Cottage Grove Post Acute

Based on interview and record review it was determined the facility failed to notify the physician of the resident's discharge to the hospital for 1 of 1 sampled resident (#39)reviewed for hospitalizations. This placed residents at risk for delayed treatment. Findings include:

Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease
and kidney disease.

A 6/8/25 Progress Note indicated Resident 39 was sent to the hospital for nausea, diarrhea, general malaise, cold sweats, and dizziness.

A review of Resident 39's clinical record revealed no indication the resident's physician was notified.

On 6/25/25 at 11:44 AM, Staff 19 (Nurse Practitioner) stated she was not informed Resident 39 was sent to the hospital on 6/8/25.

On 6/26/25 at 1:20 PM, Staff 2 (DNS) acknowledged Resident 39's physician was not notified when the resident was sent to the hospital.

Based on observation, interview and record review it was determined the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for 1 of 2 sampled residents (#38) reviewed for personal property. This placed residents at risk of loss or theft of property. Findings include:

Resident 38 was admitted to the facility in 2/2025 with diagnoses including anxiety and reduced mobility.

A 2/13/25 admission MDS revealed Resident 38 was cognitively intact.

A 3/9/25 Grievance Concern Problem Identification and Follow-Up form indicated Resident 38 reported a concern with six packs of cigarettes missing. Steps taken revealed social services reviewed and discussed options for tracking cigarettes which came into the facility. Resident 38 did not want to store her/his cigarettes at the nurse's station because "many of the locks can be opened with any key." There was no evidence of the cigarettes, so the facility would not refund or replace the cigarettes for Resident 38. Social services would place an order for maintenance to investigate the lock issue. Administration review revealed there was no evidence of Resident 38's cigarettes existence.

On 6/23/25 at 9:06 AM, Resident 38 stated the facility's rule was to store residents' smoking materials in a locked box at the nurses' station. Residents kept a key, and staff opened the box when she/he wanted to smoke. Resident 38 stated the keys distributed to residents would open all the locked boxes. Resident 38 stated in 3/2025 she/he had six packs of cigarettes missing out of the locked boxes.

On 6/25/25 at 11:31 AM, Staff 13 (CNA) stated Resident 38 reported to her she/he was missing six packs of cigarettes from the lock box. Staff 13 assisted Resident 38 with the grievance form.

On 6/25/25 at 11:46 AM, Staff 14 (Social Services Assistant) stated the facility did not allow unsupervised smokers to keep their smoking materials in a lock box in their rooms. Residents were to bring their key to the nurses' station, and a staff member opened the lock box and gave residents their smoking materials and when they were done residents return their smoking materials to the nurses' station.

On 6/25/25 at 11:44 AM, and 12:06 PM, The drawer at the nurses' station was observed to have a lock on it. Staff 5 (MDS Coordinator) opened the drawer, which was not locked. A clear box with multiple sections was observed to have locks which opened upward. A key was in the drawer on top of the clear box. The key opened multiple boxes. Staff 1 (Administrator) stated the key was a master key if needed.

On 6/27/25 at 7:21 AM, Staff 1 (Administrator) stated she would expect for staff to keep the drawer locked where the cigarettes are stored. Staff 1 stated the facility continued to work on fixing the cigarette storage as it does not work.

Based on interview and record review it was determined the facility failed to ensure appropriate information was communicated to the receiving health care institution or provider prior to a resident being transferred to the hospital for 1 of 1 sampled resident (#39) reviewed for hospitalization. This placed the resident at risk for unassessed needs. Findings include:

Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease.

A 6/8/25 Progress Note indicated Resident 39 was sent to the hospital for nausea, diarrhea, general malaise, cold sweats, and dizziness.

No evidence was found in Resident 39's clinical record to indicate the facility provided the following prior to Resident 39 being transferred to the hospital:
-Contact information of the practitioner who was responsible for the care of the resident.
-Advance directive information.
-Medications (including when last received).

On 6/27/25 at 10:19 AM, Staff 2 (DNS) stated but she was unable to provide documentation to confirm the facility provided appropriate information to the receiving health care institution or provider prior to Resident 39's transport to the emergency department on 6/8/25.

Based on interview and record review it was determined the facility failed to complete timely MDS assessments for 4 of 8 sampled residents (#s 20, 21, 32, and 33) reviewed for MDS and unnecessary medications. This placed residents at risk for unassessed needs. Findings include:

1. Resident 20 was admitted to the facility in 1/2025 with diagnoses including reduced mobility and muscle wasting.

A review of Resident 20's clinical record revealed her/his Discharge Return Not Anticipated MDS assessment was "in progress" and overdue by nine days on 6/24/25.

On 6/26/25 at 9:59 AM, Staff 5 (MDS Coordinator) stated she was very busy for the last two to three weeks and was behind on her work and confirmed Resident 20's MDS was late.

On 6/27/25 at 7:15 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for staff was to have the MDSs completed timely.

2. Resident 21 was admitted to the facility in 7/2020 with diagnoses including kidney disease and heart failure.

A review of Resident 21's clinical record revealed her/his Annual MDS assessment was "in progress" and overdue by 13 days on 6/26/25.

On 6/26/25 at 9:59 AM, Staff 5 (MDS Coordinator) stated she was very busy for the last two to three weeks and was behind on her work and confirmed Resident 21's MDS was late.

On 6/27/25 at 7:15 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for staff was to have the MDSs completed timely.

, 3. Resident 32 was admitted to the facility in 12/2024 with diagnoses including Multiple Sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord).

A review of Resident 32's clinical record revealed an 4/5/25 Quarterly MDS completed on 4/21/25.

On 6/26/25 at 10:05 AM, Staff 5 (LPN MDS Coordinator) stated Resident 32's 4/5/25 Quarterly MDS was completed on 4/21/25. Staff 5 acknowledged the 4/5/25 Quarterly MDS was completed late and should have been completed by 4/18/25.

4. Resident 33 was admitted to the facility in 2/2023 with diagnoses including schizoaffective disorder (a mental illness characterized by a combination of psychotic symptoms, similar to schizophrenia, and mood disorder symptoms, like mania or depression).

a. A review of Resident 33's clinical record revealed a 2/20/25 Annual MDS completed on 3/24/25.

On 6/26/25 at 10:05 AM, Staff 5 (LPN MDS Coordinator) stated Resident 33's 2/20/25 Annual MDS was completed on 3/24/25. Staff 5 acknowledged the 2/20/25 Annual MDS was completed late and should have been completed by 3/5/25.

b. A review of Resident 33's clinical record revealed a 5/23/25 Quarterly MDS completed on 6/9/25.

On 6/26/25 at 10:05 AM, Staff 5 (LPN MDS Coordinator) stated Resident 33's 5/23/25 Quarterly MDS was completed on 6/9/25. Staff 5 acknowledged the 5/23/25 Quarterly MDS was completed late and should have been completed on 6/5/25.

Based on interview and record review it was determined the facility failed to complete a Significant Change MDS assessment (SCSA) within the required 14 days after a determination of a significant change of condition of a resident for 1 of 1 sampled resident (#39) reviewed for hospitalizations. This placed residents at risk for unassessed care needs. Findings include:

Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease.

Resident 39's 4/14/25 Quarterly MDS indicated the resident was cognitively intact and was on hospice.

On 6/25/25 at 10:11 AM, Staff 5 (LPN/MDS Coordinator) confirmed Resident 39 graduated from hospice on 5/30/25. Staff 5 stated she did not discuss this with Resident 39 and acknowledged she did not complete a SCSA.

On 6/26/25 at 1:20 PM, Staff 2 (DNS) confirmed Resident 39 was discharged from hospice on 5/30/25 and acknowledged the facility failed to complete a SCSA for Resident 39.

Based on observation, interview, and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 1 sampled resident (#32) reviewed for pressure ulcers. This placed residents at risk for unmet wound care needs. Findings include:

Resident 32 was admitted to the facility in 12/2024 with diagnoses including Multiple Sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord).

A review of a 1/1/25 Skin & Wound Evaluation revealed Resident 32 was admitted with a Stage 3 pressure ulcer wound (a full-thickness skin loss, where the wound extends through the skin and into the fat tissue).

A 6/24/25 review of Resident 32's care plan revealed no evidence of a baseline care plan for her/his Stage 3 pressure ulcer wound.

On 6/24/25 at 2:38 PM, an observation of Resident 32's wound revealed a wound consistent with a Stage 3 pressure ulcer wound.

On 6/26/25 at 12:43 PM, Staff 3 (LPN Care Manager) stated when a resident was admitted with a pressure ulcer wound, a care plan focused on current wound(s), with a goal and interventions geared towards wound care and healing must be initiated upon admission. Staff 3 stated Resident 32 was admitted with a Stage 3 pressure ulcer wound and she acknowledged Resident 32 did not have a baseline care plan for her/his pressure ulcer wound.

On 6/27/25 at 8:34 AM, Staff 2 (DNS) stated MDS assessments must be completed timely.

2. Resident 38 was admitted to the facility in 2/2025 with a diagnoses including hypertensive heart disease with heart failure (a condition where the heart cannot pump blood effectively).

Physician orders with a start date of 3/15/25 instructed staff to obtain Resident 38's weight every day shift on Saturdays for weight monitoring.

A review of Resident 38's weights report revealed from 3/29/25 through 6/2/25, Resident 38's weight was documented on the report as obtained out of 12 times physician ordered.

The 5/2025 TAR instructed staff to obtain weekly weights every day shift every Saturday for weight monitoring with a start date of 3/15/25. The TAR was documented as "NA" three times, a weight of 172 one time, and a code six one time. There was no legend for what "NA" was defined as. Code six was indicated as "glucose."

Physician orders with a start date 6/20/25 instructed staff to obtain Resident 38's weight every day shift for cardiac monitoring.

The 6/2025 TAR instructed staff to obtain weekly weights every day shift every Saturday for weight monitoring. The TAR was documented as "NA" three times and a weight of 171 one time.

The 6/2025 TAR instructed staff to obtain daily weights every day shift for cardiac monitoring with a start date of 6/20/25. From 6/20/25 through 6/24/25, there were checks documented three times with no weights documented and the code of two documented twice, which indicated Resident 38 refused to have her/his weight obtained.

A 6/23/25 Progress Note revealed to obtain a daily weight every day shift for cardiac monitoring. No documentation of Resident 38's weight was recorded on the note.

On 6/26/25 at 8:39 AM, Staff 12 (Agency LPN) stated she documented weights on the TAR or under vitals in resident's clinical record. Staff 12 stated she did not "recall" that she documented "NA" on the TAR for Resident 38's weights. If a resident refused to have weight obtained, she would typically not document "NA."

On 6/27/25 at 7:20 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation of staff would be to complete physician ordered weights and document weights or refusals of weights in the resident's clinical record.




, Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 7 sampled residents (#s 33 and 38) reviewed for medication and pain medications. This placed residents at risk for adverse side effects and unmet needs. Findings include:

1. Resident 33 was admitted to the facility in 2/2023 with diagnoses including schizoaffective disorder (a mental illness characterized by a combination of psychotic symptoms, similar to schizophrenia, and mood disorder symptoms, like mania or depression).

Review of Resident 33's Physician Orders revealed an 4/5/25 order for Austedo 12 mg twice a day prescribed to treat drug induced dyskinesia (a movement disorder characterized by involuntary, repetitive, and sometimes jerky or writhing movements, often triggered by certain medications).

The 5/2025 MAR revealed Resident 33 did not receive Austedo on the following days:
-5/12/25 AM dose.
-5/13/24 AM and PM doses.
-5/14/25 AM and PM doses.
-5/15/25 AM dose.

Review of Medication Administration Notes between 5/12/25 and 5/15/25 revealed Resident 33 was out of Austedo, and the pharmacy was contacted on 5/14/25.

A 6/25/25 review of the 6/2025 MAR revealed Resident 33 did not receive Austedo on the following days:
-6/14/25 PM dose.
-6/15/25 PM dose.
-6/16/25 PM dose.
-6/17/25 AM dose.
-6/18/25 through 6/24/25 AM and PM doses.

A review of Medication Administration Notes between 6/14/25 and 6/24/25 revealed Resident 33 was out of Austedo, and the pharmacy was contacted on 6/17/25.

A 6/17/25 Medication Administration Note revealed Resident 33 stated she/he could feel the effects of not taking the Austedo.

A 6/20/25 Medication Administration Note revealed Resident 33's PCP was notified of the missing doses of Austedo.

A 6/25/25 Progress Note revealed Resident 33's PCP was informed of the missing doses of Austedo, and the orders were received to hold the Austedo until the medication was delivered from the pharmacy.

On 6/26/25 at 10:51 AM, Staff 2 (DNS) stated Resident 33's medication Austedo was not available from 5/12/25 until the PM dose on 5/15/25 and there was no documentation the PCP was notified. Staff 2 stated Resident 33's Austedo was not available from 6/14/25 until 6/25/25 and stated the PCP was notified on 6/20/25. Staff 2 stated her expectation was to order medications a week prior to running out of the medication so residents did not run out of medication. Staff 2 stated the PCP should be notified as soon as Resident 33's medication was not available.

Based on observation, interview, and record review it was determined the facility failed to provide appropriate pain management for 2 of 2 sampled residents (#s 33 and 39) reviewed for pain management. This failure resulted in Resident 39 not receiving her/his scheduled narcotic pain medications for three days which caused the resident to suffer from narcotic withdrawal, increased pain, and an avoidable hospitalization. This placed residents at risk for narcotic withdrawal and increased pain. Findings include:

1. Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease.

Resident 39's 4/14/25 Quarterly MDS indicated the resident was cognitively intact. Resident 39 received scheduled pain medication and PRN pain medications. Resident 39 had frequent pain, which occasionally affected her/his sleep and ADLs. On 4/23/25 Resident 39 was admitted to hospice.

On 6/23/25 at 11:25 AM, and 6/27/25 at 9:15 AM, Resident 39 stated two weeks ago, the facility ran out of her/his prescribed morphine. Resident 39 reported being informed by multiple staff members her/his medication had not been reordered. As a result, she/he went several days without receiving her/his pain medication. Resident 39 stated she/he had been taking morphine for an extended period of time and believed she/he should have been gradually titrated off the medication, rather than cut off. Resident 39 reported experiencing nausea, vomiting, and diarrhea, which led to her/him being sent to the hospital. When asked about her/his pain level when the medication was not available she/he stated "The pain I can take, it was the diarrhea that I could not tolerate." The resident indicated her/his pain was unmanaged and she/he was also concerned about her/his blood sugars being all over the place.

A 4/23/25 Hospice Physician Order instructed staff to administer morphine sulfate (narcotic pain medication) 0.75 ml three times a day for pain and give 0.75 ml every hour PRN for pain and shortness of breath.

Review of a 6/8/25 Progress Note indicated Resident 39 experienced symptoms of opiod withdrawl including: elevated blood pressure, nausea, diarrhea, general malaise, cold sweats, and dizziness. Staff reported the facility ran out of Resident 39's prescribed morphine on 6/7/25 in the morning and were unable to administer the resident's pain medication. Resident 39 experienced symptoms consistent with opioid withdrawal. Staff called the on-call provider to request a medication refill, but they did not respond. Resident 39 was transferred to the hospital for further evaluation and treatment.

A 6/2025 MAR revealed the following:
-morphine was not administered on 6/7/25 at 3:00 PM and 11:00 PM.
-morphine was not administered on 6/8/25 at 700 AM, 3:00 PM, and 11:00 PM.
-hydralazine 25 mg was administered on 6/8/25 for elevated blood pressure.
-morphine was not administered on 6/9/20 at 7:00 AM, and 3:00 PM.

A 6/8/25 Emergency Department Provider Note indicated Resident 39 admitted to the emergency department with fatigue, nausea, vomiting, diarrhea, cold chills and sweats. Resident 39 stated her/his symptoms had been ongoing for the last 24 hours. Resident 39 stated she/he took morphine due to pain related to lower extremity amputations. The resident stated the nursing facility ran out of her/his morphine two days ago. Resident 39's nurse called and confirmed the situation. It appeared "completely feasible" that the resident was experiencing opioid withdrawals since the last dose was approximately 48 hours prior. Resident 39 was provided an order for oxycodone 5 mg because the facility did not have morphine available.

A 6/8/25 Progress Note indicated Resident 39 returned from the hospital with an order for oxycodone 5 mg to be administered every four hours PRN for pain.

Resident 39's Pain Level Summary indicated the following on 6/9/25:
-12:55 AM, pain level 8/10.
-9:45 AM, pain level 8/10.
-12:13 PM, pain level 6/10.
-3:56 PM, pain level 9/10.
-11:22 PM, pain level 3/10.

On 6/24/25 at 3:50 PM, Staff 20 (LPN) stated the facility ran out of resident 39's morphine on 6/7/25. She informed the oncoming nurse and assumed the refill would be requested. The next day, she noticed the medication was not reordered and believed the resident was experiencing opioid withdrawal symptoms, including cold sweats, elevated blood pressure, and elevated blood sugar levels. Staff 20 reported leaving three messages for the on-call provider, but did not receive a response. She stated it was typical for the on-call provider not to respond to messages. Staff 20 stated the morphine was typically stocked in the back up medication stock, but administration required approval, which she described as difficult to obtain. Staff 20 added that on 6/8/25 she contacted the hospital, informed them the facility was out of Resident 39's morphine and asked if they could write a short-term prescription.

On 6/24/25 at 4:13 PM, Staff 22 (LPN) stated 6/6/25, was when she first noticed Resident 39 was running low on her/his morphine. She reported that no specific staff member was designated to re-order medications and the facility frequently ran out of medications over the weekend. On 6/7/25 during shift change Staff 22 was informed Resident 39 experienced symptoms consistent with opioid withdrawal and was transferred to the hospital. Upon the resident's return, Staff 22 noted the resident was prescribed oxycodone, but not morphine. She stated Resident 39 appeared withdrawn and was not at her/his baseline. Staff 22 further stated the resident's medication was not refilled in a timely manner and acknowledged that "it just fell through the cracks."

On 6/25/25 at 2:45 PM, Staff 25 (Prescribing Technician) confirmed the facility called the pharmacy on 6/8/25 to request a refill of Resident 39's morphine prescription.

On 6/25/25 at 3:18 PM, Staff 23 (Prescribing Technician) and Staff 21 (Pharmacist) stated on 6/9/25 at 8:17 AM, the facility requested a refill for Resident 39's morphine and the medication was delivered to the facility the evening of 6/9/25.

On 6/26/25 at 1:20 PM, Staff 2 (DNS) and Staff 24 (Regional Nurse Consultant) reviewed Resident 39's 6/2025 MAR and narcotic log. Staff 2 and Staff 24 confirmed the facility failed to administer seven doses of resident 39's morphine. Documentation indicated the medication was unavailable or not administered. Staff 2 stated the facility's expectation was for nurses to follow the established medication reordering process. Staff 2 acknowledged multiple staff failed to reorder Resident 39's medication in a timely manner. Staff 2 acknowledged Resident 39's hospitalization could have been avoided if the facility had provided timely pain management. Staff 2 confirmed the facility had ongoing issues with communication from the on-call provider and this caused a delay in residents obtaining medication refills.
, 2. Resident 33 was admitted to the facility in 11/2023 with diagnoses including polyosteoarthritis (osteoarthritis that affects five or more joints in the body simultaneously).

A public complaint was received on 3/25/25 which alleged Resident 33 did not receive her/his scheduled pain medication from 3/21/25 through 3/23/25.

A review of Physician Orders revealed a 2/22/24 order for Lyrica (a pain medication) twice a day in the morning and in the evening.

The 2/2025 MAR revealed Resident 33 did not receive Lyrica starting 3/21/25 evening dose through 3/24/25 morning dose.

Medication Administration Notes from 3/21/25 through 3/24/25 revealed Resident 33 was out of Lyrica.

A 3/23/25 Progress Note revealed Resident 33 needed a new script for Lyrica and an order refill request was placed in the provider's binder on 3/23/25.

A review of the pain monitor from 3/21/25 through 3/24/25 revealed Resident 33's pain level varied from 0/10 to 10/10.

A review of the 3/2025 CNA Pain Task documentation revealed Resident 33 experienced pain from 3/21/25 through 3/24/25 which was unchanged with non-pharmacological interventions.

On 6/23/25 at 8:23 AM, Resident 33 stated she/he had constant pain in her/his shoulders and lower back. Resident 33 stated the facility ran out of her/his medications often and she/he would go without pain medications until the pharmacy delivered the pain medications. Resident 33 stated without pain medications, her/his pain level gets to 10/10.

On 6/25/25 at 1:39 PM, Staff 17 (LPN) stated medications should be ordered when there was a week left so the resident did not run out of medications. Staff 17 stated the facility did not always have an effective system for ordering medications.

On 6/26/25 at 10:51 AM, Staff 2 (DNS) stated Resident 33's Lyrica was not available starting the evening dose on 3/21/25 through the morning dose on 3/24/25. Staff 2 stated during this time Resident 33's pain level got up to 9-10/10 but no new orders for pain control were obtained and Resident 33's as needed Tylenol was not administered. Staff 2 stated the CNA task documentation showed non-pharmacological pain control interventions were tried including distraction, repositioning, and rest, but the non-pharmacological pain interventions were not effective. Staff 2 stated her expectation would be the nurse should call the provider for a temporary order in the interim until the Lyrica arrived.

Based on observation, interview, and record review it was determined the facility failed to provide palatable food to 1 of 1 kitchen and 2 of 4 (#s 4 and 33) residents reviewed for food and kitchen tasks. This placed residents at risk for weight loss and reduced quality of life. Findings include:

1. A review of the 6/25/25 lunch menu revealed the facility was to provide: spaghetti with meatballs, herb green beans, and garlic bread sticks.

On 6/25/25 at 11:44 AM kitchen meal service was observed. Pasta, meat sauce, garlic bread sticks, and green beans were observed to be served from the steam table. Pasta was observed to be served with tongs, appeared overcooked, and broke apart as it was served. A test tray was requested.

On 6/25/25 at 12:22 PM, the test tray was sampled:
-herb green beans tasted metallic and were bland.
-garlic bread stick was doughy with no garlic flavor.
-spaghetti noodles were mushy, soft, and overcooked.
-meat sauce was flavorful but the meatball had no flavor.

On 6/25/25 at 12:29 PM, Staff 9 (Dietary Manager) was asked to test the meal. Staff 9 stated the pasta was soft, the herb green beans did not taste like "anything," the garlic bread stick had no garlic flavor and may have softened while it sat in the steam table.

On 6/25/25 at 2:33 PM, Staff 1 (Administrator) stated she would not want to have overcooked pasta to be an everyday occurrence but she has eaten the pasta and generally liked it. Staff 1 stated she expected herb green beans to be herb, would expect the garlic bread to have garlic on it.

, 2. Resident 4 was admitted to the facility in 10/2024 with diagnoses including quadriplegia (paralysis of all four limbs).

On 6/23/25 at 9:09 AM, Resident 4 stated she/he did not care for the food; the vegetables were overcooked and bland with no flavor.

On 6/25/25 at 12:22 PM, the test tray was sampled:
-herb green beans tasted metallic and were bland.
-garlic bread stick was doughy with no garlic flavor.
-spaghetti noodles were mushy, soft, and overcooked.
-meat sauce was flavorful but the meatball had no flavor.

On 6/25/25 at 12:29 PM, Staff 9 (Dietary Manager) was asked to test the meal. Staff 9 stated the pasta was soft, the herb green beans did not taste like "anything," the garlic bread stick had no garlic flavor and may have softened while it sat in the steam table.

3. Resident 33 was admitted to the facility in 2/2023 with diagnoses including depression.

On 6/23/25 at 8:17 AM, and 6/26/25 at 9:44 AM, Resident 33 stated the food was "terrible", cold, and sometimes the meat was too tough. Resident 33 stated she/he had the spaghetti for lunch on 6/25/25. Resident 33 stated the spaghetti, and the meatball did not taste good, were bland, and needed onions or some seasoning added.

On 6/25/25 at 12:22 PM, the test tray was sampled:
-herb green beans tasted metallic and were bland.
-garlic bread stick was doughy with no garlic flavor.
-spaghetti noodles were mushy, soft, and overcooked.
-meat sauce was flavorful but the meatball had no flavor.

On 6/25/25 at 12:29 PM, Staff 9 (Dietary Manager) was asked to test the meal. Staff 9 stated the pasta was soft, the herb green beans did not taste like "anything," the garlic bread stick had no garlic flavor and may have softened while it sat in the steam table.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 3 halls (West Hall) and 1 of 1 sampled resident (#28) during random observations. This placed residents at risk for exposure and contraction of infectious diseases. Findings include:

1. On 6/24/25 at 10:19 AM, Resident 44 was observed touching multiple items in the PPE cart located outside Room 12 for approximately five minutes. The resident opened multiple drawers and made contact with a facemask, N95 mask, and a stethoscope. Staff 28 (CNA) was standing behind the resident during this time and did not redirect the resident or sanitize the PPE cart following the interaction.

On 6/24/25 at 10:26 AM, Staff 14 (LPN) asked Staff 28 to not let Resident 44 touch items in the PPE supplies. Staff 28 then re-directed Resident 44 away from the PPE cart. Staff 14 acknowledged the incident did not align with infection control protocol.

On 6/26/25 at 11:43 AM, Staff 26 (RN/Infection Preventionist) acknowledged Resident 44 touching items in PPE cart and staff not sanitizing the carts afterwards was not in alignment with infection control best practice.

2. On 6/24/25 at 10:33 AM, an ice chest and water pitcher were observed on a cart on the West Hall, positioned near a room under enhanced barrier precautions. The ice scoop was sitting in an uncovered container. On the lower shelf of the cart, there were two boxes of gloves, a box of straws, and an empty cup containing a white liquid substance.

On 6/24/25 at 10:38 AM, Staff 27 (CNA) stated many residents pass by the water pitcher cart and it was difficult to ensure they did not place dirty items on the cart. Staff 27 acknowledged the presence of a soiled cup on the water pitcher cart and the uncovered ice scoop. Staff 27 stated it was a challenge to ensure residents did not place items on the cart throughout the day.

On 6/25/25 at 9:02 AM, a water pitcher with an uncovered ice scoop was observed on a cart on the West Hall, positioned near a room under EBP.

On 6/26/25 at 11:43 AM, Staff 26 (RN/Infection Preventionist) acknowledged the presence of dirty items sitting next to a clean water pitcher used to serve residents were not in alignment with infection control best practice.

3. Resident 28 was admitted to the facility in 5/2022 with diagnoses including heart failure and kidney disease.

A 5/29/25 Physician order instructed staff to clean Resident 28's right heel and cover with foam dressing daily.

A 6/9/25 Physician order instructed staff to provide wound care twice a day to Resident 28's buttocks.

On 6/24/25 at 10:40 AM, No PPE signage was observed outside Resident 28's room. Multiple staff were observed to enter Resident 28's room to provide personal care without donning PPE.

On 6/24/25 at 10:40 AM, Staff 12 (Agency LPN) confirmed Resident 28 had open wounds and she had just completed her/his wound care. Staff 29 (CNA) and Staff 30 (CNA) assisted her with Resident 28's dressing change. Staff 12 stated she was not aware the resident was supposed to be on EBP(enhanced barrier precautions). Staff 12 confirmed no signage was posted outside the resident's door. Staff 12 further added any nurse could post EBP signage.

On 6/24/25 at 11:03 AM, Staff 29 stated she was not really sure when a resident should be on precautions because the facility did not always update resident care plans. Staff 29 stated the facility did not always post signage to indicate what kind of precautions residents were on. Staff 29 confirmed she did not wear PPE when assisting with wound care.

On 6/24/25 at 11:06 AM, Staff 26 (RN/Infection Preventionist) observed Staff 12, Staff 29, and Staff 30 exiting Resident 28's room. Staff 26 stated Resident 28 should have enhanced barrier precautions signage posted due to Resident 28 having open wounds, but the signage was not posted. Staff 26 also observed Staff 12, Staff 29, and Staff 30 exiting Resident 28's room and confirmed they were not wearing PPE during wound care. Staff 26 acknowledged infection control measures were not followed.

On 6/25/25 at 8:51 AM, Staff 12 stated she was not aware she needed to wear PPE before providing direct care to residents on enhanced barrier precautions.

***************************************
OAR 411-086-0130 Nursing Services: Notification

Refer to F580
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OAR 411-087-0100 Physical Environment

Refer to F584
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OAR 411-088-0080 Notice Requirements

Refer to F628
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OAR 411-86-060 Comprehensive Assessment and Care Plan

Refer to F636, F637, and F655
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684 and F697
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OAR 411-086-0250 Dietary Services

Refer to F804
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OAR 411-86-330 Infection Control and Universal Precautions

Refer to F880
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Based on interview and record review it was determined the facility failed to ensure resident pain medication was not misappropriated for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for increased pain. Findings include:

Resident 3 was admitted October 2024 with diagnoses including a leg fracture.

Review of a facility's policy Ordering and Receiving Controlled Medications dated 1/2023 revealed the facility must document and verify the quantity of controlled substances received.

Review of a pharmacy medication receipt dated 9/26/24 revealed three cards of narcotic medication was delivered to the facility including medication for Resident 3. The receipt was initialed by Staff 3 (LPN).

Review of the Facility Reported Incident Form (FRI) dated 9/26/24 revealed a medication card of narcotics (oxycodone 10 mg 14 tablets) for Resident 3 was missing. The form indicated the resident did not miss any doses of pain medication, the facility was searched and law enforcement was notified.

Review of the Facility Reportable Incident (investigation) form dated 9/27/24 revealed on 9/26/24 between 10 PM and 10:30 PM the facility received narcotic medication for several residents including Resident 3 all in one package. The medications were received by Staff 4 (LPN) who did not check the contents of the package. At 2:45 AM Staff 3 notified the administrator Resident 3's pain medication card of 14 tablets of oxycodone was missing. The investigation also indicated the medications were not located in the building and the facility could not substantiate or unsubstantiated misappropriation at the time.

In an interview on 10/15/24 at 7:30 AM Staff 4 said on 9/26/24 pharmacy delivered some narcotic medications around 10-10:30 PM. Staff 4 said the facility received three cards of narcotics and one card was for Resident 3. Staff 4 said she double checked the package to make sure all the medications were there and placed the package behind the nursing station visible to anyone. Staff 4 said Staff 3 was administering medications to residents that night and Staff 3 was on break when the medications arrived. Staff 4 said she did not have direct observation of the package of medications from the time they arrived to 2:45 AM. Staff 4 said she told Staff 3 pain medications were delivered around 2:45 AM, and said Staff 3 had informed her Resident 3's pain medications were missing.

In an interview on 10/15/24 at 9:50 AM Staff 3 said on 9/26/24 the pharmacy delivered a package of narcotic medications while she was on break from 11:00 PM to 11:20 PM. Some time between 11:30 PM and 12 AM, Staff 3 noticed a package of medications on a computer at the nurse's station. Staff 3 said she checked the medications and found Resident 3's card of oxycodone was missing. Staff 3 said no one had told her the medications were delivered.

In an interview on 10/16/24 9:00 AM Staff 1 acknowledged facility policy was not followed by staff regarding Resident 3's medication and the medication was misappropriated.

On 9/27/24, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was misappropriation of pain medications. The Plan of Correction included: 1. Staff educated on policy and procedures of pharmaceutical receipt, documentation and storage, 2. Auditing procedure and verification processes by DON and Administrator, and 3. Monthly review of receipt and storage of medications and audits to be performed daily for three weeks, weekly for three weeks and then monthly.

Based on interview and record review it was determined the facility failed to store narcotic pain medications in a safe manner. This placed residents at risk for misappropriation of medications. Findings include:

Review of the facility's Controlled Medication Storage policy dated 1/2024 revealed narcotic pain medication must be maintained in separately locked permanently affixed compartments.

Review of a pharmacy medication receipt dated 9/26/24 revealed three cards of narcotic medication was delivered to the facility and receipt was initialed by Staff 3 (LPN).

Review of the Facility Reported Incident Form (FRI) dated 9/26/24 revealed a medication card of narcotics (oxycodone 10 mg 14 tablets) for Resident 3 was missing. The form indicated the resident did not miss any doses of pain medication, the facility was searched and law enforcement was notified.

Review of the Facility Reportable Incident (investigation) form dated 9/27/24 revealed on 9/26/24 between 10 PM and 10:30 PM the facility received narcotic medication for several residents all in one package. The medications were received by Staff 4 (LPN) who did not check the contents of the package and placed the package behind the nursing station. At 2:45 AM Staff 3 notified the administrator Resident 3's pain medication card of 14 tablets of oxycodone was missing.

In an interview on 10/15/24 at 7:30 AM Staff 4 said on 9/26/24 pharmacy delivered some narcotic medications around 10-10:30 PM. Staff 4 said the facility received three cards of narcotics. Staff 4 said she double checked the package to make sure all the medications were there and placed the package behind the nursing station visible to anyone. Staff 4 said she did not have direct observation of the package of medications from the time they arrived at 2:45 AM.

In an interview on 10/15/24 at 9:50 AM Staff 3 said on 9/26/24 the pharmacy delivered a package of narcotic medications while she was on break from 11:00 PM to 11:20 PM. Some time between 11:30 PM and 12 AM Staff 3 noticed a package of medications sitting on a computer at the nurse's station.

In an interview on 10/16/24 9:00 AM Staff 1 acknowledged facility policy was not followed by staff regarding safe storage of narcotic medications.

On 9/27/24, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was improper storage of narcotic pain medications. The Plan of Correction included: 1. Staff educated on policy and procedures of pharmaceutical receipt, documentation and storage, 2. Auditing procedure and verification processes by DON and Administrator, and 3. Monthly review of receipt and storage of medications and audits to be performed daily for three weeks, weekly for three weeks and then monthly.

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OAR 411-085-0360 Abuse

Refer to F602
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OAR 411-086-0260 Pharmaceutical Services

Refer to F761
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Based on interview and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 2 sampled residents (#253) reviewed for respiratory care. This placed residents at risk for unmet needs. Findings include:

Resident 253 admitted to the facility in 2024 with diagnoses including respiratory failure and sleep apnea (repeat lapses of breathing during sleep).

The 2/22/24 hospital Discharge Orders indicated Resident 253's oxygen levels were to be titrated (continuously measured and adjusted) to maintain oxygen saturations above 92 percent.

A 2/23/24 progress note indicated Resident 253 required continuous supplemental oxygen during the day.

The 2/23/24 baseline care plan had no information related to Resident 253's respiratory needs or equipment.

On 3/6/24 at 3:23 PM Staff 27 (LPN) stated after the initial nursing assessment was completed a unit manager was to ensure the care plan was accurate.

On 3/6/24 at 4:00 PM Staff 16 (LPN-Resident Care Manager) stated she was not aware Resident 253 required continuous oxygen. Staff 16 acknowledged the information related to the needed respiratory care and equipment for Resident 253 was not included in her/his baseline care plan.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received assistance with nail care for 2 of 5 sampled residents (#s 15 and 18) reviewed for ADLs. This placed residents at risk for poor hygiene and unmet needs. Findings include:

1. Resident 18 admitted 2022 with diagnoses including diabetes and depression.

A physician's order dated 2/7/23 directed licensed nurses to check the resident's finger and toe nails once a week on bath days and trim as needed every Tuesday evening. Staff were to document a "+" if nails were trimmed and a "-" if nails were not trimmed.

Resident 18's Comprehensive Care Plan revised 2/28/24 indicated the resident often declined nail care and staff were to "encourage" the resident to receive nail care.

According to Resident 18's 2/2024 LN Task Report she/he was scheduled for nail care on 2/6/24, 2/13/24, 2/20/24, and 2/27/24. There was no documentation on any of these days to indicate nail care was completed or refused.

On 3/4/24 at 1:54 PM Resident 18 was observed to have very long finger nails on both hands. Resident 18 stated she/he had not asked staff to trim them.

The resident was scheduled for a bath/shower on 3/5/24.

On 3/6/24 at 11:37 AM Staff 11 (CNA) stated Resident 18 was diabetic so only licensed nurses trimmed Resident 18's nails on the resident's bath days. Staff 11 stated the resident refused a shower on 3/5/24 but allowed a partial bed bath. Staff 11 stated the resident was in need of a nail trim and confirmed nail care was not provided by the nurse.

On 3/7/24 at 9:21 AM Staff 27 (LPN) confirmed she did not provide nail care to Resident 18.

On 3/7/24 at 12:56 PM Staff 15 (RNCM) and Staff 16 (LPN Resident Care Manager) confirmed Resident 18 needed nail care and there were no recent documented refusals.

, 2. Resident 15 admitted to the facility in 2022 with diagnoses including dementia.

An 4/24/23 care plan indicated Resident 15 had an ADL self-care performance deficit, and staff were to check nail length and clean on bath days and as necessary.

A 12/23/23 Annual MDS indicated Resident 15 was dependent for personal hygiene.

A 3/2024 Documentation Survey Report revealed Resident 15 was bathed on 3/1/24 and 3/5/24.

On 3/4/24 at 1:26 PM and 3/7/24 at 8:56 AM Resident 15's thumb nails were both approximately an inch long and other nails on her/his hands approximately half inch long with brown debris under the right ring finger and both left and right index fingers. On 3/7/24 Resident 15 also had a reddish tinge on top of multiple fingers around the fingernails.

On 3/7/24 at 8:52 AM Staff 1 (Administrator) indicated she would review and provide additional information.

On 3/7/24 at 10:17 AM Staff 3 (CNA) stated when bathing Resident 15 she cleaned under her/his toenails and fingernails but did not trim Resident 15's nails because she/he was diabetic and the nurses were required to trim diabetic residents' nails.

No diagnosis of diabetes was found in Resident 15's clinical record. No additional information was provided.

Based on interview and record review it was determined the facility failed to follow a physician's order for daily weights for 1 of 2 residents (#14) reviewed for respiratory care. This placed residents at risk for delay in treatment. Findings include:

Resident 14 admitted to the facility in 2021 with diagnoses including congestive heart failure (CHF), chronic respiratory failure and chronic obstructive pulmonary disease (COPD).

According to the resident's medical record she/he was hospitalized for respiratory problems and/or CHF on 11/19/23, 12/7/23, 1/16/24, and 2/21/24.

Re-admission orders dated 2/25/24 directed the facility to obtain "daily weights x 4 weeks for CHF." The order did not include parameters for physician notification, however the facility had standing orders from the medical director indicating if daily weights were obtained related to a diagnosis of CHF the physician was to be notified for weight gain greater than two pounds in 24 hours, three pounds in 72 hours or greater than five pounds in one week. There was no documented evidence the order was clarified to determine if the parameters for notification should be added.

Review of the resident's weight records revealed the following documented weights:

3/7/2024 11:09  
200.0 Lbs       
Mechanical Lift 

3/6/2024 07:37  
195.0 Lbs       
Mechanical Lift 
        

3/5/2024 08:58  
208.0 Lbs       
Mechanical Lift 

3/3/2024 13:38  
198.0 Lbs       
Mechanical Lift 

3/2/2024 16:57  
201.0 Lbs       
Mechanical Lift 
        

2/27/2024 13:34 
202.0 Lbs      
Mechanical Lift
2/25/2024 17:51 
203.0 Lbs      
Mechanical Lift

The directive for daily weights was on the TAR for licensed nurse acknowledgment. The resident's 2/2024 and 3/2024 TAR indicated to "see progress notes" for 2/26/24, 2/29/24, 3/3/24, and 3/4/24, however no corresponding progress notes were found in the record for those dates. The weight record was blank for 2/28/24 and 3/1/24.

On 3/6/24 at 2:46 PM Staff 29 (CNA) stated CNAs referred to POC (Point of Care, part of the electronic health record) for a list of residents who needed weighed and how often. Staff 29 referred to the POC record and demonstrated Resident 14 was listed as one who required weekly and/or PRN weight, not daily weights.

On 3/6/24 at 3:03 PM Staff 12 (LPN) confirmed the order for daily weights was not entered into the record for the direct care staff to know to obtain the weights daily, but it was entered under Licensed Nurse Tasks.

On 3/7/24 at 12:02 PM Staff 15 (RNCM) and Staff 16 (LPN Resident Care Manager) confirmed the order was not entered correctly and licensed staff did not follow up until 3/7/24 with the resident's primary provider to report weight variance or to clarify the order.

Based on observation, interview, and record review it was determined the facility failed to provide respiratory care and services in accordance with physician orders for 1 of 2 sampled residents (#253) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include:

Resident 253 admitted to the facility in 2024 with diagnoses including respiratory failure and sleep apnea (repeat lapses of breathing during sleep).

The 2/22/24 hospital Discharge Orders indicated Resident 253's oxygen levels were to be titrated (continuously measured and adjusted) to maintain oxygen saturations above 92 percent.

The Oxygen Sats (saturation) Summary for Resident 253 indicated her/his oxygen level on 2/22/23 was at 91 percent and no oxygen levels were monitored from 2/27/24 through 3/1/24.

A 2/23/24 progress note indicated Resident 253 required continuous supplemental oxygen during the day and the administration record was referenced.

The 2/2024 TAR had no documentation of Resident 253's oxygen order or instructions related to the monitoring of her/his oxygen equipment.

On 3/4/24 at 3:09 PM and 3/6/24 at 8:28 AM Resident 253 was observed in bed with continuous oxygen in use at two liters per minute through a nasal cannula.

On 3/6/24 at 3:11 PM Staff 24 (CNA) stated she only reported issues with Resident 253's oxygen levels if oxygen levels were below 90 percent.

On 3/6/24 at 3:41 PM Staff 22 (LPN) stated she recalled Resident 253 was admitted to the facility with supplemental oxygen. Staff 22 acknowledged orders for Resident 253's oxygen were not transcribed to the TAR and she did not verify or enter the oxygen order when Resident 253 admitted to the facility.

On 3/6/24 at 4:00 PM Staff 16 (LPN-Resident Care Manager) stated she was not aware Resident 253 required continuous oxygen and her/his oxygen order was not entered into the system.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 17, 18, 19, 20, and 21) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include:

On 12/6/22 at 9:50 AM Staff 1 (Administrator) provided the most recent performance reviews for Staff 17 (Former CNA), Staff 18 (CNA), Staff 19 (CNA), Staff 20 (CNA), and Staff 21 (CNA), which revealed the following:

- Staff 17 was hired on 12/16/04; the facility was unable to provide a performance review.
- Staff 18 was hired on 1/25/16; the facility was unable to provide a performance review but stated it was completed in 2020.
- Staff 19 was hired on 2/6/17; the facility was unable to provide a performance review.
- Staff 20 was hired on 3/2/23; the facility was unable to provide a performance review.
- Staff 21 was hired on 2/1/21; the facility was unable to provide a performance review.

On 3/7/24 at 11:08 AM Staff 1 (Administrator) acknowledged the performance evaluations were not completed annually for Staff 17, Staff 18, Staff 19, Staff 20, and Staff 21.

Based on interview and record review it was determine the facility failed to ensure the dietary manager had current certification for 1 of 1 kitchen reviewed. This placed residents at risk for unmet dietary needs. Finding include:

On 3/7/24 at 10:23 AM and 3:09 PM Staff 26 (Dietary Manager) was requested to produce her Dietary Manager certification. Staff 26 stated she believed her certification as a Dietary Manager expired in 4/2023 and she was unable to located her certificate.

On 3/8/24 at 8:30 AM Staff 1 (Administrator) acknowledged Staff 26's certification was expired.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing for 15 of 30 days reviewed for staffing. This placed residents at risk of unmet needs. Findings include:

Review of the Direct Care Staff Daily Report sheets from 2/3/24 through 3/3/24 revealed the facility did not meet minimum CNA staffing requirements on the following days: 2/3/24, 2/4/24, 2/5/24, 2/7/24, 2/8/24, 2/9/24, 2/10/24, 2/12/24, 2/13/24, 2/14/24, 2/15/24, 2/20/24, 2/23/24, 2/26/24, and 2/29/24.

On 3/7/24 at 8:35 AM Staff 1 (Administrator) stated the facility was always recruiting for new staff and were trying to reduce the use of agency staff.

OAR 411-086-0040 Admission of Residents

Refer to F 655
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F 677, F 684, and F 695
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OAR 411-086-0310 Employee Orientation and In-Service Training

Refer to F 730
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OAR 411-086-0250 Dietary Services

Refer to F 801

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 08/21/2023 and 08/27/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation and interview it was determined the facility failed to provide a clean and well maintained environment for 5 of 30 resident room floors and 1 of 3 carpeted halls. This placed residents at risk for lack of a clean and homelike environment. Findings include:

Observations made during the week of 11/14/22 through 11/18/22 revealed an area in the hallway in front of resident room eleven with carpet frayed and lifted at the seam. The carpet throughout the hall had multiple areas with dark stains and irregular shaped areas of discoloration.

On 11/15/22 12:35 PM the floor in resident room 9 was observed with black and sticky areas between the bed and the window and at the foot of each bed. The areas near the dresser had large sticky yellow stains.

On 11/16/22 at 12:40 PM Staff 14 (Housekeeper) stated the floors in resident rooms six, nine, 23, 28 and 29 were all difficult to clean and remained sticky because the facility no longer obtain special floor cleaning supplies.

On 11/16/22 at 1:01 PM Staff 13 (Housekeeping Supervisor) confirmed the special floor cleaning supplies were no longer available. Staff 13 stated the floors were cleaned daily but did not appear clean because of the condition of the floors in many rooms.

On 11/17/22 at 11:00 AM the floor in resident rooms six, nine, 23, 28 and 29 and the carpet in the south hall were observed with Staff 1 (Administrator). Staff 1 acknowledged the carpet should be replaced, the floors in the rooms observed did not appear in the best condition and specific plans to address the flooring were not available.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 3 of 5 sampled resident (#s 9, 20 and 2) reviewed for abuse. This placed residents at risk for abuse. Findings include:

1. Resident 9 was admitted to the facility in 9/2021 with diagnoses including heart failure.

The 9/1/22 Annual MDS revealed the resident had a BIMS score of 15 out of 15 (cognitively intact).

Resident 241 was admitted in 2/3/22 with diagnoses including dementia.

A 7/23/22 Incident report indicated Staff 27 (CNA) entered Resident 9's room and noticed Resident 241 had placed a plastic wet floor sign under Resident 9's legs. Staff 27 moved Resident 241 away from Resident 9. As Staff 27 moved Resident 241 away from Resident 9's room Resident 241 grabbed Resident 9's bedside table and shoved it at her/him. The Incident report further indicated Resident 9 stated she/he was attacked while she/he slept in her/his recliner. Resident 9 stated Resident 241 came into her/his room and hit her/his legs with the wet floor sign.

On 11/14/22 at 11:34 AM Resident 9 stated she/he felt abused by Resident 241.

On 11/17/22 at 9:09 AM Staff 27 stated Resident 241 was agitated and she gave the resident some space. Staff 27 stated when she turned around the resident went into Resident 9's room. Staff 27 stated she observed Resident 241 hit Resident 9 with the wet floor sign.

On 11/17/22 at 1:57 PM Staff 2 (DNS) acknowledged Resident 241 hit Resident 9 with a wet floor sign.
,
2. Resident 20 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's Disease and anxiety.

A 2/9/22 revised care plan for Resident 20's behaviors indicated staff were to keep interactions calm and polite, listen and walk away if necessary.

A FRI revealed on 8/20/22 Resident 20 exited her/his room and told Staff 7 (CNA) she/he was wet with urine, her/his bed was wet and she/he needed help. Staff 7 asked Resident 20 to wait for care and Resident 20 responded in "frustration". Staff 7 became "argumentative" and stated "I'm not going to help you if you are going to be rude to me."

On 11/17/22 at 4:46 PM Staff 11 (CNA) state she heard Staff 7 speak to Resident 20 and indicated the interaction towards Resident 20 was abusive in words and in tone.

On 11/18/22 at 9:27 AM Staff 3 (RNCM) stated she completed the investigation and interviewed Resident 20 on 8/20/22. Staff 3 stated Resident 20 was upset because of the way Staff 7 responded and did not assist with her/his care. Staff 3 acknowledged abuse by Staff 7 was substantiated.

, 3. Resident 2 admitted to the facility in 2017 with diagnoses including depression.

A 7/8/22 FRI revealed an allegation of verbal abuse from Staff 20 (former agency CNA) towards Resident 2.

An undated Facility Investigation revealed Staff 13 (Housekeeping Supervisor) heard Resident 2 say she/he did not like Staff 20, Staff 20 then responded, "I don't like you either." Staff 13 notified Staff 15 (LPN Resident Care Manager), Staff 15 spoke to Staff 20 about the incident and Staff 20 stated "yes, I did say that to her/him, and I am allowed to say that to her/him". Staff 20 was immediately sent home and verbal abuse was substantiated.

On 11/16/22 at 6:56 PM Staff 20 stated she recalled the incident and stated under her breath "I don't like you either". Staff 20 stated she did not know Resident 2 could hear her but was aware it was wrong to say that to her/him.

On 11/17/22 at 11:20 AM Resident 2 recalled the incident with Staff 20 and stated she/he felt it was verbal abuse towards her/him.

On 11/17/22 at 2:08 PM Staff 2 (DNS) reviewed the incident and stated she considered the incident to be verbal abuse.

Based on interview and record review it was determined the facility failed to ensure professional standards were followed for medication administration for 1 of 3 halls reviewed for late medications. This placed residents at risk for medication complications or worsening conditions. Findings include:

Per Division 45 Standards and Scope of Practice for the LPN and RN 851-045-0070; Conduct Derogatory to the Standards of Nursing Defined:
- Failing to dispense or administer medications in a manner consistent with state and federal law.

On 12/28/21 during the morning medication pass Staff 19 (CMA) reported Residents 29, 15 and 22 on East hall informed her they did not receive their morning medications on 12/27/21.

On 12/28/21 at 11:15 AM the facility conducted a medication administration report audit which revealed the following:

Resident 29's 12/2021 MAR revealed:
-Pantoprazole (stomach medication) scheduled at 7:00 AM before breakfast was documented as administered at 8:34 AM
-Acarbose (diabetic medication) scheduled three times a day before meals at 7:30 AM, 11:30 AM and 5:00 PM and the morning doses were documented as administered at 8:34 AM and 1:34 PM on day shift.
-Amlodipine (heart medication) scheduled to be given in the morning between 7:00 AM and 11:00 AM and was documented as administered at 1:35 PM.
-Pantoprazole (stomach medication) scheduled to be given before breakfast at 7:00 AM and was documented as administered at 8:34 AM.
-Apixaban (blood thinner) scheduled to be given twice a day between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM with the first dose documented as administered at 1:34 PM
-Glipizide (diabetic medication) scheduled to be given twice a day between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM with the first dose documented as administered at 1:34 PM.

Resident 15's 12/2021 MAR revealed:
-Alphagan (eye drops for glaucoma) to the left eye twice a day scheduled to be given between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM with the morning dose documented as administered at 1:55 PM.
-Brimonidine (eye drops for glaucoma) to the left eye twice a day scheduled to be given between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM. The instructions indicated to wait five minutes between eye drops. Both Alphagan and Brimonidine drops scheduled to be given in the morning were documented as administered at 1:55 PM, an hour before the second dose was scheduled and there was no indication the eye drops were given five minutes apart.
-Coreg (heart and blood pressure medication) scheduled with meals at 8:00 AM and 5:00 PM. The morning dose was documented as administered at 1:55 PM.

Resident 22's 12/2021 MAR revealed:
-Prilosec (stomach medication) scheduled to be given at 7:00 AM 30 minutes before the morning meal was documented as administered at 1:25 PM.
-Ofloxacin (antibiotic) and Pred Forte (steroid) eye drops were scheduled four times a day between 7:00 AM and 11:00 AM, 11:00 AM and 1:00 PM, 3:00 PM and 5:00 PM and 8:00 PM and 9:00 PM with instructions to wait five minutes between eye drops. Ofloxacin was documented as administered at 9:10 AM and 1:26 PM and the first two doses of Pred Forte were documented as administered at 1:26 PM. There was no indication the two eye drops were administered five minutes apart or that two doses of Pred Forte were actually administered during the morning shift as ordered.
-Coreg (blood pressure and heart failure medication) twice a day between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM with the first dose documented as administered at 1:25 PM.

Resident 16's 12/2021 MAR revealed:
-Baclofen (for muscle spasms) and gabapentin (used to treat nerve pain) was scheduled three times a day with the first two doses to be given between 7:00 AM and 11:00 AM and 11:00 Am and 1:00 PM. Both medications were documented as administered at 1:39 PM for the initial day shift dose. There was no indication another dose was administered on day shift.
-Simethicone (for stomach gas) to be given three times a day. The record indicated the first two doses scheduled for 8:00 AM and 12:00 PM were documented as administered at 1:40 PM.

Resident 30's 12/2021 MAR revealed:
-Lamictal (seizure medication) was scheduled every 12 hours at 9:00 AM and 9:00 PM with the first dose documented as administered at 1:36 PM.
-carboxymethylcellulose (eye drops) was scheduled four times a day at 9:00 AM and 12:00 PM on day shift. Both day shift doses were documented as administered at 1:36 PM.

Resident 12's 12/2021 MAR revealed:
-Acarbose (diabetic medication) scheduled before the first bite of the noon meal at 11:30 AM and was documented as administered at 1:38 PM.

Resident 19's 12/2021 MAR revealed:
-Pantoprazole (stomach medication) was scheduled to be given before breakfast at 7:00 AM and was documented as administered at 1:48 PM.

On 11/18/22 at 8:26 AM Staff 2 (DNS) was asked about the audit of late medications. Staff 2 stated she suspected late medication administration by Staff 21 (former RN). Staff 2 added she counseled Staff 21 previously and when Staff 21 was observed spending most of the morning at the nurses' station, she was reminded about medication pass. When Staff 19 reported the concerns expressed by the residents another audit was conducted and determined continued problems with late medication administration.

Refer to F 760

Based on interview and record review it was determined the facility failed to provide assistance with a bedpan for 1 of 1 sampled resident (#91) reviewed for ADLs. This placed residents at risk for skin breakdown. Findings include:

Resident 91 was readmitted to the facility in 8/2022 with diagnoses including hemiparesis (partial paralysis on one side of the body).

A 3/29/22 revised care plan revealed Resident 91 had an ADL self-care performance deficit and required two-person total assist with toileting, offer the bedpan to encourage continence and recheck per standard of care.

A 9/8/22 FRI investigation indicated Resident 91 was found on a bedpan and stated she/he was placed on the bedpan at approximately 4:30 PM.

On 11/15/22 at 2:37 PM Staff 16 (LPN) stated on 9/8/22 day shift reported to Staff 24 (CNA) Resident 91 was on a bedpan.

On 11/15/22 at 12:32 PM Staff 24 stated she received report at 2:30 PM from day shift Resident 91 was on a bedpan. Staff 24 stated she saw Resident 91's call light on but thought another CNA answered the light so she did not check on the resident.

On 11/15/22 at 3:25 PM Staff 6 (CNA) stated he took the resident her/his dinner tray at 4:45 PM but the resident did not want to eat due to being on the bedpan. Staff 6 stated when he left for dinner he reminded Staff 24, Staff 25 (CNA) and Staff 26 (CNA) Resident 91 was on the bedpan.

On 11/17/22 at 3:09 PM Staff 25 stated Staff 24 was assigned to Resident 91 and day shift told Staff 24 Resident 91 was on the bedpan.

On 11/17/22 at 3:23 PM Staff 26 stated she came to the facility at 6:00 PM to help staff with dinner. Staff 26 stated she spoke with the resident but she/he did not mention she/he was on the bedpan and staff did not report to her she/he was on the bedpan. Staff 26 stated at 8:30 PM she and Staff 6 found the resident on her/his bedpan. Staff 26 stated when the bedpan was removed the resident had an indentation from the bedpan.

On 11/17/22 at 4:49 PM Staff 2 (DNS) stated Staff 24 was assigned to Resident 91 and was told by dayshift the resident was on the bedpan. Staff 2 stated her expectation was when a resident was on a bedpan staff should check the resident every 15 minutes.

Based on interview and record review it was determined the facility failed to follow physician orders and care plan for 3 of 8 sampled residents (#s 2, 28 and 33) reviewed for medications and ADLs. This placed residents at risk for unmet needs. Findings include:

1. Resident 28 was admitted to the facility in 7/2021 with diagnoses including chronic pain and diabetes.

A 6/23/22 physician's order revealed a Fleet Enema (saline enema) was to be administered every 72 hours as needed if no bowel movement occurred on the following shift after a Dulcolax suppository (stool softener) application. The nurse practioner must also approve if the Fleet Enema was administered again before three days.

A 11/5/22 progress note revealed Resident 28 received bowel care after no bowel movement for three days.

The 11/2022 MAR revealed Resident 28 was provided an enema on 11/6/22 and 11/7/22.

The 11/2022 TAR revealed Resident 28 was not provided a Dulcolax Suppository prior to the administration of the enema.

Resident 28's clinical record revealed the nurse practioner was not notified about the use of the Fleet Enema one day apart.

On 11/17/22 at 12:47 PM Staff 5 (LPN) stated the first bowel care for Resident 28 on 11/5/22 was Milk of Magnesia (a laxative) and not Dulcolax. Staff 5 also stated because the first enema on 11/6/22 had minimal results for Resident 28 the second enema was administered on 11/7/22. Staff 5 stated the entire order as written was not followed because Dulcolax was not administered prior to the use of the Fleet Enema.

On 11/18/22 at 10:11 AM Staff 3 (RNCM) acknowledged orders for the administration of the Fleet Enema and Dulcolax were not followed and the nurse practioner was not notified as ordered.

2. Resident 33 was admitted to the facility in 1/2022 with diagnoses including chronic obstructive pulmonary disease and stroke.

The 1/14/22 Admission CAA indicated Resident 33 required extensive assistance with all ADL care.

The 6/16/22 revised care plan for skin integrity indicated Resident 33's heels were to be floated while in bed.

During random observations on 11/14/22 and 11/15/22 Resident 33 was sleeping in bed and her/his heels were not floated.

On 11/16/22 at 1:58 PM Staff 22 (CNA) stated Resident 33 did not like to have her/his heels floated and nurses including Staff 18 (LPN/IP) were informed.

On 11/16/22 at 3:57 PM Staff 18 stated when Resident 33 first admitted staff told him that Resident 33 refused to have her/his heels floated and told Staff 3 (RNCM). Staff 18 was unaware Resident 33 remained care planned to have her/his heels floated.

On 11/18/22 at 10:05 AM Staff 3 stated she was unaware Resident 33's heels were not floated and acknowledged Resident 33's care plan was not followed.

, 3. Resident 2 was admitted to the facility in 2018 with diagnoses including atrial fibrillation (irregular heart rhythm).

A 7/20/22 physician's order revealed Resident 2 took digoxin (medication to treat irregular heart rhythms) daily related to artrial fibrillation.

A 7/26/22 physician's order revealed the facility staff were to complete a serum digoxin level on Resident 2 per a 7/26/22 pharmacy recommendation to monitor for potential adverse consequences of digoxin therapy. A review of Resident 2's medical record revealed no results of the ordered serum digoxin level.

On 11/17/22 at 12:58 PM Staff 2 (DNS) stated Resident 2's serum digoxin level was not completed as ordered.








Based on interview and record review it was determined the facility failed to obtain physician orders for CRE (intestinal bacterial infection) screening for 19 of 40 residents (#s 2, 6, 15, 22, 29, 30, 31, 34, 35, 38, 243, 505, 508, 510, 512, 513, 514, 518 and 519 reviewed for informed consent. This placed residents at risk for unnecessary medical intervention. Findings include:

On 11/14/22 an email was sent to Staff 1 (Infection Preventionist) from a State agency regarding a carbapenemase producing organism/CPO (bacteria which cause serious infections and are difficult to treat) case who was a former resident at the facility. The email indicated the State agency wanted to schedule a full-facility screening and collect specimens, via rectal swabs, of residents.

A facility letter sent to residents and families indicated the screening of resident would be conducted on 11/17/22 which consisted of a rectal swab on every resident.

No physician orders were located for Residents 2, 6, 15, 22, 29, 30, 31, 34, 35, 38, 243, 505, 508, 510, 512, 513, 514, 518 and 519 regarding screening for CRE.

In an interview on 1/9/23 at 10:30 AM Staff 1 indicated on 11/14/22 he received a call from a State agency informing him of a former resident who tested positive for a CRE. Staff 1 indicated rectal swabs were completed on 11/17/22 for residents. Staff 1 acknowledged there was no written physician orders for residents 2, 6, 15, 22, 29, 30, 31, 34, 35, 38, 243, 505, 508, 510, 512, 513, 514, 518 and 519 for the facility to perform the screening.

Based on observation, interview and record review it was determined the facility failed to prevent the development of a pressure ulcer, failed to ensure accurate and completed wound assessments, failed to care plan the pressure ulcer and failed to demonstrate the resident's clinical condition made the development of a pressure ulcer unavoidable for 1 of 1 sampled resident (#35) reviewed for pressure ulcers. This resulted in Resident 35 developing an unstageable (full thickness skin preventing view of the depth of the wound) pressure ulcer. Findings include:

Resident 35 was admitted to the facility in 10/2022 with diagnoses including heart failure and malnutrition.

The 10/17/22 Significant Change CAA indicated Resident 35 was at risk for pressure ulcers related to incontinence of bowel and bladder and needed assistance with ADLs. Resident 35 had a Stage 3 (full thickness skin loss) pressure ulcer.

The 10/5/22 care plan indicated the resident had bladder incontinence. The resident will remain free
from skin breakdown due to incontinence and brief use

A Progress Note dated 10/7/22 indicated Resident 35 had an unblanchable area to her/his coccyx (tailbone). This was not identified as a Stage 1 pressure ulcer (unblanchable area).

A Skin and Wound Assessment sheet dated 10/31/22 indicated the resident had a pressure ulcer. There was no documentation of the site, stage, description, measurements or if the physician was notified.

A Skin and Wound Assessment sheet dated 11/15/22 indicated the resident had a pressure ulcer. There was no documentation of the site, stage or description of the pressure ulcer.

A Skin and Wound Assessment sheet dated 11/17/22 indicated the resident had an unstageable pressure ulcer.

A review of Resident 35's 10/5/22 through 11/14/22 electronic record revealed no indication staff educated the resident regarding the risks and benefits of repositioning while in bed or the resident's non-compliance with repositioning prior to the development of the unstageable pressure ulcer.

Random observations from 11/14/22 through 11/18/22 on day and evening shifts revealed Resident 35 lying flat on her/his back.

On 11/15/22 at 4:53 Staff 6 (CNA) stated Resident 35 refused to change positions while in bed.

On 11/16/22 at 12:30 PM Staff 25 (CNA) stated Resident 35 refused to reposition while in bed and staff reported this to nursing.

On 11/16/22 at 12:40 PM Staff 26 (CNA) stated Resident 35 refused to reposition while in bed and nursing was aware.

On 11/16/22 at 2:47 PM Staff 15 (LPN/RCM) stated she was aware the resident refused to reposition while in bed but this was not documented in the electronic record. Staff 15 stated she provided staff education multiple times on the importance of repositioning residents every two hours to avoid pressure ulcers and to document refusals but they did not comply. Staff 15 stated Resident 35 refused repositioning and acknowledged staff did not document the resident's refusals to reposition while in bed.

On 11/17/22 at 1:31 PM Staff 2 (DNS) acknowledged on 10/7/22 Resident 35 had a Stage 1 pressure ulcer and a skin sheet should have been completed. Staff 2 further stated Resident 35's pressure ulcer worsened to a Stage 3 and was now unstageable. Staff 2 acknowledged the Skin and Wound Assessment sheets were inaccurate and incomplete and Resident 35's care plan did not have information related to the resident's pressure ulcer.

Based on interview and record review it was determined the facility failed to ensure narcotic records were reconciled based on standards of practice for 3 of 3 halls reviewed for narcotic reconciliation. This placed residents at risk for misappropriation of medications. Findings include:

On 11/17/22 at 10:19 AM observations of the facility's narcotic books for the last three months to current revealed:
-The South hall book 1 had 23 of 30 days in 9/2022, 12 of 14 days in 10/2022 and 9 of 17 days in 11/2022 for which there was lack of reconciliation evidence.
-The South hall book 15 had 26 of 30 days in 9/2022, 24 of 31 days in 10/2022 and 7 of 17 days in 11/2022 for which there was lack of reconciliation evidence.
-The East hall book had 19 of 30 days in 9/2022, 18 of 31 days in 10/2022 and 9 of 17 days in 11/2022 for which there was lack of reconciliation evidence.
-The West hall PRN book had 26 of 30 days in 9/2022, 21 of 31 days in 10/2022 and 4 of 17 days in 11/2022 for which there was lack of reconciliation evidence.
-The West hall book had 18 of 30 days in 9/2022, 16 of 31 days in 10/2022 and 15 of 17 days in 11/2022 for which there was lack of reconciliation evidence.

On 11/18/22 at 8:26 AM the narcotic books and reconciliation was discussed with Staff 2 (DNS). Staff 2 stated she recently became aware of the lack of signatures for reconciliation of narcotics and had a plan to audit the books. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure significant medication errors did not occur for 7 of 17 residents (#s 12, 15, 16, 19, 22, 29 and 30) reviewed for medication administration times. This placed residents at risk for seizures, blood sugar, stomach and blood pressure issues and medication complications. Findings include:

On 12/28/21 during the morning medication administration Staff 19 (CMA) was told by several residents they did not receive their medications on the morning of 12/27/21.

A facility audit conducted on 12/28/21 of the morning medication administration for 12/27/21 revealed multiple episodes of late medication administration.

On 12/28/21 at 11:15 AM the facility conducted a medication administration report audit which revealed the following:

1. Resident 29 was admitted to the facility in 2021 with diagnoses including diabetes.

Resident 29's 12/2021 MAR revealed:
-Pantoprazole (stomach medication) scheduled at 7:00 AM before breakfast was documented as administered at 8:34 AM
-Acarbose (diabetic medication) scheduled three times a day before meals at 7:30 AM, 11:30 AM and 5:00 PM and the morning doses were documented as administered at 8:34 AM and 1:34 PM on day shift.
-Amlodipine (heart medication) scheduled to be given in the morning between 7:00 AM and 11:00 AM and was documented as administered at 1:35 PM.
-Pantoprazole (stomach medication) scheduled to be given before breakfast at 7:00 AM and was documented as administered at 8:34 AM.
-Apixaban (blood thinner) scheduled to be given twice a day between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM with the first dose documented as administered at 1:34 PM
-Glipizide (diabetic medication) scheduled to be given twice a day between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM with the first dose documented as administered at 1:34 PM.

2. Resident 15 was admitted to the facility in 2021 with diagnoses including cardiac disease and chronic respiratory failure.

Resident 15's 12/2021 MAR revealed:
-Alphagan (eye drops for glaucoma) to the left eye twice a day scheduled to be given between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM with the morning dose documented as administered at `1:55 PM.
-Brimonidine (eye drops for glaucoma) to the left eye twice a day scheduled to be given between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM. The instructions indicated to wait five minutes between eye drops. Both Alphagan and Brimonidine drops scheduled to be given in the morning were documented as administered at 1:55 PM, an hour before the second dose was scheduled and there was no indication the eye drops were given five minutes apart.
-Coreg (heart and blood pressure medication) scheduled with meals at 8:00 AM and 5:00 PM. The morning dose was documented as administered at 1:55 PM.

3. Resident 22 was admitted to the facility in 2019 with diagnoses including reflux disease and diabetes.

Resident 22's 12/2021 MAR revealed:
-Prilosec (stomach medication) scheduled to be given at 7:00 AM 30 minutes before the morning meal was documented as administered at 1:25 PM.
-Ofloxacin (antibiotic) and Pred Forte (steroid) eye drops were scheduled four times a day between 7:00 AM and 11:00 AM, 11:00 AM and 1:00 PM, 3:00 PM and 5:00 PM and 8:00 PM and 9:00 PM with instructions to wait five minutes between eye drops. Ofloxacin was documented as administered at 9:10 AM and 1:26 PM and the first two doses of Pred Forte were documented as administered at 1:26 PM. There was no indication the two eye drops were administered five minutes apart or that two doses of Pred Forte were actually administered during the morning shift as ordered.
-Coreg (blood pressure and heart failure medication) twice a day between 7:00 AM and 11:00 AM and 3:00 PM and 5:00 PM with the first dose documented as administered at 1:25 PM.

4. Resident 16 was admitted to the facility in 2021 with diagnoses including muscle spasms and pain.

Resident 16's 12/2021 MAR revealed:
-Baclofen (for muscle spasms) and gabapentin (used to treat nerve pain) was scheduled three times a day with the first two doses to be given between 7:00 AM and 11:00 AM and 11:00 Am and 1:00 PM. Both medications were documented as administered at 1:39 PM for the initial day shift dose. There was no indication another dose was administered on day shift.
-Simethicone (for stomach gas) to be given three times a day. The record indicated the first two doses scheduled for 8:00 AM and 12:00 PM were documented as administered at 1:40 PM.

5. Resident 30 was admitted tot he facility in 2020 with diagnoses including epilepsy.

Resident 30's 12/2021 MAR revealed:
-Lamictal (seizure medication) was scheduled every 12 hours at 9:00 AM and 9:00 PM with the first dose documented as administered at 1:36 PM.
-carboxymethylcellulose (eye drops) was scheduled four times a day at 9:00 AM and 12:00 PM on day shift. Both day shift doses were documented as administered at 1:36 PM.

6. Resident 12 was admitted to the facility in 2020 with diagnoses including diabetes.

Resident 12's 12/2021 MAR revealed:
-Acarbose (diabetic medication) scheduled before first bite of meal at 11:30 AM was documented as administered at 1:38 PM.

7. Resident 19 was admitted to the facility in 2019 with diagnoses including gastroesophageal reflux disorder.

Resident 19's 12/2021 MAR revealed:
-Pantoprazole (stomach medication) was scheduled to be given before breakfast at 7:00 AM and was documented as administered at 1:48 PM.

On 11/18/22 at 8:26 AM Staff 2 (DNS) was asked about the investigation and audit of late medications. Staff 2 stated she suspected late medication administration by Staff 21 (former RN). Staff 2 added she counseled Staff 21 previously and when she was observed spending most of the morning at the nurses' station Staff 21 was reminded about medication pass. When Staff 19 reported the concerns expressed by the residents another audit was conducted and determined continued problems with late medication administration.

******************************
OAR 411-087-0100 Physical Enviornment: Generally

Refer to F584
******************************
OAR 411-085-0360 Abuse

Refer to F600

******************************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F658, F677, F684, F760
******************************
OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care

Refer to F686
******************************
OAR 411-086-0260 Pharmaceutical Services

Refer to F755
******************************

Based on interview and record review it was determined the facility failed to ensure residents were free from verbal abuse and neglect of care for 1 of 3 sampled residents (#29) reviewed for abuse. This placed residents at risk for verbal abuse and neglect of care. Findings include:

Resident 29 re-admitted to the facility in 8/2021 with diagnoses including schizophrenia, anxiety, post-traumatic stress disorder and Stage IV pressure ulcers (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.)

The 6/20/21 FRI indicated Witness 2 (Former LPN) refused to perform wound treatment and antagonized Resident 29. The FRI indicated the facility substantiated emotional abuse and neglect of care.

Resident 29's 7/26/20 Care Plan revealed Resident 29 was at risk for ineffective coping related to wanting to direct care. Interventions included to utilize two staff members for all care.

The June 2021 TARs revealed the following wound treatments were not completed as scheduled on 6/20/21:
* Lidocaine Gel 4% (pain medication treatment): apply to hips topically (on skin) daily in AM for wound pain.
* Bilateral ischial (buttocks) wounds and right trochanter (hip) wound: change the dressings daily, irrigate wound with 3 ml of modified Dakin's solution (antiseptic), pat wound and surrounding area dry. Apply no sting skin barrier wipe around wound, lightly pack wounds with antimicrobial strip packing and apply mepilex border foam dressing one time a day related to Stage IV pressure ulcers.
* Left trochanter hip wound: change dressing daily, irrigate wound with saline or Dakin's solution moistened-gauze to wound base for five to 10 minutes, rinse, pat dry and apply no sting barrier wipe around the wound. Apply Medihoney (medical-grade honey-based product for wound management) and aquacel (dressing made from sodium carboxymethylcellulose) to the open wound including areas of undermining (significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface). Apply mepilex border foam dressing one time a day related to left hip Stage IV pressure ulcer.

The 6/20/21 Facility Investigation included the following witness statements:
* Staff 21 (CMA) Stated Witness 2 was unwilling to complete wound care on Resident 29.
* Staff 18 (CNA) stated Witness 2 told Resident 29 she/he would have to wait for the next shift to get her/his wound care completed because Resident 29 previously stated, "Fuck you, you fat bitch". Witness 2 repeated those exact words to Resident 29 twice. Resident 29 responded multiple times she/he just wanted the wound care completed so she/he could get up [out of bed].
* Staff 14 (CNA) stated Witness 2 said she would not care for Resident 29. Staff 14 stated Resident 29 requested wound care more than once and Witness 2 replied she/he had to wait until the following shift.
* Staff 6 (LPN Resident Care Manager) stated Witness 2 reported to her she would not complete wound care on Resident 29 due to being called a "fat bitch" and told to leave the resident's room. Staff 6 instructed Witness 2 to complete the wound care or it would be considered neglect of care. Staff 6 stated the following shift she took over Resident 29's care, clarified the situation with the resident and completed the missed wound care treatments.
* Staff 2 (DNS) stated Witness 2's statement of the incident did not correspond with the witness statements.

The 6/20/21 Facility Investigation revealed Witness 2 was terminated for emotional abuse and neglect due to reports by Resident 29, multiple staff members and Witness 2's inconsistent reporting. Witness 2 did not follow Resident 29's care plan and induced behaviors in order to avoid performing care. Resident 29 wanted her/his wound care completed and Witness 2 refused to provide care. The Facility Investigation substantiated verbal abuse and neglect.

On 12/17/21 at 10:03 AM Staff 14 verified on 6/20/21 Witness 2 refused to care for Resident 29 although she/he requested wound care multiple times and told Resident 29 she/he would have to wait for the oncoming shift to complete the wound care.

On 12/17/21 at 10:15 AM Staff 2 stated on 6/20/21 Witness 2 lied about Resident 29's behaviors, attempted to induce behaviors, did not follow Resident 29's care plan and refused to complete the physician ordered wound care treatments. Staff 2 further stated the facility substantiated verbal abuse and neglect of care and terminated Witness 2. Staff 2 stated she no longer had Witness 2's contact information [so Witness 2 was unable to be contacted].

Based on interview and record review it was determined the facility failed to accurately complete MDS assessments for 4 of 4 sampled residents (#s 6, 13, 29 and 15) reviewed for pain, dental issues and abuse. This placed residents at risk for inaccurate medical records and ineffective pain management. Findings include:

1. Resident 6 readmitted to the facility on 12/3/21 with diagnoses including chronic pain syndrome.

The 9/15/21 annual MDS Section J included documentation a pain assesment should be completed. The pain assessment portion was marked "not assessed".

On 12/17/21 at 10:06 AM Staff 2 (DNS) confirmed the pain assessment portion of Section J should be completed.

2. Resident 13 readmitted to the facility on 7/24/21 with diagnoses including nerve pain.

The 10/1/21 quarterly MDS Section J included documentation a pain assessment should be completed. The pain assessment portion was marked "not assessed".

On 12/17/21 at 10:06 AM Staff 2 (DNS) confirmed the pain assessment portion of Section J should be completed.

3. Resident 29 readmitted to the facility on 8/18/21 with diagnoses including chronic pain.

The 11/8/21 quarterly MDS Section J included documentation a pain assessment should be completed. The pain assessement portion was marked "not assessed".

On 12/17/21 at 10:06 AM Staff 2 (DNS) confirmed the pain assessment portion of Section J should be completed.

4. Resident 15 readmitted to the facility in 2019 with diagnoses including dementia.

On 12/15/21 at 12:52 PM Staff 5 (Social Services Director) confirmed Resident 15 had a full set of dentures (had no teeth).

The 10/5/21 annual MDS Section L was marked "No" for lacking teeth/no natural teeth/edentulous.

On 12/15/21 at 3:58 PM Staff 2 (DNS) confirmed the MDS should provide an accurate reflection of the resident's status.

Based on interview and record review it was determined the facility failed to revise the care plan for 1 of 1 sampled resident (#15) reviewed for dental concerns. This placed residents at risk for unnecessary cares. Findings include:

Resident 15 readmitted to the facility in 2019 with diagnoses including dementia. Resident 15 was significantly cognitively impaired.

The 11/19/21 care plan revealed Resident 15 wore upper and lower dentures and required the assistance of one staff for dental cares. Interventions for proper denture insertion were included.

On 12/14/21 at 10:56 AM Staff 14 (CNA) indicated she did not believe Resident 15 wore dentures. With this surveyor Staff 14 looked in Resident 15's room and did not find dentures but did find denture adhesive.

On 12/14/21 at 11:16 AM Staff 12 (CNA) indicated Resident 15 refused to wear dentures. Staff 12 added she believed the resident only wore them four or five times a while ago but not recently. Staff 12 did not know where the dentures were.

On 12/14/21 at 11:54 AM Staff 5 (Social Services Director) stated Resident 15 had dentures but because the resident threw them away or sent them to the laundry, the dentures were stored in Staff 5's office. Staff 5 added Resident 15 had a fitting for the dentures and they fit but the resident chose not to wear them. Staff 5 confirmed the care plan was not updated to reflect this change.

On 12/15/21 at 3:58 PM Staff 2 (DNS) confirmed the care plan did not reflect Resident 15's current dental preferences.

Based on interview and record review it was determined the facility failed to ensure staff adhered to accepted professional standards related to nursing care and services for 1 of 3 sampled residents (#29) reviewed for abuse. This placed residents at risk for verbal abuse and neglect of care. Findings include:

851-045-0070
Conduct Derogatory to the Standards of Nursing Defined
Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to:
(1) Conduct related to general fitness to practice nursing:
(a) Demonstrated incidents of violent, abusive, intimidating, neglectful or reckless behavior; or
(b) Demonstrated incidents of dishonesty, misrepresentation, or fraud.
(2) Conduct related to achieving and maintaining clinical competency:
(a) Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established;
(3) Conduct related to the client ' s safety and integrity:
(c) Failing to develop, implement or modify the plan of care;
(i) Leaving or failing to complete any nursing assignment, including a supervisory assignment, without notifying the appropriate personnel and confirming that nursing assignment responsibilities will be met;
(o) Failing to establish or maintain professional boundaries with a client; or in unacceptable behavior towards, or in the presence of, the client's family. Such behavior includes, but is not limited to, using derogatory names, derogatory or threatening gestures, or profane language.
(8) Conduct related to other federal or state statute or rule violations:
(d) Abusing a client;
(e) Neglecting a client;
(h) Engaging in other unacceptable behavior towards or in the presence of a client. Such conduct includes but is not limited to using derogatory names, derogatory gestures or profane language;

Resident 29 re-admitted to the facility in 8/2021 with diagnoses including schizophrenia, anxiety, post-traumatic stress disorder and Stage IV pressure ulcers (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures).

The 6/20/21 FRI indicated Witness 2 (Former LPN) refused to perform wound treatment and antagonized Resident 29. The FRI indicated the facility substantiated emotional abuse and neglect of care and terminated Witness 2.

The 6/20/21 Facility Investigation included the following witness statements:
* Staff 21 (CMA) Stated Witness 2 was unwilling to complete wound care on Resident 29.
* Staff 18 (CNA) stated Witness 2 told Resident 29 she/he would have to wait for the next shift to get her/his wound care completed because Resident 29 previously stated, "Fuck you, you fat bitch". Witness 2 repeated those exact words to Resident 29 twice. Resident 29 responded multiple times she/he just wanted the wound care completed so she/he could get up [out of bed].
* Staff 14 (CNA) stated Witness 2 stated she would not care for Resident 29. Staff 14 stated Resident 29 requested wound care more than once and Witness 2 replied she/he had to wait until the following shift.
* Staff 6 (LPN Resident Care Manager) stated Witness 2 reported to her she would not complete wound care on Resident 29 due to being called a "fat bitch" and being told to leave the resident's room by Resident 29. Staff 6 instructed Witness 2 to complete the wound care or it would be considered neglect of care. Staff 6 stated the following shift she took over Resident 29's care, clarified the situation with the resident and completed the missed wound care treatments.
* Staff 2 (DNS) stated Witness 2's statement of the incident did not correspond with the witness statements.

The 6/20/21 Facility Investigation concluded due to reports by Resident 29, multiple staff members and Witness 2's inconsistent reporting, Witness 2 was terminated for emotional abuse and neglect. Witness 2 did not follow Resident 29's care plan and induced behaviors in order to avoid performing care. Resident 29 wanted wound care completed and Witness 2 refused to provide care. The Facility Investigation substantiated verbal abuse and neglect.

On 12/17/21 at 10:15 AM Staff 2 stated on 6/20/21 Witness 2 lied about Resident 29's behaviors, attempted to induce behaviors, did not follow Resident 29's care plan and refused to complete the physician ordered wound care treatments. Staff 2 further stated the facility substantiated verbal abuse and neglect of care. Staff 2 further stated she no longer had Witness 2's contact information [so Witness 2 was unable to be contacted].

Refer to F600.

,

Based on observation, interview and record review it was determined the facility failed to provide supervision for swallowing safety for 1 of 2 residents (#3) reviewed for risk of aspiration and/or choking. Resident 3 required supervision while eating and was observed to be left unattended with her/his meal during continuous observations. This failure resulted in an immediate jeopardy situation. Findings include:

Resident 3 was admitted to the facility in 8/2019 with diagnoses including stroke, dementia and dysphagia (difficulty swallowing).

Resident 3's 11/22/21 Quarterly MDS indicated Resident 3 was severely cognitively impaired and required one person physical assist when eating.

A 5/2020 physician order indicated the kitchen was to provide Resident 3's meal tray early due to Resident 3 requiring eating assistance.

Resident 3's 11/18/21 care plan indicated Resident 3 coughed and choked at baseline and was on swallowing precautions. Resident 3 was to remain upright during meals and for 30 minutes afterwards with one person standby assist to encourage Resident 3 to clear her/his mouth and to regulate fluids and yogurt bites with meals.

Continuous observations on 12/8/21 from 12:19 PM through 12:43 PM revealed:
Resident 3 was in her/his room with no staff present. Resident 3 was upright in bed with a meal tray and liquids in front of her/him. Resident 3 independently ate yogurt with adaptive silverware. Resident 3's consumed approximately 40 percent of the meal without staff present.

On 12/8/21 at 1:25 PM Staff 20 (CNA) stated Resident 3 required supervision by staff for each meal to prevent her/him from choking. Staff 20 further stated she documented on Resident 3's daily plan of care Resident 3 consumed lunch independently that day.

On 12/8/21 at 1:59 PM Staff 6 (LPN Resident Care Manager) stated based on Resident 3's care plan staff were required to continually supervise and assist Resident 3 during meals to prevent aspiration and choking.

On 12/8/21 at 4:29 PM the facility was notified the failure to provide supervision for Resident 3 who was at risk for aspiration was determined to be an immediate jeopardy situation.

An immediate plan of correction (POC) was requested.

On 12/8/21 at 5:49 PM the facility submitted a final POC.

The IJ removal Plan included:
-Resident 3 was assessed for signs and symptoms of aspiration.
-Orders were put into place for a speech therapy evaluation for those with potential upgrades.
-Family will be re-educated on what to monitor while assisting residents with meals.
-Staff including agency staff will be educated on following the care plan.
-Monitoring staff for following care plans as written.
-Monitoring Plan of Care responses for potential swallowing/eating problems.
-Audits to be completed on residents to ensure those with any level of assistance for eating are properly managed and monitored three times a day for 30 days.
-Random staff interviews to ensure understanding of standby assist and following care plans two per shift for month then once per shift for one month.
-Results will be brought to QAPI for ongoing monitoring and changes if needed.

On 12/9/21 at 9:00 AM the facility's implementation of the IJ removal plan was verified with staff interviews to ensure staff were educated on swallowing/aspiration precautions and the facility administrator was notified the immediate jeopardy was removed.

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OAR 411-085-0360 Abuse

Refer to F600
********************************
OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F636 and F657
********************************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F658
********************************
OAR 411-086-0140 Nursing Services: Problem Resolution &
Preventive Care

Refer to F689
********************************

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 06/21/2021 and 06/27/2021, 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.

Based on interview and record review the facility failed to notify the resident of the grievance resolution for 1 of 4 residents (#8) reviewed for grievances. This placed residents at risk for unaddressed concerns. Findings include:

Resident 8 admitted to the facility in 2017 with diagnoses including diabetes.

In an interview on 3/2/21 Resident 8 stated she/he had filed grievances with the facility and had not been notified if and how the grievances were resolved.

A review of the grievances filed by Resident 8 revealed there was no documented follow up with grievances dated 2/25/21 or 10/21/20.

In an interview on 3/11/21 at 1:46 PM Staff 20 (SSD) stated the 2/25/21 and 10/21/20 grievances were related to care issues so they were routed to the Director of Nurses for resolution and follow up with the resident. Staff 20 further stated she did not keep those grievances for the grievance binder and did not keep them in the grievance log.

In an interview on 3/15/21 at 4:34 PM Staff 2 (DNS) stated she did not follow up with Resident 8 regarding the 2/25/21 or 10/21/20 grievances, further stated the process is for the Social Services Director to follow up on all grievances.

In an interview on 3/17/21 at 6:04 PM Staff 1 (Administrator) stated the process for grievances was to resolve them and then follow up with the resident who initially completed the grievance to ensure they were aware of the resolution. Staff 1 confirmed there was no indication Resident 8's 2/25/21 or 10/21/20 grievances were resolved and reviewed with her/him.

Based on interview and record review the facility failed to provide a timely transfer for 1 of 4 residents (# 8) reviewed for quality of care. This placed residents at risk for unmet needs. Findings include:

Resident 8 admitted to the facility in 2017 with diagnoses including diabetes.

An 8/5/20 Grievance/Concern form revealed:
- Resident 8 reported she/he was placed in the power wheelchair before 6 PM, later asked to be transferred to the manual wheelchair due to pain and was told no due to the staff being too busy.
- Staff 22 (LPN) stated Resident 8 asked to be transferred on 8/4/20 between 10:10 pm and 10:30 pm, but the staff were too busy with other residents. Staff 22 statement further indicated Resident 8 called the administrator to complain, and at 12:30 AM the administrator told her to transfer Resident 8.
- In an 8/5/20 statement Staff 15 (LPN) stated Staff 22 would not allow the staff to transfer Resident 8 to another wheelchair, but only to bed due to there being only three CNAs on shift.

An 8/4/20 Physician Note revealed Resident 8 had pressure ulcers on her/his hips, causing pain.

A review of Resident 8's care plan revealed her/him to require two staff using a mechanical lift to transfer her/him.

In an interview on 3/2/21 at 12:30 pm Resident 8 stated she/he had wounds and was not to sit in the wheelchair for more than a couple hours. Resident 8 stated Staff 22 refused to allow her/him to be transferred on 8/4/20.

In an interview on 3/22/21 Staff 2 (DNS) reviewed the 8/5/20 Grievance/Concern, stated Resident 8 would develop pain after a hour in the power wheelchair and would request to move to the manual wheelchair. Staff 2 confirmed Resident 8 was not provided care in a reasonable amount of time.

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OAR 411-085-0310 Residents' Rights: Generally

Refer to F585
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
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