enema administration was documented on the MAR) after lunch with no bowel movement by the end of the shift. The resident continued with nausea (no nausea was documented prior to this note) and vomited once. The resident's abdomen was hard and bowel tones were sluggish. The note did not indicate Staff 5 contacted an RN or the physician for further instructions. The note indicated "will continue to monitor." - On 3/21/23 at 4:39 AM a Progress Note indicated Resident 33 was transported to the hospital by ambulance at 4:00 AM. The resident woke for her/his sleep with multiple episodes of vomiting which was dark brown in color and appeared to be fecal matter. The resident had not had a bowel movement for several days despite being administered Milk of Magnesia and an enema. - On 3/22/23 at 2:50 AM a Progress Note indicated the resident was in the ICU, intubated and on a ventilator. Resident 33's Hospital History and Physical dated 3/21/23 revealed the resident was diagnosed with a small bowel obstruction (blockage of the small intestine), aspiration pneumonia (infection of the lungs related to food or liquids breathed into the lungs) and pulmonary emboli (blockage of arteries in the lungs). The resident died on 3/24/23. On 6/14/23 at 9:16 AM Resident 33's Care Plan, physician's orders and Progress Notes were reviewed with Staff 5 (LPN). Staff 5 stated she recalled Resident 33 and the incident on 3/20/23. Staff 5 stated she did not remember notifying anyone, such as Staff 2 (DNS) or the physician on 3/20/23. Staff 5 stated she usually did not contact Staff 2 for bowel issues and faxes were the normal method to contact the physician. Staff 5 stated she did not know how to contact the on-call provider. On 6/13/23 at 2:37 PM and 6/14/23 at 11:04 AM Resident 33's Care Plan, physician's orders and Progress Notes were reviewed with Staff 2. Staff 2 stated the physician should have been informed of the resident's condition on 3/20/23. Staff 2 stated the nurses were aware they could call her to evaluate any questions they had. Staff 2 stated the on-call provider was available by fax, text or phone and the charge nurse had the authority to send resident's out to the hospital based on their nursing judgement. Staff 2 verified the physician was not notified on 3/20/23 about Resident 33's condition. , 2. Resident 16 was admitted to the facility in 2020 with diagnoses including diabetes. a. An 11/18/22 physician order indicated Resident 16 was prescribed Lantus (a drug used to control the amount of sugar in the blood) two times a day for diabetes. Hold for CBG less than 90. A review of Resident 16's 5/1/23 through 6/10/23 DAR (Diabetic Administration Record) indicated the resident's Lantus was not given according to physician orders on the following days: -5/2 evening dose with no rationale provided; -5/17 morning dose with a progress note indicating the resident was in shower/activity; -5/28 evening dose with a progress note indicating insulin was given by the day nurse. On 6/14/23 at 9:54 AM Staff 2 (DNS) reviewed Resident 16's Lantus DARs and stated the resident's Lantus should have been given on the dates identified and if a resident was in an activity or shower, the nurse should find the resident and administer the insulin or administer the insulin as soon as the resident was available. Staff 2 stated if the day nurse administered insulin, the day nurse should document. b. A 10/21/22 physician order indicated Resident 16 was prescribed Insulin lispro (a short acting type of insulin) after meals. Hold if intake was less than 25%. Notify the physician of CBG's greater than 500. A review of Resident 16's 5/1/23 through 6/10/23 DAR (Diabetic Administration Record) indicated the resident's lispro was not given according to physician orders on the following days: -5/2 dinner dose with no rationale provided; -5/6 dinner dose with no rationale provided; -5/7 dinner dose with no rationale provided; -5/12 lunch dose with a progress note which indicated the resident was in an activity; -5/17 breakfast dose with a progress note which indicated the resident was in the shower or activity; -5/21 dinner dose with a progress note which indicated the insulin was given by the day nurse; -5/24 breakfast dose with a progress note which indicated the resident was in an activity; -5/25 breakfast with no rationale provided; -5/28 dinner dose with a progress note which indicated the insulin was given by the day nurse; -5/30 lunch dose with no rational provided; -5/31 lunch dose with a progress note which indicated the resident was in an activity; -6/3 dinner dose with a progress note which indicated the insulin was held due to the resident's blood sugar being 132; -6/7 lunch dose with a progress note which indicated the resident was in an activity. On 6/14/23 at 9:54 AM Staff 2 (DNS) reviewed Resident 16's lispro DARs and stated the resident's lispro should have been given on the dates identified and if a resident was in an activity or shower, the nurse should find the resident and administer the insulin or administer the insulin as soon as the resident was available. Staff 2 stated if the day nurse administered insulin, the day nurse should document. 3. Resident 20 was admitted to the facility in 2020 with diagnoses including end stage renal disease. A 3/11/23 physician order indicated Resident 20 was prescribed Nova Source (a nutritional supplement which provides protein, vitamins and minerals specifically for people with chronic kidney disease on dialysis) one time a day for end stage kidney disease. A review of Resident 20's 5/1/2023 through 6/12/2023 TARs indicated the resident's Nova Source was not given according to physician orders on the following days: 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10, 5/12, 6/6, 6/7, 6/8 and 6/11. On 6/11/23 at 11:05 AM Resident 20 stated she/he was supposed to receive Nova Source every day but had not received it for at least the past three weeks. Resident 20 stated every time she/he asked about it, she/he was told it was on order. On 6/12/23 at 10:32 AM Staff 11 (LPN) stated Resident 20 was supposed to receive Nova Source once a day and thought it was being ordered. On 6/12/23 at 11:24 AM and 6/13/23 at 12:32 PM Staff 2 (DNS) stated the facility was currently out of Nova Source. Staff 2 stated she was notified by text that more Nova Source needed to be ordered but she did not see the text so none was ordered.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident # 33 has discharged. Resident #16 will receive her insulin per order. Order updated to meet residents needs. Resident # 20 has Nova Source available, and it will be ordered on a scheduled basis to ensure availability. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents at risk for deficient practice. Audits will be complete to ensure no residents are being affected by this deficient practice and addressed as needed. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Resident records will be monitored 5 days a week to ensure medications, supplements and treatments are administered per order or rational is noted why medications are not administered. Education will be provided to nursing staff on appropriate reasons to hold medication Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. Audits will be complete 5 days a week for 3 months to ensure medications, treatments and procedures are complete per orders. Then random audits will be complete ongoing to ensure continued compliance. Results will be presented at QAPI Include dates when corrective action will be completed. July 13, 2023 DNS or delegee is responsible for correction of deficiency

Based on observation and interview it was determined the facility failed to ensure the residents' environment was free from hazards for 1 of 1 facility randomly observed. This placed residents at risk for injury and blood borne infection. Findings include: On 6/12/23 at 7:29 AM a large sharps container was observed attached to the right side of the medication cart on the third floor. The sharps container did not have a safety flap and was full of used needles and lancets. On 6/12/23 at 7:40 AM Staff 11 (LPN) stated he had not noticed the sharps container was full and had no safety flap. He reported the concern to Staff 2 (DNS) and got a new sharps container but could not find the key to unlock the retaining device which kept the full sharps container secured to the medication cart. Staff 11 stated when the next shift came to work they might know where the key was. On 6/13/23 at 8:15 AM and 6/13/23 at 10:32 AM the sharps container was observed still attached to the medication cart full of needles and lancets with no safety flap. On 6/13/23 at 11:01 AM Staff 2 was shown the sharps container, she acknowledged the sharps container was full of needles and lancets and the container should have a safety flap.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. No residents were affected by this deficient practice. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Sharps container was changed out to meet safety requirements. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Weekly audits will be complete to ensure sharps containers are appropriately covered and replaced per guidelines. Education will be provided to staff on how to put sharps containers together and replacement guidelines. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Weekly audits will be complete X 3 months then randomly to ensure guidelines followed. Will present results to QAPI Include dates when corrective action will be completed. July 27, 2023 DNS or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to promptly intervene when a resident experienced severe weight loss for 1 of 3 sampled residents (#30) reviewed for nutrition. This resulted in an unplanned severe weight loss for Resident 30 and placed residents at risk for unplanned weight loss. Findings include: Resident 30 was admitted to the facility in 2023 with diagnoses including Multiple Sclerosis (disease of the brain and spinal cord). On 6/11/23 at 10:48 AM Witness 1 (Family) stated Resident 30 lost 17 pounds in about a month. Resident 30's diet order dated 5/4/23 included a general diet with regular texture and thin consistency (for fluids). Resident 30's Nutritional Status CAA dated 5/11/23 did not indicate a nutritional problem, a comprehensive assessment of the resident's nutritional status or the impact on the resident. Resident 30's Care Plan initiated on 5/4/23 for ADLs and nutrition included the following interventions: - Set-up assistance for eating. - "Explain and reinforce to [the resident] the importance of maintaining the diet ordered. Encourage [her/him] to comply. Explain consequences of refusal, obesity/malnutrition risk factors." (The resident was ordered a regular diet therefore it was not evident why this intervention was pertinent.) - Provide and serve the diet as ordered. Monitor and record the resident's intake at each meal. - The RD will evaluate [the resident] and make diet change recommendations as needed. - Weigh the resident weekly. Resident 30's weight record from 5/4/23 through 6/8/23 revealed the resident lost 18 pounds or 6.7% body weight over 35 days. Resident 30's meal intake record from 5/14/23 through 6/11/23, (29 days or 87 meals) revealed 54% of meals were documented as 76-100% eaten and 31% were 51-75% eaten. Resident 30's Nutritional Assessment dated 5/18/23 indicated the resident received a general diet which was appropriate at that time. The resident's meal acceptance was around 75%. The resident was at increased nutritional risk due to an elevated BMI (body mass index). The resident's overall health would likely benefit from a gradual weight decrease. Goals included stable weight with gradual weight decrease okay and to notify the RD as needed. (The assessment did not indicate what specific risks Resident 30 was at risk for due to the elevated BMI. The assessment also did not specify what a gradual weight loss would be or a specific plan to achieve a gradual weight loss.) Resident 30's Progress Notes from 5/4/23 through 6/9/23 revealed no documentation to indicate the resident was reassessed for weight loss, new interventions implemented, referral to the RD, notification to the resident's family or notification to the physician regarding the resident's severe weight loss. On 6/12/23 at 11:04 AM Resident 30's weight loss was reviewed with Staff 2 (DNS). Staff 2 stated the resident was reviewed at the facility's monthly dietary meeting and the RD should have made a progress note and put updated dietary recommendations in her in-box. Staff 2 checked her in-box and reviewed the progress notes. She stated there was no progress note or new dietary recommendations. Staff 2 verified Resident 30's Nutritional Status CAA was not comprehensive, the resident lost 18 pounds over 35 days, the weight loss was not planned and the resident's family and physician were not immediately notified. Staff 2 confirmed there was no evidence of a reassessment of the resident's nutritional status or rationale for no new interventions after the resident lost 18 pounds.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. MD and family aware of wt loss. MD did not write order to implement supplements to prevent further wt loss. Weight has stabilized. Diet changed to include finger foods to ease eating and staff to assist finishing meals as needed Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Residents will be reviewed for weight loss and interventions have been care planned as appropriate. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Weekly nutrition meetings assessing weights will be held with immediate notification of resident representative and MD and appropriate dietary interventions. RD will be notified of changes for recommendations between visits. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. Weekly audits X 3 months to ensure compliance. Results will be presented to QAPI Include dates when corrective action will be completed. July 13, 2023 DNS or delegee is responsible for correction of deficiency

Based on observation, interview and record review it was determined the facility failed to conduct post dialysis assessments of resident's condition for 2 of 2 sampled residents (#s 20 and 27) reviewed for dialysis. This placed residents at risk for potential unmet care needs upon return from dialysis. Findings include: The facility's Hemodialysis Access Care policy and procedure dated 9/2010 indicated the Care Immediately Following Dialysis Treatment was as follows: -"Mild bleeding from site (post-dialysis) can be expected. Apply pressure to insertion site and contact dialysis center for instructions". -"If there is major bleeding from site (post-dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify clamps are closed on lumens. This is a medical emergency. Do not leave resident alone until emergency services arrive". 1. Resident 20 was admitted to the facility in 2020 with diagnoses including end stage renal disease. Resident 20's 4/28/21 Dialysis Care Plan indicated the resident received dialysis on Monday, Wednesday and Friday. A review of Resident 20's health care record and dialysis communication notebook revealed no evidence of any post-dialysis assessments. On 6/12/23 at 10:22 AM Resident 20 was observed leaving for dialysis. Resident 20 returned from dialysis at 4:16 PM. On 6/11/23 at 11:22 AM Resident 20 stated she/he went to dialysis three times a week. Resident 20 reported the nurses never assessed her/him upon returning from dialysis and she/he usually removed the pressure bandages sometime the next day. On 6/12/23 at 5:00 PM Resident 20 stated no nurse completed a post-dialysis assessment since she/he returned from dialysis. On 6/12/23 at 5:05 PM Staff 11 (LPN) stated he did not complete post-dialysis assessments on residents but if the CNAs noticed any issues they would tell the nurse. On 6/13/23 at 8:05 AM Resident 20 was observed to still have two pressure bandages on her/his left arm from dialysis on 6/12/23. Resident 20 stated no staff assessed her/his arm or removed the bandages. Resident 20 then removed the bandages and placed them on her/his bedside table. On 6/13/23 at 12:32 PM Staff 2 (DNS) stated she expected nursing staff to complete a post-dialysis assessment when a resident returned from dialysis. Staff 2 stated she expected staff to check the access site, palpate trill (feel for a vibration), look for any bleeding and remove the pressure bandage at some point. , 2. Resident 27 was admitted to the facility in 4/2023 with diagnoses including end state renal disease and diabetes. Resident 27's Care Plan identified she/he needed dialysis due to end stage renal disease, which was scheduled every Tuesday, Thursday and Saturday. Interventions included to monitor and report any problems with the resident's access site to the dialysis clinic. There was no documentation in the resident's Progress Notes since her/his admission of a post dialysis evaluation. On 6/11/23 at 1:30 PM Resident 27 was observed in her/his room sitting on her/his bed with the TV on. Resident 27 stated she/he was on dialysis and showed this surveyor her/his fistula site located on the upper left arm. Resident 27 stated on her/his dialysis days she/he removed the pressure dressing herself/himself after four hours and stated she/he was not assessed after returning from dialysis appointments. On 6/13/23 at 2:52 PM Resident 27 was observed to return from her/his dialysis appointment. On 6/13/23 at 3:50 PM Staff 4 (RN) stated she was unaware what type of dialysis site Resident 27 had, missed giving Resident 27 her/his morning medications because she was running late and had not observed or assessed Resident 27 since she/he had returned from the dialysis clinic. On 6/13/23 at 4:06 PM Resident 27 was observed in bed and had not yet been assessed from her/his return from the dialysis clinic. On 6/14/23 at 11:44 AM Staff 2 (DNS) stated there were no post dialysis assessments in Resident 27's chart because they had not been completed. Staff 3 (RNCM) stated it was her expectation residents on dialysis were assessed within 15 minutes of their return to the facility and all vital signs were completed.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident # 20 and #27 have updated orders place on EMAR to check dialysis cite upon return from dialysis and directions to remove pressure dressings. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. There are no other residents at risk in the facility. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Post admission audits will be done to ensure appropriate orders are in place for post dialysis assessments. Education will be provided to nursing staff on appropriate post dialysis assessment. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Audits will be complete weekly x 3 month then random audits will be done for dialysis patients to ensure deficient practice will not recur. Results will be presented at QAPI Include dates when corrective action will be completed. July 27, 2023 DNS or delegee is responsible for correction of deficiency

Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 6/11/23 the facility provided a list of residents who: -Required one or two person assistance with bathing: 17; -Were fully dependent for bathing: 17; -Required one or two person assistance for eating: 5; -Were fully dependent on staff for eating: 6; -Required one or two person assistance for toileting: 9; -Were fully dependent on staff for toileting: 25; -Required one or two person assistance with transfers: 12; -Were fully dependent on staff for transfers: 20; -Required one or two person assistance with dressing: 19; -Were fully dependent on staff for dressing: 12. Random observations revealed the following: On 6/12/23 at 8:18 AM seven residents in the 300 dining room for breakfast. Three residents were waiting to be assisted with eating and four residents were eating on their own. There was only one CNA in the dining room to assist residents with eating their breakfast until 8:35 AM when a second CNA arrived after passing trays to residents in the hallway. On 6/12/23 at 8:48 AM a resident was heard frequently yelling for help in the 300 hallway. Several staff passed by the resident's room and at 8:57 AM a CNA entered the room. On 6/13/23 at 8:43 AM there were seven residents in the 300 dining room for breakfast. One resident sat with untouched food in front of her/him. Staff 8 (CNA) was assisting another resident with eating. At 8:48 AM a second CNA arrived to assist residents with eating. Staff 8 reported trays arrived at 8:00 AM, the CNAs passed the hall trays and then assisted residents in the dining room. On 6/11/23 at 10:58 AM Resident 20 stated the facility utilized many staff from different agencies and those staff were unfamiliar with her/his needs or how to provide care for her/him. On 6/12/23 at 2:54 PM Witness 1 (Family) stated there were several times the CNA staff were unable to get her family member up for meals because the facility did not have enough CNA staff. Witness 1 stated the previous week she was visiting her family member and asked CNA staff to get her/him up for dinner. She reported the CNA staff were unable to get her family member up as requested because there were only two CNAs working on the hallway; one CNA was giving a shower and the other CNA had to pass dinner trays. Witness 1 stated this happened many other times, too. On 6/12/23 at 2:08 PM Staff 15 (CNA) stated there were many residents who required assistance with eating and there were not enough CNAs to provide timely eating assistance so it took a long time to get through meal service. Staff 15 stated residents often complained about the length of time it took staff to respond to call lights. Staff 15 reported CNA staff often did not get to take their breaks or lunches and they sometimes worked after their shift ended in order to get care completed. Staff 15 stated there were at least eight residents on the 300 hallway that required two person assistance to get them out of bed so many times they could not get all the residents up who wanted to get up for meals. On 6/12/23 at 3:38 PM Staff 19 (CNA) stated there were times when there was not enough CNA staff to get residents up for the dinner meal. On 6/12/23 at 10:24 AM Staff 14 (RN) stated the 300 hallway had high acuity residents and many of them required two person assistance to get out of bed. Staff 14 stated sometimes showers got bumped, CNAs were unable to get all the residents up that needed to be up for meals and residents were not always repositioned every two hours. On 6/13/23 at 10:57 AM Staff 8 (CNA) reported she often did not get breaks or lunches and sometimes worked over her shift to get resident care completed. Staff 8 stated many of the residents in the facility required a lot of assistance and she often could not complete all of her assigned showers or reposition and turn residents as frequently as required. On 6/14/23 at 9:47 AM staffing concerns were reviewed with Staff 2 (DNS). Staff 2 stated she was aware there were residents who expressed concerns with staffing and the facility had many residents with high acuity needs. Staff 2 acknowledged staffing was challenging and it was difficult to get staff hired because of being in a rural area.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. No residents were identified Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have potential to be affected by the same deficient practice. Facility will be staffed per CMS guidelines for acuity vs minimal staffing ratio Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur New admission referrals will be reviewed for acuity before accepting them for admission to allow care needs can be met based on staffing ratios. Resident acuity will be reviewed in morning meeting to assist with determining appropriateness of admits Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Weekly audits will be complete on residents needs vs current staffing rations X 3 months then monthly ongoing. Results will be present at QAPI Include dates when corrective action will be completed. July 27, 2023 Administrator or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to staff a registered nurse for 8 consecutive hours per day 7 days per week for 14 out of 103 days reviewed for staffing. This placed all residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports dated 1/1/23 through 2/28/23 and 5/1/23 through 6/14/23 revealed the facility had no RN coverage for eight consecutive hours on the following days: 1/4, 1/5, 1/6, 1/18, 1/22, 2/13, 5/15, 5/22, 5/23, 5/27, 5/28, 5/29, 6/2 and 6/10. On 6/14/23 at 9:47 AM Staff 2 (DNS) confirmed the facility lacked RN coverage on the identified days.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. No residents were identified as being affected Address how the facility will identify other residents having the potential to be affected by the same deficient practice. No residents were identified as being affected Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Requesting an updated waiver to meet current staffing. Ads are posted with sign-on bonus to attract RN staffing. All efforts are being made to obtain RN coverage in accordance with current waiver including request to agencies for coverage Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Weekly audits will be completed x3 months then monthly ongoing. Results will be discussed at QAPI Include dates when corrective action will be completed. July 27, 2023 Administrator or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 2 of 5 sampled CNA staff (#s 19 and 23) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 6/12/23 indicated the following employees had not received their annual performance evaluations: -Staff 19 (CNA), hire date 9/8/21: no annual performance reviews were provided. -Staff 23 (CNA), hire date 1/6/22; no annual performance reviews were provided. On 6/12/23 at 1:24 PM Staff 18 (Human Resources) confirmed annual performance reviews for the identified staff were not completed.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. No residents were identified Address how the facility will identify other residents having the potential to be affected by the same deficient practice Nurse Aid Perform Updated and complete Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. HR will provide DNS/RCM scheduled evaluations monthly. DNS/RCM will complete the review within the month of review due date and return to HR. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Weekly audits will be complete X3 months then monthly ongoing to ensure solutions are lasting. Results will be presented to QAPI Include dates when corrective action will be completed. July 27, 2023 HR or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 32 of 45 days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: Review of the 5/1/23 through 6/14/23 DCSDRs indicated the following days when required information was missing or inaccurate on the daily postings: 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18, 5/19, 5/20, 5/21, 5/22, 5/23, 5/25, 5/26, 5/27, 5/28, 5/29, 5/30, 5/31, 6/1, 6/2, 6/3, 6/4, 6/5, 6/6, 6/8, 6/9, 6/10, 6/11, 6/12, 6/13 and 6/14. On 6/14/23 at 9:47 AM Staff 2 (DNS) confirmed the facility's failure to complete required information on the DCSDRs.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. No residents identified Address how the facility will identify other residents having the potential to be affected by the same deficient practice No residents identified Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur Education on correctly completing the form will be provided to all staff responsible for completing the Nurse Staffing Information sheet. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Weekly audits X 3 months will be complete to ensure solutions are lasting. Results will be presented to QAPI Include dates when corrective action will be completed.07/27/2023 DNS or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary medications for 2 of 5 sampled residents (#s 16 and 84) reviewed for medications. This placed residents at risk for diarrhea, skin breakdown, dehydration and weight loss. Findings include: 1. Resident 84 was admitted to the facility in 2023 with diagnoses including respiratory failure. Resident 84's 6/2023 MAR revealed the resident had a physician's order for Miralax (a laxative also called polyethylene glycol) administered BID and a physician's order for polyethylene glycol administered BID. The MAR revealed the following dates when both Miralax and polyethylene glycol were administered: - 6/6/23 four doses were administered. - 6/7/23 four doses were administered. - 6/8/23 three doses were administered. - 6/9/23 three doses were administered. - 6/10/23 four doses were administered. - 6/11/23 three doses were administered. Resident 84's bowel record from 6/3/23 through 6/12/23 revealed the resident had 25 bowel movements, 17 were recorded as "Loose/Diarrhea". On 6/13/23 at 11:12 AM Staff 2 (DNS) confirmed the orders for Miralax and polyethylene glycol were duplicative and the MAR indicated both medications were administered. Staff 2 confirmed the resident's bowel record with numerous "Loose/Diarrhea" charted which was indicative the medications were administered. On 6/14/23 at 9:54 AM Staff 12 (Consultant Pharmacist) confirmed Miralax and polyethylene glycol were the same medications and administering both would be duplicative therapy. , 2. Resident 16 was admitted to the facility in 2020 with diagnoses including diabetes. a. A review of Resident 16's 5/15/23 through 6/12/23 MAR indicated an order for MiraLax (a laxative) which was administered one time a day for constipation. The order indicated to hold the medication if Resident 16 had loose stools. The MAR indicated Resident 16 was administered MiraLax daily and there were no instances when the medication was held. A review of Resident 16's Bowel Elimination Flowsheets from 5/15/23 through 6/12/23 indicated Resident 16 had loose stools on the following dates: 5/19, 5/20, 5/21, 5/28, 5/29, 6/4, 6/10 and 6/11. On 6/13/23 at 2:56 PM Staff 14 (RN) stated there was no consistent method to notify nurses when residents' bowel medications needed to be held due to loose stools. She stated sometimes she was notified to hold bowel medications by nurses passing information along via sticky notes, sometimes there was an "ON HOLD" written in the healthcare record and sometimes CNAs verbally notified the nurses. On 6/14/23 at 9:54 AM Staff 2 (DNS) confirmed Resident 16's bowel medication should have been held on the identified dates and she expected bowel medications to be held when residents had loose stools. b. A review of Resident 16's 5/15/23 through 6/12/23 MAR indicated an order for Colace (a stool softener) which was administered one time a day for constipation. The order indicated to hold the medication if Resident 16 had loose stools. The MAR indicated Resident 16 was administered Colace daily and there were no instances when the medication was held. A review of Resident 16's Bowel Elimination Flowsheets from 5/15/23 through 6/12/23 indicated Resident 16 had loose stools on the following dates: 5/19, 5/20, 5/21, 5/28, 5/29, 6/4, 6/10 and 6/11. On 6/13/23 at 2:56 PM Staff 14 (RN) stated there was no consistent method to notify nurses when residents' bowel medications needed to be held due to loose stools. She stated sometimes she was notified to hold bowel medications by nurses passing information along via sticky notes, sometimes there was an "ON HOLD" written in the healthcare record and sometimes CNAs verbally notified the nurses. On 6/14/23 at 9:54 AM Staff 2 (DNS) confirmed Resident 16's Colace should have been held on the identified dates and she expected bowel medications to be held when residents had loose stools. c. A review of Resident 16's 5/15/23 through 6/12/23 MAR indicated an order for Senna Plus (a laxative) which was administered two times a day for constipation. The order indicated to hold the medication if Resident 16 had loose stools. The MAR indicated Resident 16 was administered Senna daily and one morning dose was held on 6/4/23. There were no other instances when the medication was held. A review of Resident 16's Bowel Elimination Flowsheets from 5/15/23 through 6/12/23 indicated Resident 16 had loose stools on the following dates: 5/19, 5/20, 5/21, 5/28, 5/29, 6/4, 6/10 and 6/11. On 6/13/23 at 2:56 PM Staff 14 (RN) stated there was no consistent method to notify nurses when residents' bowel medications needed to be held due to loose stools. She stated sometimes she was notified to hold bowel medications by nurses passing information along via sticky notes, sometimes there was an "ON HOLD" written in the healthcare record and sometimes CNAs verbally notified the nurses. On 6/14/23 at 9:54 AM Staff 2 (DNS) confirmed Resident 16's Senna Plus should have been held on the identified dates and she expected bowel medications to be held when residents had loose stools.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #84 orders have been reviewed and updated to receive the correct dose of medications. A follow up questions report will be run daily to identify when resident #18 has loose stools to prevent unnecessary medications. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents at potential risk for deficient practice. A follow up questions report will be run daily to identify when residents are experiencing loose stools to prevent unnecessary medications. Staff educated to discontinue duplicate medications on EMAR to prevent unnecessary medications. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur Education will be done with staff responsible for administering medications on how to run a follow up questions report prior to administering bowel medications. Medication review will be complete with care plan review to help identify unnecessary medications. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting. Audits will be complete weekly x 3 months then randomly to ensure solutions are lasting. Results will be presented at QAPI Include dates when corrective action will be completed. July 27, 2023 DNS or delegee is responsible for correction of deficiency

Based on observation, interview and record review it was determined the facility failed to store drugs and biologicals in locked compartments for 2 of 2 treatment carts and 2 of 2 medication carts observed during this survey. This placed residents at risk for medication diversion and accidents. Findings include: 1. On 6/11/23 at 11:26 AM a medication cart and a treatment cart were observed in the hallway outside the nurses' station on the third floor. Both carts were unlocked, and no staff were in sight of the carts. Staff 11 (LPN) verified the carts were not locked. On 6/14/23 at 10:58 AM Staff 2 (DNS) stated the carts should be locked when staff are not using them. , 2. On 6/14/22 at 8:16 AM a treatment cart was observed to be unlocked on the 4th floor. The nurse was not in view of the cart. On 6/14/22 at 8:20 AM Staff 5 (LPN) acknowledged the treatment cart was unlocked. On 6/14/22 at 8:48 AM a medication cart was observed to be unlocked on the 4th floor. The nurse was not in view of the cart. On 6/14/22 at 8:50 AM Staff 5 acknowledged the medication cart was unlocked. On 6/14/23 at 10:58 AM Staff 2 (DNS) stated the carts should be locked when staff are not using them.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. No residents were identified. Address how the facility will identify other residents having the potential to be affected by the same deficient practice No residents were identified Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Request out to pharmacy for self-locking carts. Retractable key fobs will be purchased to prevent leaving carts unlocked. Education will be provided to all staff who work on Med/Tx carts on importance of locking carts. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Random audits will be done to ensure carts are locked consistently. Those employees not locking their carts will receive disciplinary action. Include dates when corrective action will be completed. July 27, 2023 DNS or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 20 of 103 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident care and services. Findings include: A review Direct Care Staff Daily Reports dated 1/1/23 through 2/28/23 and 5/1/23 through 6/14/23 revealed the following days when there was no RN coverage for eight consecutive hours from the start of day shift and the end of evening shift. 1/4, 1/5, 1/6, 1/18, 1/22, 2/13, 5/14, 5/15, 5/18, 5/19, 5/22, 5/23, 5/27, 5/28, 5/29, 6/1, 6/2, 6/5, 6/6 and 6/10. On 6/14/23 at 9:47 AM Staff 2 (DNS) confirmed the facility lacked RN coverage on the identified days.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. No residents were identified as being affected Address how the facility will identify other residents having the potential to be affected by the same deficient practice. No residents were identified as being affected Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Requesting an updated waiver to meet current staffing. Ads are posted with sign-on bonus to attract RN staffing. All efforts are being made to obtain RN coverage in accordance with current waiver including request to agencies for coverage Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Weekly audits will be completed x3 months then monthly ongoing. Results will be discussed at QAPI Include dates when corrective action will be completed. July 27, 2023 Administrator or delegee is responsible for correction of deficiency

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 14 of 103 sampled days reviewed for sufficient staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the facility Direct Care Staff Daily Reports dated 1/1/23 through 2/28/23 and 5/1/23 through 6/14/23 revealed the facility had insufficient CNA staff based on state minimum staffing ratios for one or more shifts on the following dates: 1/12, 1/14, 1/17, 1/21, 2/19, 2/24, 2/25, 2/26, 2/27, 2/28, 5/21, 5/30, 5/31 and 6/4. On 6/14/23 at 9:27 AM Staff 2 (DNS) acknowledged the lack of CNA coverage on the identified days. ,

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. No residents were identified Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have potential to be affected by the same deficient practice. Facility will be staffed per CMS guidelines for acuity vs minimal staffing ratio Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur New admission referrals will be reviewed for acuity before accepting them for admission to allow care needs can be met based on staffing ratios. Resident acuity will be reviewed in morning meeting to assist with determining appropriateness of admits Indicate how the facility plans to monitor its performance to make sure that solutions are lasting Weekly audits will be complete on residents needs vs current staffing rations X 3 months then monthly ongoing. Results will be present at QAPI Include dates when corrective action will be completed. July 27, 2023 Administrator or delegee is responsible for correction of deficiency

******************** OAR 411-085-0130 Nursing Services: Notification Refer to F580 ******************** OAR 411-087-0100 Physical Environment: Resident Rights Refer to F584 ******************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F636 ******************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658, F677, F684 and F698 ******************** OAR 411-086-0140 Quality of Care: Nursing Services: Problem Resolution & Preventative Care Refer to F689 ******************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventative Care Refer to F692 and F757 ******************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725, F727 and F732 ******************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F730 ******************** OAR 411-086-0260 Pharmacy Services: Pharmaceutical Services Refer to F761 ********************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/22/2023 and 05/28/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 03/13/2023 and 03/19/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/26/2022 and 01/01/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/12/2022 and 09/18/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review it was determined the facility failed to revise care plans to accurately reflect the use of a transfer assistive device, the presence of a pressure ulcer and the associated interventions, to reflect accurate catheter information and dressing preferences for 4 of 4 sampled residents (#s 1, 4, 6 and 20) reviewed for person centered care plans. This placed residents at risk for unmet care needs. Findings include: 1. Resident 4 was admitted to the facility in 2/2015 with diagnoses including cerebral infarction (stroke). Resident 4's 8/18/21 Care Plan identified Resident 4 with limited mobility and a Hoyer (mechanical lift) with two staff assistance was required for transfers. Resident 4's Kardex, the tool used by CNAs to direct the resident's care, indicated Resident 4 was transferred with a Hoyer and two staff assistance. On 7/26/22 at 10:30 AM and 4:46 PM Staff 6 (CNA) and Staff 7 (CNA) stated they used the Kardex to find information such as transfer status of a resident. Staff 6 and Staff 7 stated Resident 4 was transferred with a sit-to-stand mechanical device at times per her/his preference and transferred with a Hoyer other times. On 7/27/22 at 9:16 AM and 10:25 AM Staff 5 (RN) stated Resident 4 was transferred with a Hoyer only and no other lifts were used and Staff 3 (RNCM) stated Resident 4 was transferred with a sit-to-stand mechanical lift and a Hoyer lift. Staff 5 stated the transfer directions were to be on the Kardex and the Care Plan. On 7/27/22 at 1:23 PM Staff 2 (DNS) stated staff used the Kardex and Care Plan as tools to direct Resident 4's care. Staff 2 stated she believed Resident 4 was transferred with a sit-to-stand mechanical lift and a Hoyer lift. Staff 2 stated the transfer status and mechanical devices were to be on the Kardex and the Care Plan and acknowledged the sit to stand information was missing and inconsistent with Resident 4's transfer care needs. 2. Resident 6 was admitted to the facility in 11/2021 with diagnoses including rheumatoid arthritis (chronic disease affecting the joints). A 7/1/22 progress note written by Staff 3 (RNCM) indicated Resident 6 had a pressure wound on her/his left buttock. In the note, Staff 3 indicated a cushion would be added to Resident 6's recliner to provide more pressure relief. Review of Resident 6's Kardex and Care Plan revealed no information regarding the pressure wound or the added cushion. On 7/26/22 at 1:37 PM and 1:58 PM Staff 5 (RN) and Staff 8 (CNA) stated in addition to shift-to-shift report, they used the Kardex and the Care Plan to find information about Resident 20's care needs. On 7/27/22 at 12:55 PM Staff 2 (DNS) acknowledged the recliner cushion intervention was not included on the Kardex and Care Plan and the pressure wound information was not added to the Care Plan until 7/26/22, 25 days after the pressure wound was identified. 3. Resident 20 was admitted to the facility in 6/2018 with diagnoses including diabetes mellitus type 2. Resident 20's 7/2022 physician orders included an order for a urinary catheter: size 16FR/10 cc (cubic centimeters) balloon. Resident 20's Care Plan, last revised 3/15/22 indicated a urinary catheter size 18FR/30 cc balloon. On 7/26/22 at 12:56 PM and 1:37 PM Staff 5 (RN) stated she referred to the Care Plan for information regarding the residents' care needs. On 7/27/22 at 10:09 AM Staff 3 (RNCM) stated she was primarily responsible for updating and revising residents' Care Plans. On 7/27/22 at 2:31 PM Staff 2 (DNS) acknowledged the Care Plan did not accurately reflect Resident 20's urinary catheter size as indicated by the physician order. , 4. Resident 1 was admitted to the facility in 11/2019 with diagnoses including communication deficits. Resident 1's Care Plan, active on 7/26/22, included the level of assistance required for dressing but no information regarding clothing preferences. From 7/25/22 through 7/28/22 Resident 1 was observed wearing no shirt on all observations. On 7/26/22 at 1:08 PM Witness 1 (Resident Representative) stated Resident 1 preferred to be clothesless when in bed. On 7/26/22 at 1:23 PM Staff 6 (CNA) stated information regarding a resident's care preferences were found in their Care Plans. Staff 6 also stated Resident 1 preferred to wear no clothing. Staff 6 stated she was unsure if Resident 1's clothing preferences were in her/his Care Plan. On 7/27/22 at 3:12 Staff 3 (RNCM) stated information regarding a resident's clothing preferences was shared to CNAs on a Care Plan or Kardex, the tool used by CNAs to direct resident care. Staff 3 confirmed no information concerning Resident 1's clothing preferences was included in her/his Care Plan but having that information included was a good idea. On 7/28/22 Staff 2 (DNS) confirmed Resident 1's Care Plan or Kardex did not include information regarding clothing preferences and stated these were to be updated to reflect resident specific care instructions.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice Care plans for residents 1, 4, 6, and 20 have been updated to accurately reflect and meet the residents care needs. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by the same deficient practice and care plans will be reviewed and updated as they are needed to ensure person centered care. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur Education has been provided on patient centered care plans to ensure residents needs are identified and met. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Nursing will complete random audits on 4 care plans a month x 3 months and results shared with QAPI committee for the next two quarterly meetings. Include dates when corrective action will be completed DNS or delegee is responsible for correction of deficiency

Based on observation, interview and record review it was determined the facility failed to complete routine assessments, implement pressure ulcer interventions and failed to perform would care as ordered to promote healing of a pressure ulcer for 1 of 2 sampled residents (#6) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: The facility's 7/2017 Prevention of Pressure Ulcers/Injuries Policy and Procedure indicated to keep the skin clean and free of exposure to urine and fecal matter, reposition residents at least every hour who are chair-bound and reposition more frequently as needed, based on the condition of the skin and the resident's comfort. Resident 6 was admitted to the facility in 11/2021 with diagnoses including rheumatoid arthritis (chronic disease affecting the joints). Resident 6's 5/15/22 Quarterly MDS assessment indicated Resident 6 was moderately cognitively impaired, frequently incontinent and at risk for pressure ulcers, she/he required a pressure reducing device in the chair and she/he was on a repositioning program. On 7/25/22 at 11:44 AM Resident 6 was unable to participate in an interview. Resident 6 was not oriented to the date, time or the year and was unable to demonstrate use of her/his call light. Observations of Resident 6 were conducted 7/25/22 through 7/27/22 between the hours of 8:29 AM and 4:11 PM. During these observations, Resident 6 sat upright in her/his recliner without an added pressure-reducing cushion, she/he did not reposition her/himself, staff did not reposition the resident and incontinence care was not provided routinely. Resident 6's call light was observed to be clipped to the wall and out of her/his reach at times. A 7/1/22 progress note written by Staff 3 (RNCM) indicated Resident 6 had a pressure wound on her/his left buttock. In the note, Staff 3 indicated the wound measured 1.3 cm in diameter, the physician would be notified, an order would be obtained for a dressing to protect the skin from moisture and a cushion would be added to Resident 6's recliner to provide more pressure relief. A 7/1/22 Wound Weekly Observation Tool revealed Staff 3 (RNCM) assessed Resident 6's pressure ulcer and documented the following information: - Facility acquired, date acquired field blank - Site and type: Stage 2 pressure wound to the left buttocks - Measurements: 1.3 cm length and 1.3 cm width - Granulation tissue (beefy red) 100% - No undermining, no tunneling - Small amount of thin watery drainage - Peri wound condition: fragile - No wound odor A 7/1/22 physician order specified the following: - Cleanse with wound cleanser and pat dry. - Apply barrier film to entire site and allow to dry. - Cover with a bordered foam or similar dressing to protect from moisture and soiling. - Change dressing [every other day] and PRN for soiling/dislodgement. Review of Resident 6's health record revealed no documented pressure ulcer assessments completed after 7/1/22. Review of Resident 6's Care Plan revealed no pressure ulcer information such as location and characteristics of the pressure wound. The Care Plan lacked resident-centered pressure ulcer interventions such as the added cushion, frequency of repositioning and wound care treatment details. Resident 6's 7/2022 TAR revealed no documentation on 7/10/22 and 7/22/22 to indicate wound care was completed as ordered on those dates. On 7/26/22 at 1:58 PM Staff 8 (CNA) stated she believed Resident 6 had a skin issue on her/his bottom and the resident preferred to stay up in her/his recliner for the day. Staff 8 stated she found information about the resident in the Care Plan and was unaware if Resident 6 required an extra cushion in the recliner. Staff 8 stated residents are to be repositioned every two hours, Resident 6 often refused to be repositioned, and she waited for the resident to use the call light when she/he wanted to be toileted and/or repositioned. On 7/26/22 at 2:06 PM Staff 9 (CNA) stated she waited for Resident 6 to call to be toileted and/or repositioned and often the resident refused. On 7/26/22 at 2:08 PM Resident 6's pressure ulcer wound care was observed. Resident 6's incontinence brief was removed and observed heavily saturated with urine and soiled with feces. Resident 6's pressure ulcer dressing was soiled and displaced off the wound and her/his buttocks skin was moist, fragile and macerated (occurs when skin is in contact with moisture for extended periods of time). Staff 5 removed the soiled dressing and completed wound care. Staff 5 stated she didn't think there were recent wound measurements and she measured the wound at 2 cm length, 1.2 cm width and 0.1 cm depth. Staff 5 stated the wound appeared "different and open" compared to the last time she saw the wound. When asked about the extra cushion in the recliner, Staff 5 stated she was unsure why the extra cushion was missing from the recliner. On 7/27/22 at 10:17 AM Staff 3 (RNCM) stated Resident 6 had a pressure ulcer on her/his buttocks and the wound was likely caused by the resident's frequent incontinence and increased sitting time in the recliner. Staff 3 stated pressure ulcer wounds were to be assessed weekly to determine if the wound was healing or worsening and to ensure the dressings and interventions were appropriate. Staff 3 stated weekly assessments were to include wound measurements, wound bed characteristics and presence of infection. Staff 3 stated if a wound worsened, the physician and family were to be notified. Resident 6's health record was reviewed with Staff 3. Staff 3 acknowledged there were no pressure ulcer wound assessments completed after 7/1/22, the resident's Care Plan did not identify the pressure ulcer and did not include resident-centered interventions related to the pressure ulcer. On 7/27/22 at 12:55 PM Staff 2 (DNS) stated Resident 6 had a pressure ulcer wound to her/his left buttocks, likely caused by pressure from sitting in the recliner. Staff 2 stated on 7/26/22, Staff 5 told her the wound was improved and getting better. When asked about Resident 6's wound interventions, Staff 2 stated an extra cushion was placed in the recliner after the pressure ulcer was identified. Staff 2 stated pressure ulcer wounds were to be assessed and measured weekly for healing or worsening and the findings were to be documented. When asked if Resident 6's wound was measured weekly, Staff 2 was unable to locate additional wound assessments or measurements completed after 7/1/22. Resident 6's Care Plan was reviewed with Staff 2 and she acknowledged the Care Plan did not accurately reflect Resident 6's wound status and did not include the extra cushion intervention. Staff 2 was notified regarding the absence of the extra recliner cushion in Resident 6's room and she was unable to find documentation regarding the lack of the cushion. Staff 2 was notified regarding Resident 6's lack of routine and timely incontinence care and repositioning and stated she expected residents to be repositioned every two hours.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice Care plan for resident # 6 has been reviewed and updated to include current interventions in the treatment of pressure ulcer. Weekly wound measurements have been added to the treatment record so they are completed per order. Address how the facility will identify other residents having the potential to be affected by the same deficient practice Residents with pressure ulcers have the potential to be affected by the same deficient practice. Weekly wound care documentation will be reviewed and addressed for all residents with skin issues. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur Education has been provided to nursing staff on prevention and treatment of pressure ulcers. Weekly wound care meeting started to review wound healing progress or lack of and to ensure wound records are complete. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Nursing will have weekly wound meetings results will be shared with the QAPI committee monthly then quarterly for the next two quarterly meetings. Include dates when corrective action will be completed DNS or designee is responsible for correction of deficiency

Based on observation, interview and record review it was determined the facility failed to follow physician orders for a urinary catheter for 1 of 1 sampled resident (#20) reviewed for urinary catheter. This placed residents at risk for adverse urinary catheter effects. Findings include: Resident 20 was admitted to the facility in 6/2018 with diagnoses including diabetes mellitus type 2. Resident 20's 6/11/18 Quarterly MDS indicated Resident 20 had an indwelling urinary catheter. Resident 20's 7/2022 physician orders included an order for an indwelling urinary catheter: size 16FR (size of the lumen inserted through the urethra into the bladder) with a 10cc (cubic centimeters) balloon (device used to anchor the lumen in the bladder). A 7/22/22 progress note written by Staff 13 (RN) revealed the following: "resident's foley was leaking. Old foley was pulled out and replaced with a new one with sterile technique. New foley's balloon inflated with 30 cc of [normal saline]. No leaks noted." The progress note lacked additional information regarding the size of the urinary catheter lumen. Resident 20's 7/2022 TAR revealed no documentation to indicate the catheter was changed or replaced with a catheter of the appropriate size. Observations of Resident 20 and her/his urinary catheter were conducted 7/25/22 through 7/27/22 between the hours of 8:31 AM and 3:50 PM. During these observations, Resident 20 was observed to have an indwelling urinary catheter. On 7/27/22 at 2:26 PM Resident 20's indwelling urinary catheter size was verified with Staff 5 (RN). The catheter size was observed to be 16FR/30cc and did not correlate with the physician's order. Staff 5 stated she referred to physician orders for directions and size related a resident's indwelling catheter. On 7/27/22 at 2:31 PM Staff 2 (DNS) stated nurses were to follow physician orders regarding all aspects of resident care. Staff 2 was notified of the findings of this investigation and was informed Resident 20's current indwelling urinary catheter did not correlate with the physician orders.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice Clarification orders received from MD on size and catheter lumen and balloon for resident #20. Cath changed to correct size without incident. Orders updated on TAR and care plan to reflect size. Address how the facility will identify other residents having the potential to be affected by the same deficient practice Residents with foley catheters have the potential to be affected by the same deficient practice. All residents with foley catheters have had a chart review to ensure care plan, order and actual foley catheter match. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur Education has been provided to nursing staff on importance of following MD orders. Nursing will perform random audit weekly x 3 weeks then monthly x 3 months to ensure Cath size order, care plan and actual foley in use match. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Audit results will be presented to the QAPI committee for the next two quarterly meetings. Include dates when corrective action will be completed DNS or delegee is responsible for correction of deficiency

Based on observation, interview and record review it was determined the facility failed to ensure appropriate indications for the use of antipsychotic medication for 1 or 1 (#12) sample resident reviewed for an unnecessary psychotropic medication. This placed residents at risk for unnecessary use of psychotropic medications and adverse side effects. Findings include: Resident 12 was admitted to the facility in 5/2021 with diagnoses including dementia and anxiety disorder. A 3/18/22 Health Status Note from Staff 4 (Social Service Director) revealed Staff 4 believed Resident 12 experienced "worrisome" thoughts which included hearing people talking about taking Resident 12 away. Staff 4 indicated Resident 12 identified her/his thoughts had become more intrusive. A 4/8/22 Health Status Note indicated Resident 12's PCP was contacted concerning Resident 12's suspected anxiety and delusions. Resident 12's PCP indicated an option of placing Resident 12 on low dose Risperidone, an antipsychotic prescribed to treat schizophrenia. Resident 12 declined receiving Risperidone. A 5/12/22 Progress Note indicated Staff 4 left a message for the resident's PCP to provide additional information to Resident 12's recent aggressive behaviors including "digging nails into staff" when attempting to redirect Resident 12's increased level of anxiety. A 5/12/22 Progress Note indicated Resident 12 returned from her/his PCP visit with a new order for Risperidone 0.25 mg once a day for delusional disorders. Resident 12's 5/2022 Annual MDS Assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating normal cognitive function. Resident 12's 5/2022 Annual Psychotropic CAA indicated Resident 12 received Risperidone for delusional disorder with care plan interventions including, medicate per MD order to assess effectiveness and for adverse side effects. Resident 12's 5/2022 care plan for psychotropic medications indicated the resident was on an antipsychotic with the goal of monitoring interventions which included: shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, dry mouth, depression, suicidal ideation, and social isolation. The resident's care plan further documented she/he had high anxiety and was care planned to receive once a week reassurance conversations with the facility's social worker. Resident 12's 6/2022 Behavior Monitoring Program assessment indicated the use of Risperidone 0.25 MG for delusional disorders with the goal of reducing Resident 12's anxiety. There was no evidence a comprehensive assessment was conducted prior to Resident 12 receiving an antipsychotic medication to rule out possible contributing factors that warranted the use of an antipsychotic. In addition, there was no assessment to show the facility's efforts in implementing alternative approaches including non-pharmacological approaches was performed prior to beginning the Risperidone. On 7/27/22 at 1:54 PM Staff 5 (RN) stated the primary use of the Risperidone was to "take off the edge of her/his anxiety a little bit" as Resident 12 experienced high anxiety. On 7/27/22 3:34 PM Staff 3 (RNCM) stated an anxiety assessment was performed on Resident 12 at a behavioral health assessment center, but the facility never received a report of the assessment which was the basis for Resident 12 receiving Risperidone. On 7/28/22 at 2:58 PM Staff 2 (DNS) stated Resident 12's PCP made the decision to place the resident on Risperidone. Staff 2 further indicated the behavioral health assessment center failed to complete an assessment to justify Resident 12's use of Risperidone.

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice Appropriate indications for the use of antipsychotic medications have been obtained for resident #12. Address how the facility will identify other residents having the potential to be affected by the same deficient practice Residents receiving antipsychotic medications have the potential to be affected by the same deficient practice. Residents who started antipsychotic medications after admit have had a chart review to ensure appropriate indications for use have been met. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur Education has been provided to staff on appropriate indications for use for antipsychotic medications prior to initiation of medication. Random audits will be complete by nursing on those starting antipsychotic medications after admit ensuring appropriate indications for use present. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Audit results will be presented to the QAPI committee for review monthly for the next three months then quarterly for the next two quarters. Include dates when corrective action will be completed DNS or delegee is responsible for correction of deficiency

******************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ******************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686, F690 and F758 ********************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/02/2022 and 05/08/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/21/2022 and 02/27/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

1.

Based on interview and record review it was determined the facility failed to ensure provision of education to residents or the residents' representatives regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine and failed to maintain accurate COVID-19 vaccination resident records for 4 of 5 sampled residents (#s 5, 8, 10 and 11) reviewed for COVID-19 vaccine immunization. This placed residents at risk for the COVID-19 virus and for a lack of information to make an informed decision related to COVID-19 vaccination. Findings include: The 5/11/21 Centers for Medicare & Medicaid Services (CMS) QSO-21-19-NH COVID-19 Vaccine Immunization Requirements for Residents and Staff directed facilities to do the following: -Before offering COVID-19 vaccine, each resident or the resident representative received education regarding the benefits and risks and potential side effects associated with the vaccine; -Maintain appropriate documentation to reflect the facility provided the required COVID-19 vaccine education; -The resident's medical record included documentation that indicates, at a minimum, the following: a) The resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine; b) Each dose of COVID-19 vaccine administered to the resident. Resident 5 was admitted to the facility in 8/2021 with diagnoses including orthopedic aftercare. Review of Resident 5's health record revealed no COVID-19 Vaccine Record Card. A 8/11/21 progress note written by Staff 16 (RN) revealed the following: "Offered COVID vaccine to resident several times. Declined." No evidence was found to indicate Resident 5 received education regarding risks, benefits, and side effects of the COVID-19 vaccine. On 9/2/21 at 1:51 PM Staff 2 acknowledged there was no evidence Resident 5 was provided with education regarding risks, benefits and side effects of the COVID-19 vaccine. Resident 8 was admitted to the facility in 12/2020 with diagnoses including ventricular tachycardia (abnormal, fast heart rate). Resident 8's COVID-19 Vaccination Record Card indicated the first dose of Moderna (a two-dose COVID-19 vaccination series) was administered on 4/22/21. No other documentation was found on Resident 8's COVID-19 Vaccine Record Card. Review of Resident 8's health record revealed no evidence of informed consent or that Resident 8 received education regarding risks, benefits, and side effects of the COVID-19 vaccine. There was no documentation found to indicate the recommended second dose of Moderna was offered or administered. On 9/2/21 at 1:34 PM Staff 2 (DNS) stated she believed Resident 8 received the Johnson & Johnson single dose COVID-19 vaccine. Resident 10 was admitted to the facility in 5/2021 with diagnoses including lung cancer. Review of Resident 10's health record revealed no COVID-19 Vaccine Record Card. A 5/21/21 progress note written by Staff 7 (RN) revealed the following: "Offered [COVID] vaccine today but declined at this time." No evidence was found to indicate Resident 10 received education regarding risks, benefits, and side effects of the COVID-19 vaccine. There was no documentation found to indicate Resident 10 was offered the COVID-19 vaccine again after 5/21/21. On 9/2/21 at 1:48 PM Staff 2 stated she thought Resident 10 received the COVID-19 vaccine and would need to look into it further. Staff 2 stated she was unsure Resident 10 was cognitively able to make the decision and the family needed to be contacted regarding the COVID-19 vaccine. Resident 11 was admitted to the facility in 3/2021 with diagnoses including benign neoplasm of meninges (brain tumor). Review of Resident 11's health record revealed no COVID-19 Vaccine Record Card. A 4/20/21 progress note written by Staff 2 revealed the following: "Resident offered COVID vaccine today. Declined [related to] not feeling well." A 8/11/21 progress note written by Staff 16 revealed the following: "Resident was offered a COVID vaccination but declined. Resident stated [she/he] heard on TV not to take the vaccine if a person "is at risk for a brain bleed" which [she/he] states [she/he] is due to [her/his] aneurysm. Resident asked if [she/he] could wait, however the vaccines were already mixed and could not be held. Resident was notified of this, explaining that vaccinations are only available at certain times due to how they have to be stored. Resident voiced understanding and declined the vaccination." No evidence was found to indicate Resident 11 received education regarding risks, benefits, and side effects of the COVID-19 vaccine On 9/2/21 at 1:55 PM Staff 2 stated Resident 11 refused the vaccine "several" times and confirmed there was no evidence Resident 11 was provided with education regarding risks, benefits, and side effects of the COVID-19 vaccine. On 9/7/21 at 11:01 AM Staff 1 (Administrator) was notified of the findings of this investigation. Staff 1 stated Resident 8 received the 1st dose of Moderna in the facility, was subsequently hospitalized two times and missed the 2nd dose of Moderna. Staff 1 stated Resident 8 received the Johnson & Johnson single dose COVID-19 vaccine while in the hospital. Staff 1 acknowledged Resident 8's records did not accurately reflect Resident 8's COVID-19 vaccine status and lacked the required informed consent and education regarding the COVID-19 vaccine. Staff 1 acknowledged there was no evidence in Resident 5's, Resident 10's and Resident 11's health records to indicate the residents received education regarding risks, benefits, and side effects of the COVID-19 vaccine and confirmed the facility lacked a system for documentation and provision of COVID-19 vaccine education. 2. Based on interview and record review it was determined the facility failed to develop policies and procedures associated with the provision, education, informed consent, refusal and documentation associated with the COVID-19 vaccine. This placed residents at risk for a lack of updated information regarding the COVID-19 vaccine. Findings include: The 5/11/21 Centers for Medicare & Medicaid Services (CMS) QSO-21-19-NH COVID-19 Vaccine Immunization Requirements for Residents and Staff directed facilities to develop policies and procedures to educate residents or resident representatives and staff regarding the benefits and potential side effects associated with the COVID-19 vaccine. Review of the facility's policies and procedures revealed no policy and procedure associated with the COVID-19 vaccine to include components of provision, education, informed consent, refusal and documentation. On 9/7/21 at 11:01 AM Staff 1 (Administrator) was notified of the findings of this investigation. No additional policies and procedures were provided.

F887 Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident 8 and 5 have discharged from the facility. Resident 10 and 11 have been provided with education regarding risk, benefits, and side effects of the COVID 19 vaccine and it has been noted in the resident’s record. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents are at risk for not receiving education regarding risk, benefits, and side effects of the COVID 19 vaccine. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On admit and as needed r/t vaccine status residents will be provided with education regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine. Proof of this will be in the resident’s medical record. Residents or representative will have the opportunity to accept or refuse a COVID-19 vaccine and change their decision. Policy and procedure associated with the COVID-19 vaccine to include components of provision, education, informed consent, refusal and documentation available. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Weekly audits will be complete X 4 weeks then monthly audits X 3 months, results will be reviewed in facility QAPI Include dates when corrective action will be completed. The DNS or delegate is responsible for ensuring compliance.

******************************** OAR 411- 086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F887

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/23/2021 and 08/29/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.