Forest Grove Post Acute

Resident 2 admitted to the facility in 4/2026 with diagnoses including hypothyroidism. -á The 4/17/26 physician orders indicated Resident 2 was to receive levothyroxine (thyroid medication) once daily.-á -á The 4/2026 MARs indicated Resident 2 did not receive levothyroxine on the following dates: 4/18/26; 4/19/26; 4/20/26 and 4/21/26.\ -á No information was found in the resident's clinical record related to the failure to administer the levothyroxine. -á On 6/11/26 at 2:53 PM Staff 2 (DNS) acknowledged Resident 2 did not receive levothyroxine on the identified dates.-á-á

Corrective Action for Resident Affected: Resident #2 has been discharged from the facility. Identification of Other Residents at Risk: An audit of all current residents receiving routine medications was completed to identify any missed medication administrations without appropriate documentation or physician notification. Any concerns identified were immediately addressed. Systemic Changes: Licensed nurses and CMAs were re-educated on medication administration requirements, documentation expectations, physician notification requirements, and procedures for addressing unavailable or omitted medications. Monitoring: The DNS or designee will audit 5 resident medication administration records weekly for 4 weeks and monthly thereafter for 2 months to verify medications are administered as ordered and omissions are appropriately documented and reported. Audit results will be reviewed through the facility QAPI process and corrective action implemented as needed.

Resident 1 admitted to the facility on 4/1/26 with diagnoses including dementia. A 4/2/26 physician order indicated the use of a foley (indwelling) catheter. The 4/2/26 Care Plan indicated Resident 1 had a foley catheter in place with interventions including changing the catheter per facility policy and physician order. Review of Resident 1GÇÖs progress notes from 4/7/26 through 4/23/26 revealed the following: -On 4/7/26 Resident 1 pulled out the catheter during night shift. Nursing staff attempted to reinsert the catheter, but the resident refused. -á -On 4/20/26 during a care conference meeting Resident 1GÇÖs family asked about the catheter and were informed by Staff 3 (LPN Resident Care Manager) the resident previously had a catheter and Staff 3 would follow up. -á -On 4/23/26 the provider reviewed the resident's bladder scan and indicated the foley did not need to be replaced. There was no indication in Resident 1GÇÖs medical record the physician was notified of the resident pulling out the catheter, and there was no catheter in place, until 4/20/26 (13 days later). On 6/11/26 at 10:30 AM Staff 3 stated if a resident pulled out a catheter and refused to have it reinserted the provider was to be notified to get further direction on how to proceed. Staff 3 stated she notified the provider of Resident 1 not having a catheter in place when she asked for a post void scan (bladder scan) on 4/20/26. Staff 3 acknowledged the provider was not notified until 13 days after the resident pulled out the catheter and physician orders were not followed related to use of a catheter.-á On 6/11/26 at 2:31 PM Staff 2 (DNS) acknowledged Resident 1GÇÖs physician orders were not followed related to having a catheter in place and the provider was not notified in a timely manner after the catheter was pulled out.

Corrective Action for Resident Affected: Resident #1 currently has an indwelling urinary catheter in place per physician order. The physician order, care plan, and treatment record were reviewed to ensure the resident's current catheter management needs are accurately reflected. Identification of Other Residents at Risk: An audit of all residents with indwelling urinary catheters was conducted to ensure physician orders were current, catheters were present as ordered, and any catheter removals or changes had appropriate physician notification and documentation. Systemic Changes: Licensed nurses were re-educated regarding physician notification requirements following unplanned catheter removal and refusal of treatment. Monitoring: The DNS or designee will audit all residents with indwelling urinary catheters weekly for 4 weeks and monthly thereafter for 2 months to verify physician orders are followed, catheter status is accurately documented, and physician notification occurs timely when indicated. Findings will be reviewed through the QAPI process and additional corrective action implemented as necessary.

Resident 20 was admitted to the facility in 6/2025 with diagnoses including dementia and depression. -á A 6/11/25 physician order indicated Resident 20 was prescribed the following PRN psychotropic medications: -Quetiapine Fumarate 25 MG Oral Tablet an antipsychotic indicated for agitation. -Prochlorperazine Maleate 5 MG Oral Tablet an antipsychotic indicated for nausea. -Hydroxyzine HCl 10 MG Oral Tablet an anxiolytic indicated for anxiety or insomnia. -á There was no evidence found in Resident 20GÇÖs medical record to indicate her/his physician documented a rationale for extended use of the PRN psychotropic medications past 14 days, or evaluated her/his PRN psychotropics since admission to the facility.-á -á A 7/11/25 pharmacy review of Resident 20GÇÖs medications recommended the facility discontinue her/his PRN psychotropic medications GÇ£for non use.GÇ¥ The PRN psychotropic medications were discontinued on 7/22/25. -á On 7/4/25 at 1:21 PM Staff 3 stated she was unaware that PRN psychotropics were limited to 14 days. Staff 3 acknowledged Resident 20GÇÖs PRN psychotropic medication orders went beyond 14 days without a documented rationale for extended use, or evaluation by a physician.

Plan of Correction: Corrective action for residents affected: Resident 20’s PRN psychotropic medications were discontinued on 7/22/2025. How the facility will identify other residents at risk: A facility-wide audit of all residents receiving PRN psychotropic medications was conducted on 8/20/2025 to ensure compliance with the 14-day limitation and proper documentation of physician rationale for any extensions. Systemic changes put in place: Nursing staff were re-educated on PRN psychotropic medications requiring a 14 day stop date. Monitoring to ensure compliance: The Director of Nursing or designee will review PRN psychotropic orders weekly for 4 weeks, then monthly for 3 months to ensure timely discontinuation or documented physician rationale. Any non-compliance will result in immediate re-education or corrective action. Audit results will be reviewed monthly in the QAPI Committee for 3 months. Completion Date: 08/27/2025

1. The facilityGÇÖs 8/2024 Smoking Policy for Independent and Supervised states residents who wished to smoke were to have a smoking evaluation upon admission or at the time they decided to smoke, to evaluate their ability to smoke safely. Resident 57 was admitted to the facility in 10/2024 with diagnoses including Chronic Obstructive Pulmonary Disease (a lung and airway disease that restricts breathing). Resident 57GÇÖs 10/20/24 Baseline Care Plan stated she/he was an independent and safe smoker. -á The 5/7/25 Quarterly MDS indicated Resident 57 was cognitively intact. -á A review of Resident 57GÇÖs clinical record revealed no indication a smoking assessment was completed. On 7/21/25 the facility provided a list of residents who smoked independently, and Resident 57 was included on the list. On 7/21/25 at 12:36 PM Resident 57 was observed disposing of her/his cigarette on a bucket lid and not in the designated receptacle. On 7/22/25 at 1:33 PM Resident 57 stated she/he was an active smoker and smoked independently since admitting to the facility. Resident 57 expressed she/he was never assessed or observed for smoking safety, and she/he was provided the facility smoking policy for her/his review and signature about two weeks ago. On 7/22/25 at 12:52 PM Staff 3 (LPN Resident Care Manager) stated, per facility policy, residents were assessed for smoking safety upon admission. Staff 3 acknowledged resident 57 smoked independently and the residentGÇÖs care plan indicated she/he smoked independently, but there was no evidence in the clinical record to indicate an assessment was completed. , 2. The facility's 3/2020 Smoking Policy and Procedure stated, GÇ£Residents who do not meet the established criteria to smoke independently are provided assistance/supervision during all smoking activities.GÇ¥ -á Resident 78 was admitted to the facility in 5/2022 with diagnoses including vascular dementia. -á Resident 78GÇÖs 5/21/22 Smoking Care Plan revealed the following: -The resident was allowed to smoke with supervision. -The resident's smoking supplies were to be stored in the medication room. -á -á -á On 7/21/25 at 11:30 AM Resident 78 was observed in her/his room with a pack of cigarettes stored inside her/his crossbody bag. -á On 7/21/25 at 12:29 PM Resident 78 was observed independently entering the smoking area with smoking supplies. Resident 78 proceeded to smoke a cigarette, which was lit by another resident in the smoking area. No staff were observed in the smoking area with Resident 78 while she/he smoked. -á On 7/21/25 at 3:37 PM Staff 13 (CNA) stated supervised smokers were required to keep their supplies GÇ£locked up at the nurses station.GÇ¥ -á On 7/21/25 at 4:03 PM Staff 14 (LPN) stated Resident 78 required supervision for smoking. Staff 14 further stated staff assigned to residents were care planned for supervised smoking were to conduct the following process: -á -Obtain the residentGÇÖs smoking supplies from the assigned nurse and accompany her/him to the smoking area. -Light the residentGÇÖs cigarette for her/him and provide one to one supervision from within the smoking area. -á On 7/21/25 at 4:34 PM Staff 3 (LPN Resident Care Manager) acknowledged Resident 19 was supposed to receive supervision with smoking and was not to have cigarettes stored in her/his room.

Plan of Correction: Corrective action for residents affected: Resident 57’s smoking evaluation assessment was completed on 7/22/2025. Resident 78 had their smoking materials secured immediately on 7/22/2025, and supervision was implemented per facility policy. Residents were educated on safe smoking practices and supervision requirements. How the facility will identify other residents at risk: A facility-wide audit of all residents who smoke was conducted on 7/24/2025 to ensure smoking assessments were completed, materials were secured, and supervision was provided according to policy. Systemic changes put in place: The smoking policy was reviewed and reinforced with staff, emphasizing assessment, secure storage of smoking materials, and supervision requirements. Residents who smoke were re-educated on policy, safe practices, and supervision requirements. Monitoring to ensure compliance: The Administrator or designee will conduct random audits of all smoking residents 3x weekly for 4 weeks, then monthly for 3 months to verify smoking materials are secured and supervision is occurring. Audit results will be reviewed in the QAPI Committee monthly for 3 months, and any issues will be addressed immediately. Completion Date: 08/27/2025

On 7/21/25 at 3:40 PM Staff 1 (Administrator) provided a list of bariatric residents between 6/1/25 and 7/17/25. Each day the facility claimed four bariatric residents, which indicated the facility was to have one additional CNA staff for each shift. A review of Direct Care Staff Daily reports from 6/1/25 through 7/17/25 revealed the following days when the state minimum bariatric CNA staffing ratios were not met:-á -6/5/25 day shift and evening shift -6/7/25 day shift and evening shift -6/8/25 day shift, evening shift and night shift -6/12/25 day shift and night shift -6/13/25 day shift and night shift -6/14/25 day shift -6/15/25 day shift and evening shift -6/16/25 day shift -6/19/25 night shift -6/25/25 night shift -6/27/25 day shift, evening shift and night shift -6/28/25 day shift -6/29/25 day shift -7/2/25 night shift -7/6/25 day shift -7/11/25 day shift -7/12/25 night shift On 7/24/2025 at 10:47 AM Staff 1 reviewed staffing and acknowledged the facility did not staff to the minimum bariatric CNA staffing ratios on the identified dates.

Plan of Correction – Deficiency M0185 Tag: Bariatric Criteria and Services CFR(s): OAR 411-070-0087 1. Corrective action taken for those residents found to have been affected by the deficient practice: All bariatric residents identified as qualifying for the bariatric reimbursement rate continued to receive care and services without interruption. Upon identification of the deficiency, the facility immediately reviewed resident needs, reassessed staffing assignments, and confirmed that all bariatric residents had their care needs safely met during the period in question. 2.How the facility will identify other residents at risk: No other residents were identified as being affected. 3. Measures put in place or systemic changes made to ensure that the deficient practice will not recur: The Administrator will review the daily staffing report to confirm that additional CNA coverage is present for bariatric residents per regulatory requirement. The staff scheduler has been educated and re-trained on bariatric staffing requirements and will ensure that schedules reflect additional CNA coverage. 4. How the facility will monitor to ensure the deficient practice will not recur (quality assurance): The Admin or designee will conduct weekly audits of staffing schedules and daily staffing reports for 12 weeks to verify compliance with bariatric CNA staffing requirements. Results will be reviewed in monthly QAPI meetings. After 12 weeks, audits will be conducted monthly for 6 months and ongoing as part of the facility’s routine quality monitoring.

Based on observation, interview and record review it was determined the facility failed to follow physician's orders related to oxygen administration for 5 of 7 sampled residents (#s 13, 15, 16, 17 and 19) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: 1. Resident 13 was admitted to the facility in 9/2024, with diagnoses including chronic respiratory failure with hypoxia (lack of oxygen) and heart failure. Resident 13's 9/20/24 Physician's Orders indicated staff was to administer oxygen continuously at 1 liter per minute via nasal cannula. Resident 13's 12/2024 TAR revealed staff documented the resident was on oxygen continuously at 1 liter per minute via nasal cannula. On 12/17/24 at 10:48 AM, observations of Resident 13's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 13's oxygen was set at 2 L/min. Staff 3 acknowledged the resident's physician orders were not followed. On 12/17/24 at 2:15 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders. 2. Resident 15 was admitted to the facility in 11/2024, with diagnoses including chronic obstructive pulmonary disease (COPD) and emphysema (chronic lung disease). Resident 15's 12/11/24 Physician's Orders indicated staff was to administer oxygen continuously at 2 liters per minute via nasal cannula. Resident 15's Weights and Vitals Summary from 12/1/24 through 12/19/24 revealed 12 entries which revealed the resident was on room air (no oxygen was administered). On 12/17/24 at 10:55 AM, observations of Resident 15's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 15's oxygen was set at 1.5 liters per minute. Staff 3 acknowledged the physician orders were not followed. On 12/17/24 at 2:15 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders. 3. Resident 16 was re-admitted to the facility in 12/2024, with diagnoses including acute respiratory failure with hypoxia (lack of oxygen) and transient cerebral ischemic attack (stroke). Resident 16's 12/6/24 Physician's Orders indicated staff were to administer continuous oxygen at 1 liter per minute per nasal cannula. Resident 16's 12/2024 TAR revealed staff were monitoring the resident's oxygen levels, but were not documenting the amount of liters per minute of oxygen the resident was receiving. On 12/17/24 at 10:58 AM, observations of Resident 16's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 16's oxygen was set at 1.5 liters per minute. Staff 3 acknowledged the physician orders were not followed. On 12/17/24 at 2:15 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders. 4. Resident 17 was admitted to the facility in 12/2024, with diagnoses including congestive heart failure and acute respiratory failure with hypoxia (low oxygen). Resident 17's 12/13/24 Physician's Orders revealed no orders for oxygen. Resident 17's 12/16/24 Daily Skilled Charting Form revealed the resident "continued with oxygen via nasal cannula". On 12/17/2024 at 10:51 AM, observations of Resident 17's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 17's oxygen was set at 2.5 liters per minute. Staff 3 acknowledged the physician orders were not followed. On 12/17/24 at 2:15 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders. 5. Resident 19 was admitted to the facility in 9/2024, with diagnoses including chronic obstructive pulmonary disease and dysphagia (difficulty swallowing) following cerebrovascular disease (stroke). Resident 19's 12/17/24 physicians order revealed staff were to administer oxygen continuously at 2 liters per minute via nasal cannula. Resident 19's 12/2024 TAR revealed staff administered oxygen at 2 liters per minute nasal cannula. On 12/17/2024 at 10:50 AM, observations of Resident 19's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 19's oxygen was set at 1.5 liters per minute. Staff 3 acknowledged the physician orders were not followed. On 12/17/24 at 2:15 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders.

Forest Grove Post Acute Plan of Correction 1:A) Resident 13's oxygen was corrected to 1L/min via nasal canula. B) Resident 15’s oxygen order was updated to 2L/min via nasal canula with 2-4 L/min PRN. C) Resident 16 discharged from the facility on 12/24/2024. D) Resident 17 discharged from the facility on 12/23/2024. E) Resident 19’s oxygen order was updated to 2-4L/min via nasal canula PRN. 2: Residents on oxygen were audited to ensure their concentrators correctly reflected provider orders. 3: LNs have been re-educated on following provider orders. 4: DNS or designee will audit for following provider oxygen orders weekly x4 weeks and then monthly x2 months. The results of the audit will be forwarded to the QAPI committee for review and further recommendations. 5: Administrator is responsible for ensuring compliance

************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F695 ***************************

Based on interview and record review, it was determined the facility failed to treat residents with dignity and respect for 1 of 2 sampled residents (#32) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: Resident 32 was admitted to the facility in 2/2021 with diagnoses including ventricular tachycardia (irregular heartbeat) and chronic obstructive pulmonary disease (a disease that causes obstructed airflow from the lungs). Resident 32's 2/13/24 Annual MDS indicated she/he was cognitively intact. A facility investigation created and signed by Staff 2 (Interim Administrator) on 4/11/24 indicated Staff 8 (LPN) lifted Resident 32's left arm to remove her/his jacket, obtain her/his blood pressure and apply a lidocaine patch. Per the investigation, Staff 8 did not stop when Resident 32 told her the action caused her/him increased pain in her/his left shoulder. This action resulted in Staff 8 being placed on administrative leave while the facility completed an internal investigation. On 6/10/24 at 12:52 PM Resident 32 stated she/he told staff about her/his shoulder pain prior to the incident because, "I didn't want people to pull on it." She/he also stated, "When she was lifting my arm I told her to stop because it hurt so bad." Resident 32 said she/he thought Staff 8 was in a hurry and needed to get it done." On 6/11/24 at 3:15 PM Staff 8 stated she forgot Resident 32 had pain in her/his left shoulder when she started to help her/him remove her/his jacket on 4/11/24. She said she apologized to Resident 32 and told her/him "I forgot you had pain in your shoulder." A review of Resident 32's care plan initiated 3/1/24 revealed staff were advised to "allow 'no' to be a response, follow through with what you say you will do, give choices whenever possible, avoid rushing cares, maintain calm demeanor and provide active listening." On 6/11/24 at 4:22 PM Staff 2 stated [Staff 8] no longer worked in the facility and was in a hurry and did not slow down when lifting Resident 32's arm. He added, "She should have been more patient and listened to the resident." Staff 2 confirmed Resident 32 was already receiving a lidocaine patch for shoulder pain and acknowledged Staff 8, "should have taken her time and not caused [Resident 32] more pain."

Resident #32 has been interviewed post incident and reports she has no further concerns regarding lack of respect and dignity. Resident #32 continues to report she feels this interaction was not intentional The administrator reviewed grievances for the last 30 days for instances of residents being treated with lack of dignity and respect; no other instances identified LNs and CNAs have been re-educated on treating residents with respect and dignity Administrator or designee will audit grievances for instances of residents being treated with lack of dignity or respect weekly x 4 weeks then monthly x2 months. The results of the audit will be forwarded to the QAPI committee for review and further recommendations Administrator is responsible for ensuring compliance

Based on interview and record review it was determined the facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) in a timely fashion for 1 of 3 sampled residents (#29) reviewed for Beneficiary Protection Notification. This placed residents at risk for unknown financial liabilities. Findings include: Resident 29 was admitted to the facility in 2/2024 with diagnoses including metabolic encephalopathy (a problem in the brain caused by chemical imbalances in the blood) and chronic obstructive pulmonary disease (a disease that causes obstructed airflow from the lungs). Resident 29's Admission Record indicated she/he was her/his own responsible party and her/his 2/27/24 Admission MDS revealed she/he was cognitively intact. A review or Resident 29's health record revealed her/his last covered day of Medicare Part A Service was 4/22/24. No evidence was found in Resident 29's medical record to indicate the facility provided her/him with a SNF ABN, Form CMS-10055. On 6/11/24 at 12:33 PM Staff 9 (Social Services Director) confirmed Resident 29's last covered day of Medicare Part A services was 4/22/24 and stated she issued it to the resident on 6/11/24. Staff 9 acknowledged she issued it late and stated it should have been issued to Resident 29 on or before her/his last covered day under Medicare Part A Service. On 5/3/24 at 10:37 AM Staff 1 (Administrator) stated, "We should be giving residents 48 hour notice so they are aware of the change."

F582 – Medicaid/Medicare Coverage/Liability Notice Failure to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN). SNF ABN was reviewed with resident #29. Resident #29 signed SNF ABN No other residents affected Social Services have been re-educated on when to issue SNF ABN Administrator or designee will audit for SNF ABN completion weekly x 4 weeks then monthly x2 months. The results of the audit will be forwarded to the QAPI committee for review and further recommendations Administrator is responsible for ensuring compliance

Based on interview and record review it was determined the facility failed to provide assistance with incontinence care in a timely manner for 2 of 3 residents (#s 30 and 56) reviewed for ADLs. This placed residents at risk of delayed assistance with personal hygiene and increased risk of skin impairment. Findings include: 1. Resident 30 was admitted to the facility in 7/2023 with diagnoses including acute systolic (congestive) heart failure (a type of heart failure that occurs in the heart's left ventricle) and type two diabetes mellitus (a disease that occurs when blood sugar is too high). Resident 30's 7/17/23 Admission MDS indicated she/he was cognitively intact, frequently incontinent of bowel and bladder and she/he required extensive physical assistance from two persons to use the toilet. Resident 30's 7/17/23 Care Plan revealed staff were directed to "offer and assist [Resident 30] with using the toilet upon awakening; after meals; before rest/HS; NOC rounds and as [she/he] asks." On 6/10/24 at 10:17 AM Witness 1 (Case Manager) reported during an in-person visit with Resident 30 on 2/1/24, she observed her/him use her/his call light to request incontinence care. She stated three CNAs entered Resident 30's room at different times but did not provide her/him with incontinence care. She stated a fourth CNA arrived and provided Resident 30 with incontinence care. Witness 1 reported Resident 30 told her it was typical for her/him to wait approximately two hours for care to be provided after pressing her/his call button. On 6/12/24 at 12:56 PM Staff 27 (LPN) stated there are times where Resident 30 told her she/he had to wait a long time for caregivers to provide care. On 6/12/24 at 5:15 PM Staff 1 (Administrator) stated he was aware of complaints regarding long call light response times for incontinence care. He said he expected staff to respond to call lights in a timely fashion. He added, "We will re-emphasize that again with them." , 2. Resident 56 was admitted to the facility on 3/2024 with diagnoses including hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease). Resident 56's Care Plan dated 3/27/24 indicated the resident required two-person extensive assistance with toileting, one-to-two-person assistance with bed mobility and mechanical lift assistance with transfers out of bed. On 6/10/24 at 11:15 AM Resident 56 stated on 6/7/24 approximately 8:00 AM she/he pressed the call light for toileting assistance. Resident 56 stated about 15 minutes later, Staff 13 (CNA) came into her/his room to deliver the breakfast tray. Resident 56 informed Staff 13 she/he had a bowel movement and needed to be changed. Staff 13 stated she would return after delivering the trays but did not return. Resident 56 stated she/he waited over 90 minutes before calling the front receptionist to ask for assistance. On 6/12/24 at 10:25 AM Staff 14 (CNA) stated she was the CNA hall partner with Staff 13 who was assigned to Resident 56 on 6/7/24. Staff 14 stated she noticed Resident 56 had her/his call light on for a long time and she answered the resident's call light after completing all her morning ADL cares for her residents. Staff 14 stated Resident 56 was crying and very upset that she/he was left in her/his soiled brief for almost two hours. On 6/12/24 at 11:37 AM Staff 17 (Receptionist) stated she answered a phone call from Resident 56 who stated she/he had been waiting for nursing assistance for two hours. Staff 17 stated she walked down to the nurses' station to get assistance for Resident 56. On 6/12/24 at 12:10 PM Staff 13 stated she was assigned to Resident 56 on 6/7/24 and did not provide incontinence care in a timely manner. Staff 13 stated there was confusion on the room assignments and she was not aware she was assigned to Resident 56 until Staff 14 provided the incontinence care for the resident. On 6/13/24 at 11:44 AM Staff 2 (Interim Administrator) stated he expected that resident care would be provided in a timely manner and staff answered all the call lights regardless of room assignments.

F677 – ADL Care Provided for Dependent Residents Failure to provide assistance with incontinence care in a timely manner. Residents 56 and 30 have been interviewed and report call light response times have improved and report no adverse outcomes Incontinent dependent residents identified and reviewed for incontinence and satisfaction with staff response to incontinent needs, addressing any concerns identified. CNAs, LNs and RCMs have been re-educated on providing continence care in a timely manner Administrator or designee will audit for providing continence care in a timely manner weekly x4 weeks then monthly x2 months. The results of the audit will be forwarded to the QAPI committee for review and further recommendations Administrator is responsible for ensuring compliance

Based on interview and record review it was determined the facility failed to ensure a resident received pressure ulcer treatments for 1 of 1 sampled resident (#4) reviewed for pressure ulcers. This failure resulted in Resident 4's pressure ulcer worsening. Findings include: Resident 4 admitted to the facility in 2017 with diagnoses including hypertension and diabetes. The undated facility Event Summary Report indicated the following: -Resident 4 had a dressing in place dated 12/27/23 to her/his right ankle. -On 12/27/23 Staff 8 (LPN) measured Resident 4's wound on the right ankle and measurements were given to the Staff 12 (Former DNS) as requested. There was a dressing in place on the right ankle and Staff 8 measured the wounds and replaced the old bandage with a new one. -On 12/27/23 the wound measured 1.8 cm x 1.2 cm. -On 1/3/24 at approximately 1:30 PM Staff 11 (RNCM) and Staff 10 (LPN Resident Care Manager) completed wound rounds with the outside wound care provider. -On 1/3/24 the dressing was removed and revealed a Stage 3 pressure ulcer that measured 2 cm x 2.5 cm x 0.3 cm revealing a deterioration of the wound. On 6/12/24 at 10:53 AM Staff 11 stated on 1/3/24 she completed wound rounds with Staff 10 and the outside wound care provider. Staff 11 stated Staff 8 measured the wound on 12/27/23 and provided the measurements to Staff 12. Staff 11 stated she did not recall the observation of the dressing and wound from 1/3/24. On 6/12/24 at 11:14 AM Staff 10 stated on 1/3/24 she completed wound rounds with Staff 11 and the outside wound care provider and Resident 4 had a dressing on her/his right ankle initialed by Staff 8 and dated 12/27/23. Staff 11 stated the dressing was saturated when it was removed, and the information was reported to Staff 12. Staff 10 further stated Staff 8 measured the wound on 12/27/23 and reported the measurements to Staff 12. On 6/12/24 at 11:22 AM Staff 8 stated she worked on 12/27/23 and Resident 4 had a dressing on her/his ankle. Staff 8 stated she removed the dressing and took measurements of the wound and provided the measurements to Staff 12. Staff 8 stated she did not remember if she put a new dressing on the wound after measuring it. On 6/14/24 at 11:17 AM Staff 12 stated she was working as the DNS on 12/27/23 and Staff 8 provided Resident 4's right ankle wound measurement. Staff 12 stated she emailed the measurements to a resident care manager, there was no follow up notification to the physician and no orders were put in place for the pressure ulcer. Staff 12 acknowledged she did not follow up on the wound and wound care was not implemented. Staff 12 stated on 1/3/24 the facility staff and wound care provider identified there were no treatments in place for the wound from 12/27/23 through 1/3/24. Staff 12 stated in-services were provided regarding pressure ulcer assessments and wound care on 1/3/24. On 6/14/24 at 11:33 AM Staff 2 acknowledged Resident 4's pressure ulcer to the right ankle measured 1.8 cm x 1.2 cm on 12/27/23, treatments were not put in place and physician orders were not obtained until 1/3/24. Staff 2 acknowledged the wound worsened and on 1/3/24 the wound measured 2 cm x 2.5 cm x 0.3 cm. Staff 2 stated an in-service was provided on 1/3/24. On 6/14/24 at 10:54 AM the facility provided information to indicate education and an in-service was provided to nursing staff related to the identified incident. The deficient practice was determined to be past non-compliance, corrected on 1/3/24.

Based on Interview and record review was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNAs (#14, 18, 19, 20 and 21) reviewed for staff performance reviews. This placed residents at risk for lack of care by competent staff. Findings include: On 6/14/24 at 11:06 AM a review of facility personnel records with Staff 2 (Interim Administrator) indicated the following: - Staff 14 (CNA) was hired on 8/20/20; no annual performance review was completed. - Staff 18 (CNA) was hired on 8/20/04; no annual performance reviews were completed. - Staff 19 (CNA) was hired on 11/12/10; no annual performance reviews were completed. - Staff 20 (CNA) was hired on 6/14/18; no annual performance reviews were completed. -Staff 21 (CNA) was hired on 11/5/21; no annual performance reviews were completed. On 6/14/24 at 11:43 AM Staff 2 confirmed the annual performance reviews were not completed for Staff 14, Staff 18, Staff 19, Staff 20, or Staff 21. Staff 2 stated it was his expectation the annual performance reviews were completed annually.

F730 – Nurse Aide Perform Review – 12hr/yr In-Service Failure to ensure CNAs received annual performance reviews CNAs have received annual performance reviews Administrator and DNS have been re-educated on completing CNA performance reviews annually Administrator or designee will audit for CNA annual performance review completion weekly x 4 weeks then monthly x2 months. The results of the audit will be forwarded to the QAPI committee for review and further recommendations Administrator is responsible for ensuring compliance

Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 7 out of 30 days reviewed for staffing. This placed residents, the public and staff at risk for lack of accurate staffing information. Findings include: On 6/10/24 at 3:51 PM the Direct Care Staff Daily reports were provided from 5/7/24 through 6/10/24. The forms revealed seven instances where portions of the form were left blank or were incomplete. The incomplete information included census, number of staff working and number of hours worked. On 6/14/24 at 10:21 AM Staff 1 (Administrator) and Staff 22 (Corporate Consultant) acknowledged the Direct Care Staff Daily reports were incomplete for 7 out of 30 days. Staff 1 stated it was her expectation staff completed the daily staffing sheets at the beginning of each shift every day.

F732 – Posted Nurse Staffing Information Failure to ensure the daily staffing posting was accurate Staffing sheets have been corrected DNS, RCMs and floor nurses have been re-educated on completing the daily staffing posting accurately Administrator or designee will audit for daily staffing posting completion weekly x 4 weeks then monthly x2 months. The results of the audit will be forwarded to the QAPI committee for review and further recommendations Administrator is responsible for ensuring compliance

Based on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained for 1 of 1 medication storage refrigerator reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: On 6/13/24 at the medication refrigerator temperature logs were observed to be blank on the following dates: -5/3/24 -5/10/24 -5/11/24 -5/12/24 -5/13/24 -5/18/24 -5/19/24 -5/20/24 -5/21/24 -5/26/24 -5/27/24 -5/28/24 -5/31/24 -6/1/24 -6/2/24 -6/3/24 -6/4/24 -6/9/24 On 6/13/24 at 11:37 AM Staff 2 (DNS) acknowledged the blank temperature logs for the identified dates for the medication refrigerator and stated the expectation was for the nurse to complete the temperature logs.

F761 – Label/Store Drugs and Biologicals Failure to ensure appropriate medication storage No residents identified DNS, RCMs and floor nurses have been re-educated on ensuring medication refrigerator temperature log is completed daily Administrator or designee will audit for daily medication refrigerator temperature completion weekly x 4 weeks then monthly x2 months. The results of the audit will be forwarded to the QAPI committee for review and further recommendations Administrator is responsible for ensuring compliance

**************************** OAR 411-085-0310: Resident Rights: Generally Refer to F550 **************************** 411-085-0320: Residents' Rights: Charges and Rates Refer to F582 **************************** 411-086-011: Nursing Services: Resident Care Refer to F677 **************************** 411-086-0140: Nursing Services: Problem Resolution and Preventive Care Refer to F686 **************************** 411-086-0100: Nursing Services: Staffing Refer to F725 and F732 **************************** 411-086-0310: Employee Orientation and In-Service Training Refer to F730 **************************** 411-086-0260: Pharmaceutical Services Refer to F761 ****************************

Based on interview and record review it was determined the facility failed to order home health and in home care giving service to ensure a safe discharge for 1 of 2 sampled residents (#4) reviewed for discharge. This placed residents at risk for unsafe discharge. Findings include. Resident 4 was admitted to the facility in 2022 with diagnoses including elevated white blood cell count and muscle weakness. Resident discharged to the community on 9/1/23. A 7/15/23 Admission MDS revealed Resident 4 with a BIMS of 15 out of 15 which indicated no cognitive impairment. A 9/28/23 Hospital Discharge Summary revealed Resident 4 presented to the emergency department on 9/7/23 due to generalized weakness caused by the resident's inability to get up from her/his recliner. Additional hospital notes revealed Resident 4 was a resident of the facility six days prior to hospital admission and was not set up with in home health and caregiving services prior to discharge. On 10/5/23 at 1:05 PM Staff 3 (SSD) indicated she could not verify and confirm the date of service for in home health care and caregiving services prior to residents discharge. On 10/5/23 at 1:18 PM Staff 4 (PT) stated Resident 4 was recommended to a higher level of care due to the resident level of function related to transfers prior to discharge on 9/1/23. Staff 4 indicated the Resident 4 had poor capacity to recognize safety concerns which presented as a challenge for at home discharge. On 10/5/23 at 10:01 AM Staff 1 (Administrator) confirmed findings and provided no additional information.

1. Identified resident is a recurrent skilled resident at Forest Grove Rehab and Care Center, a safe discharge will be planned accordingly 2. Administrator or designee will audit all future discharges to ensure necessary services are in place 3. Social Services Director and Social Services Coordinator have been re-educated on the importance of coordinating necessary resources for discharges 4. Administrator or designee will audit all discharges weekly for four weeks and then monthly for two months to ensure resident discharge needs are met. Results of audits will be brought to QAPI for review.

************************** 411-088-0030 Considerations Required Prior to Transfer (safe/orderly/transfer/discharge) Refer to F624 **************************

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from verbal abuse for 1 of 3 sampled residents (#2) reviewed for abuse. This placed residents at risk for mental anguish and psychosocial decline. Findings include: The facility 2/2019 Abuse Screening, Training, Identification, Investigation, Reporting and Protection Policy defined verbal abuse as "the use of oral, written or gestured communication to a resident or visitor that describes a resident(s) in disparaging or derogatory terms." Resident 2 admitted to the facility in 2021 with diagnoses including femur fracture. The 3/11/22 Quarterly MDS indicated Resident 2 was cognitively intact. Resident 2's 3/31/22 Care Plan indicated Resident 2 agreed that when Resident 16 went out to the smoking area, she/he would call staff to come assist her/him back to her/his room and/or when Resident 16 was out in the smoking area/patio Resident 2 would wait until Resident 16 left to minimize interacting with her/him. Resident 16 admitted to the facility in 2018 with diagnoses including dementia without behavioral disturbances and anxiety disorder. The 9/23/21 Annual MDS Dementia CAA indicated Resident 16 was alert and at risk for further cognitive loss. Staff were to provide cognitive support, reorienting and redirecting as needed. The 3/12/22 Quarterly MDS indicated Resident 16 had moderately impaired cognition (BIMS 11). The 8/31/22 BIMS Assessment indicated Resident 16 was cognitively intact (BIMS 13). Resident 16's 8/1/19 Care Plan last updated 8/22/22 indicated the following: -Behavior monitoring due to sexually inappropriate actions when staff were in room attempting to provide care, specifically female caregivers; -Cursing and yelling at staff during care; -History of sexually touching himself/ejaculation; -Inappropriate name calling/calling other residents names; -Provide privacy to resident by pulling curtain closed or closing door; -Offer hand hygiene; -Remind [her/him] that calling other residents or staff inappropriate names is not appropriate and not acceptable. An incident report dated 3/22/22 indicated Resident 2 informed the Administrator that on 3/21/22 while she/he was in the resident smoking area, Resident 16 came out to the smoking area and preceded to sit and stare at her/him. Resident 2 asked Resident 16 to please not sit there and stare and that she/he did not appreciate it. Resident 16 preceded to call her/him "f****** c***". Per Resident 2, the exchange was witnessed by another resident but the alleged witness was unable to recall the incident when interviewed. Resident 2 was encouraged to call staff when she/he felt "the presence" of Resident 16 while in smoking area. Both are independent smokers and continued to be independent smokers. An incident report dated 3/26/22 indicated Resident 2 requested to speak to the Administrator about an incident that happened sometime during the mid-morning in the smoking area between Resident 2 and Resident 16. Resident 2 stated she/he was sitting in the smoking area and Resident 16 was staring at her/him. Resident 2 stated she/he asked Resident 16 to please not stare at her/him. Resident 2 stated Resident 16 extinguished her/his cigarette and was "rolling away" in her/his wheelchair and Resident 16 said "I am sorry I called you a b**** before, I really should have called you a c***." Resident 16 went inside the building. The Administrator asked Resident 2 if she/he felt safe and she/he said "yes" and did not want Resident 16 to say "mean things" or stare at her/him. Behavior Monitoring indicated Resident 16 had "sexually inappropriate behavior" on 4/16/22, 7/21/22 and 7/22/22. There was no indication of what the behavior was, how the behavior was addressed, or if the care plan was updated. Interviews with residents revealed the following: -8/30/22 at 3:03 PM Resident 20 stated Resident 16 continuously "harassed" Resident 2 "for months." Resident 20 stated Resident 16 called Resident 2 "vulgar names" including "cunt" and also "blows [her/him] kisses" and Resident 2 was upset about the behaviors. Resident 20 stated staff told Resident 2 that Resident 16 had dementia and did not know what [she/he] was doing but Resident 16 "knows exactly what [she/he] is doing." -8/31/22 at 8:56 AM Resident 21 stated Resident 16 "harassed" Resident 2 for the past eight months and Resident 2 asked Resident 16 to leave her/him alone. Resident 21 stated she/he observed Resident 16 call Resident 2 a "sweetie," "cunt," and "I want to eat your pussy." Resident 21 stated Resident 16 sat at the window near the smoking areas and "blows [Resident 2] kisses." Resident 21 stated the behavior was reported to staff on several occasions and staff stated Resident 16 had dementia and Resident 16 was not monitored. -9/2/22 at 9:50 AM Resident 22 stated she/he observed Resident 16 call Resident 2 a "cunt," "bitch" and "whore." Resident 22 further stated Resident 16 sat near the sliding glass door and stared at Resident 2 while she/he was in the smoking area. On 8/30/22 at 1:35 PM and 2:07 PM Staff 20 (CNA) stated Resident 16 fully exposed her/himself in her/his room with the door open and masturbated while looking out in the hall and this occurred daily. Staff 20 stated he closed the curtain if he saw this behavior to provide Resident 16 privacy. Staff 20 stated he observed Resident 16 tell Resident 2 "I want you to suck my dick, I want to play with your tits, and I want to grab you." Staff 20 stated Resident 2 told Resident 16 to "please just get away from me" and Resident 2 was upset. Staff 20 stated this happened a "couple of months ago" in the dining room and outside in the courtyard. Staff 20 stated he told Resident 16 the behavior was inappropriate and reported the incident to a nurse but was unsure of the nurse's name and did not believe she still worked at the facility. Staff 20 stated he witnessed Resident 16 make inappropriate sexual comments to residents once or twice weekly. Staff 20 stated Resident 16 had a history of being inappropriate with female staff. Staff 20 stated Resident 16 was aware of what she/he was doing. On 8/30/22 at 1:57 PM Staff 26 (LPN) stated Resident 16 masturbated "all the time" with the door open while looking around her/his room and into the hall. Staff 26 stated Resident 16 was "100 percent" alert and oriented. On 8/30/22 at 3:11 PM Staff 4 (CNA) stated Resident 2 was dependent on staff to take her/him to and from the smoking area and could not self-propel in her/his wheelchair. Staff 4 stated she had not seen Resident 2 and Resident 16 interact. On 8/31/22 at 6:22 AM Resident 16 was observed masturbating with her/his room door wide open and no privacy curtain pulled. Staff were observed passing by. On 8/31/22 at 11:26 AM Staff 19 (Social Services) stated Resident 16 had a history of saying things to Resident 2 such as "hey beautiful, how are you doing gorgeous?" and also called her/him a "bitch" and a "cunt". Staff 19 stated when Resident 2 reported the incidents to her the resident was upset and crying and Resident 2 felt like not enough was being done about Resident 16's behavior. Staff 19 stated Resident 2 did not want to be around Resident 16 which was difficult since both residents were smokers. Staff 19 further stated Resident 16 had a history of sitting outside of Resident 2's room and attempted to talk to her/him. Staff 19 stated she talked to Resident 16 about her/his behaviors but an hour later Resident 16 would be "right next to [Resident 2] again." On 9/1/22 at 2:49 PM Resident 2 stated Resident 16 called her/him a "fucking bitch and a cunt," "I want to lick your pussy," and called her/him names "almost daily." Resident 2 stated Resident 16 "blows kisses at me and does vulgar things with [her/his] tongue." Resident 2 stated she/he reported the incidents to multiple staff on multiple occasions. Resident 2 stated when she/he saw Resident 16 she/he started sweating profusely and did not want to be harassed every day. Resident 2 stated her/his previous room was down the hall from Resident 16 and she/he observed Resident 16 masturbating with the door open when passing by the room on several occasions. On 9/1/22 at 3:19 PM Resident 16 stated Resident 2 was "smart, pretty" and she/he "liked" Resident 2 but they were currently in a "pissing match." Resident 16 stated she/he called Resident 2 a "bitch and a cunt" and "[she/he] hasn't got over it" and "[she/he] deserves it." Resident 16 stated staff talked to her/him regarding the behaviors but she/he wanted to get Resident 2 "alone" to talk to her/him and apologize, but Resident 2 did not want to talk to her/him. Resident 16 stated she/he "blew [Resident 2] kisses." Resident 16 denied making sexually inappropriate comments to Resident 2. On 9/1/22 at 3:45 PM and 9/2/22 at 11:49 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated Resident 2 told staff of the identified incidents that occurred on 3/21/22 and 3/26/22. Staff 1 stated a plan was made to have Resident 2 and Resident 16 go out to the smoking area at different times of the day and staff were informed of the plan. Staff 1 further stated Resident 2 enjoyed staying out in the smoking area all day. Staff 1 and Staff 2 stated they were unaware of other incidents between Resident 2 and Resident 16 and staff did not report further incidents to them. Staff 1 and Staff 2 acknowledged the incidents occurred on 3/21/22 and 3/26/22 and Resident 2's care plan was not updated until 3/31/22 and Resident 16's care plan was not updated as of 9/1/22 for interventions to prevent further the incidents.

1) #16 has been placed on 1:1 that will continue until alternative placement arranged. Care plan updated for both resident #2 and #16. 2) No other residents identified. Resident #16 to remain 1:1 to prevent potential events. 3) Staff educated on the policy and procedure of Abuse and Neglect. Reporting guidelines addressed during education. Resident council also educated on reporting concerns. 4) The Nursing Director/designee will conduct weekly reviews of 5 resident abuse interviews to ensure all concerns addressed x 4 weeks, and then every 2 weeks x 2 months. This will include direct questions regarding verbal abuse by resident #16 5) The findings of these reviews will be reported in the next Risk Management/QA/QAA/QAPI Committee meeting for 3 months then, until committee determines substantial compliance has been met and recommends quarterly monitoring 6) Social Service/ DNS Responsible. Date of compliance 9/29/22

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of financial resources for 1 of 3 sampled residents (#6) reviewed for misappropriation of property. This placed residents at risk for misuse of personal funds. Findings include: The facility's Gift and Gratuities Policy dated 2015, indicated employees were not to accept gifts from residents. The policy indicated the acceptance of gifts of cash is never permissible and no gift or items of value of any kind should be solicited from residents. The policy was signed by Staff 11 (former Activities Assistant) on 7/24/19. Resident 6 admitted to the facility 2018 with diagnoses including depression. Resident 6 was identified to be alert and oriented. On 5/4/21 an incident was reported indicating Staff 8 (Business Office Manager) received a phone call from Resident 6's bank. The bank alleged Resident 6 had written several checks to Staff 11 including a check for $900. The facility investigation indicated on 5/4/22 Staff 8 was notified by Resident 6's bank of checks ($300, $500 and $900) written to Staff 11. Staff 8 directed the bank not to authorize the $900 check. Staff 11 was contacted and indicated the money was used to purchase personal items for Resident 6 (cell phone, hearing aid and groceries). The resident was interviewed and indicated she/he wrote Staff 11 the checks willfully. Resident 6 was upset, angry and indicated she/he could do what she/he wanted with her/his money and trusted Staff 11. Staff 11 was out state on vacation and was suspended upon her return on 5/13/21. Staff 11 stated she received checks from Resident 6 in the amount of $300 and $900. Staff 11 stated the $300 was for reimbursement that Resident 6 insisted she take. Staff 11 indicated she did not accept the checks for financial gain and it "gave [Resident 6] dignity" in getting the things she/he wanted. Staff 11 stated the $900 was for items she saw while on vacation that Resident 6 may have wanted. Staff 11 indicated there were other checks written to her that had been deposited. Staff 11 was asked to provide any receipts she had and to provide documentation of all checks deposited. Upon review, it was identified that additional checks in the amount of $60, $100, and $300 were written to her which Staff 11 indicated she forgot about. Upon conclusion of the investigation, the allegation of misappropriation was substantiated as Staff 11 was unable to account for or provide all receipts and violated facility policy. Staff 11 was terminated. On 8/30/22 at 1:25 PM Resident 6 stated Staff 11 "did nothing wrong." Resident 6 stated she/he wrote the checks to Staff 11 because Staff 11 bought many items for her/him including a pillow and was paying her back. Resident 6 stated she/he was aware Staff 11 was going on vacation to Florida and was afraid Staff 11 may get "stuck there" or may "get in trouble" so she wrote Staff 11 a check for $900 to pay her back plus an additional $50. Resident 6 stated Staff 11 told her/him she was not allowed to accept the check, but she/he insisted that she take the money to pay her back. On 8/31/22 at 9:15 AM Staff 8 (Business Office Manager) stated Resident 6's bank contacted her and informed her that one of Resident 6's checks was attempted to be cashed by Staff 11 in Florida. Staff 8 stated in talking with the bank it was discovered that other checks were written to Staff 11. Staff 8 stated Resident 6 was reimbursed for all the checks written to Staff 11. Staff 8 stated a resident trust account was in place at the time of the incident and all resident money was to be signed out by the resident for staff to do any resident shopping. Staff 8 stated Staff 11 was aware of the process and "knew better" than to accept money from Resident 6. On 8/31/22 at 9:44 AM Staff 9 (Activities Director) stated he received a call from Staff 1 (Administrator) who informed him that Resident 6's bank called indicating Staff 11 attempted to cash a check from Florida. Staff 9 stated Staff 11 would often buy items for residents using her own money. Staff 9 stated he told Staff 11 that she did not have to use her own money and could be reimbursed. Staff 9 stated Staff 11 indicated she purchased items for Resident 6 and one of the checks for $500 was for the last six months of items that were purchased. Staff 9 stated no receipts were ever provided. Staff 9 stated Staff 11 "knew better" and was told they were not allowed to directly handle resident's personal funds. On 8/31/22 at 10:24 AM Staff 1 (Administrator) stated Staff 8 informed him that Resident 6's bank contacted her about a $900 check that was attempted to be cashed in Florida by Staff 11. Staff 1 stated he spoke with Resident 6 who became upset and stated she/he gave the money to Staff 11 to buy her/him things in Florida. Staff 1 stated he informed Resident 6 that staff were not allowed to accept personal money from residents. Staff 1 stated when he spoke with Staff 11 regarding the $900, Staff 11 stated Resident 6 wanted her to purchase items for her/him while she was on vacation in Florida. Staff 1 stated Staff 11 indicated she used her own money to purchase items for Resident 6 and could no longer do so. Staff 1 stated Staff 11 confirmed she cashed the checks and would purchase items for Resident 6 and return any change to the resident. Staff 1 stated in reviewing Staff 11's bank statements, additional checks for smaller amounts were identified written by Resident 6 to Staff 11. Staff 1 stated Staff 11 was able to provide only some of the receipts for items she purchased for Resident 6. Staff 1 confirmed the allegation of misappropriation of resident funds was substantiated for Resident 6. On 8/31/22 at 12:32 PM Staff 11 indicated she became "really attached" to Resident 6 and vise versa. Staff 11 state she assisted residents with needs the facility did not provide such as clothes. Staff 11 stated Resident 6 requested "specific items" be purchased, and the resident would occasionally write her a check with any change given back to the resident. Staff 11 stated she was going to Florida and was busy preparing for the trip and accepted the check for $900 from Resident 6. Staff 11 stated the $900 was never used and never went into her account. Staff 11 stated she accepted the check because Resident 6 was "upset and felt neglected." Staff 11 stated the situation went "too far." Staff 11 acknowledged there was a process in place regarding shopping for residents and indicated she followed the process until she accepted the $900. Staff 11 stated she "knew better" but felt "pressured" by Resident 6 to accept the money. Staff 11 stated she never accepted money from other residents.

1) #2 situation has been resolved 2) No other resident affected based on interviews. Resident council educated about gift giving and offering money/checks. Staff 11 is no longer employed at the facility and no other employees or residents identified. 3) Staff educated on F602 483.12 Freedom from Abuse, Neglect, and Exploitation with an emphasis on not being allowed to receive any gifts or gratuities or offer to do banking from or for resident or their families. Resident council addressed in meeting to discuss gifts an gratuities. 4) The Nursing Director/designee will conduct weekly reviews of 5 resident abuse interviews that include financial exploitation questions. 5) Weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these reviews will be reported in the next Risk Management/QA/QAA/QAPI Committee meeting for 3 months then, until committee determines substantial compliance has been met and recommends quarterly monitoring. 6) Social Service/ DNS Responsible. Date of compliance 9/29/22

Based on interview and record review it was determined the facility failed to thoroughly investigate allegations of verbal abuse for 1 of 3 sampled residents (#2) reviewed for abuse. This placed residents at risk for mental anguish and psychosocial decline. Findings include: The facility 2/2019 Abuse Screening, Training, Identification, Investigation, Reporting and Protection Policy defined verbal abuse as "the use of oral, written or gestured communication to a resident or visitor that describes a resident(s) in disparaging or derogatory terms." The facility's 2/2019 Accident/Incident Policy indicated "all resident to resident altercations require an incident investigation to be started for each resident, regardless of whether the altercation was physical, verbal or attempted...if in doubt about what constitutes an incident, fill out the report." An incident report dated 3/22/22 indicated Resident 2 informed the Administrator that on 3/21/22 while she/he was in the resident smoking area, Resident 16 came out to the smoking area and preceded to sit and stare at her/him. Resident 2 asked Resident 16 to please not sit there and stare and that she/he did not appreciate it. Resident 16 preceded to call her/him "f****** c***". Per Resident 2, the exchange was witnessed by another resident but the alleged witness was unable to recall the incident when interviewed. Resident 2 was encouraged to call staff when she/he felt "the presence" of Resident 16 while in smoking area. Both are independent smokers and continued to be independent smokers. An incident report dated 3/26/22 indicated Resident 2 requested to speak to the Administrator about an incident that happened sometime during the mid-morning in the smoking area between Resident 2 and Resident 16. Resident 2 stated she/he was sitting in the smoking area and Resident 16 was staring at her/him. Resident 2 stated she/he asked Resident 16 to please not stare at her/him. Resident 2 stated Resident 16 extinguished her/his cigarette and was "rolling away" in her/his wheelchair and Resident 16 said "I am sorry I called you a b**** before, I really should have called you a c***." Resident 16 went inside the building. The Administrator asked Resident 2 if she/he felt safe and she/he said "yes" and did not want Resident 16 to say "mean things" or stare at her/him. The identified investigations did not include witness statements, other resident interviews, including the alleged perpetrator, and resident care plans were not updated for interventions to prevent further incidents. On 9/1/22 at 3:45 PM and 9/2/22 at 11:49 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) acknowledged there were no witness statements for both incidents and Resident 2's care plan was not updated until 3/31/22 and Resident 16's care plan was not updated as of 9/1/22 related to the incidents. Staff 1 and Staff 2 acknowledged a thorough investigation was not completed for the incidents that occurred on 3/21/22 and 3/26/22. Refer to F600.

1) #16 has been placed on 1:1 that will continue until alternative placement arranged. Care plan updated for both resident #2 and #16 completed. 2) No other residents affected. Grievances, incidents, resident council meeting minutes and resident abuse interviews reviewed to ensure any identified reportable were completed. 3) Administration, clinical management, and social services educated to the policy and procedure on Abuse and Neglect reporting and timelines. Included, is education on obtaining witness reports from those involved and other residents that may have been affected and other pertinent information regarding the accusation and care plan updates as appropriate. 4) The Administrator/designee will conduct weekly reviews of resident abuse interviews, grievances, and incidents to ensure investigations are complete to ensure all aspects of the investigation are included and reported as appropriate. Care plans will be updated when deemed necessary. 5) Weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these reviews will be reported in the next Risk Management/QA/QAA/QAPI Committee meeting for 3 months then, until committee determines substantial compliance has been met and recommends quarterly monitoring. 6) Administrator/Social services Responsible. Date of compliance 9/29/22

Based on interviews and record review it was determined the facility failed to ensure Staff 11 (Activities Assistant) adhered to professional standards related to misappropriation of resident personal funds for 1 of 3 sampled resident (#6) reviewed for misappropriation of property. This placed residents at risk for misuse of financial resources. Findings include: The facility's Gift and Gratuities Policy dated 2015, indicated employees were not to accept gifts from residents. The policy indicated the acceptance of gifts of cash is never permissible and no gift or items of value of any kind should be solicited from residents. The policy was signed by Staff 11 (former Activities Assistant) on 7/24/19. Resident 6 admitted to the facility 2018 with diagnoses including depression. Resident 6 was identified to be alert and oriented. On 5/4/21 an incident was reported indicating Staff 8 (Business Office Manager) received a phone call from Resident 6's bank. The bank alleged Resident 6 had written several checks to Staff 11 including a check for $900. The facility investigation indicated on 5/4/22 Staff 8 was notified by Resident 6's bank of checks ($300, $500 and $900) written to Staff 11. Staff 8 directed the bank not to authorize the $900 check. Staff 11 was contacted and indicated the money was used to purchase personal items for Resident 6 (cell phone, hearing aid and groceries). The resident was interviewed and indicated she/he wrote Staff 11 the checks willfully. Resident 6 was upset, angry and indicated she/he could do what she/he wanted with her/his money and trusted Staff 11. Staff 11 was out state on vacation and was suspended upon her return on 5/13/21. Staff 11 stated she received checks from Resident 6 in the amount of $300 and $900. Staff 11 stated the $300 was for reimbursement that Resident 6 insisted she take. Staff 11 indicated she did not accept the checks for financial gain and it "gave [Resident 6] dignity" in getting the things she/he wanted. Staff 11 stated the $900 was for items she saw while on vacation that Resident 6 may have wanted. Staff 11 indicated there were other checks written to her that had been deposited. Staff 11 was asked to provide any receipts she had and to provide documentation of all checks deposited. Upon review, it was identified that additional checks in the amount of $60, $100, and $300 were written to her which Staff 11 indicated she forgot about. Upon conclusion of the investigation, the allegation of misappropriation was substantiated as Staff 11 was unable to account for or provide all receipts and violated facility policy. Staff 11 was terminated. On 8/30/22 at 1:25 PM Resident 6 stated Staff 11 "did nothing wrong." Resident 6 stated she/he wrote the checks to Staff 11 because Staff 11 bought many items for her/him including a pillow and was paying her back. Resident 6 stated she/he was aware Staff 11 was going on vacation to Florida and was afraid Staff 11 may get "stuck there" or may "get in trouble" so she wrote Staff 11 a check for $900 to pay her back plus an additional $50. Resident 6 stated Staff 11 told her/him she was not allowed to accept the check, but she/he insisted that she take the money to pay her back. On 8/31/22 at 9:15 AM Staff 8 (Business Office Manager) stated Resident 6's bank contacted her and informed her that one of Resident 6's checks was attempted to be cashed by Staff 11 in Florida. Staff 8 stated in talking with the bank it was discovered that other checks were written to Staff 11. Staff 8 stated Resident 6 was reimbursed for all the checks written to Staff 11. Staff 8 stated a resident trust account was in place at the time of the incident and all resident money was to be signed out by the resident for staff to do any resident shopping. Staff 8 stated Staff 11 was aware of the process and "knew better" than to accept money from Resident 6. On 8/31/22 at 9:44 AM Staff 9 (Activities Director) stated he received a call from Staff 1 (Administrator) who informed him that Resident 6's bank called indicating Staff 11 attempted to cash a check from Florida. Staff 9 stated Staff 11 would often buy items for residents using her own money. Staff 9 stated he told Staff 11 that she did not have to use her own money and could be reimbursed. Staff 9 stated Staff 11 indicated she purchased items for Resident 6 and one of the checks for $500 was for the last six months of items that were purchased. Staff 9 stated no receipts were ever provided. Staff 9 stated Staff 11 "knew better" and was told they were not allowed to directly handle resident's personal funds. On 8/31/22 at 10:24 AM Staff 1 (Administrator) stated Staff 8 informed him that Resident 6's bank contacted her about a $900 check that was attempted to be cashed in Florida by Staff 11. Staff 1 stated he spoke with Resident 6 who became upset and stated she/he gave the money to Staff 11 to buy her/him things in Florida. Staff 1 stated he informed Resident 6 that staff were not allowed to accept personal money from residents. Staff 1 stated when he spoke with Staff 11 regarding the $900, Staff 11 stated Resident 6 wanted her to purchase items for her/him while she was on vacation in Florida. Staff 1 stated Staff 11 indicated she used her own money to purchase items for Resident 6 and could no longer do so. Staff 1 stated Staff 11 confirmed she cashed the checks and would purchase items for Resident 6 and return any change to the resident. Staff 1 stated in reviewing Staff 11's bank statements, additional checks for smaller amounts were identified written by Resident 6 to Staff 11. Staff 1 stated Staff 11 was able to provide only some of the receipts for items she purchased for Resident 6. Staff 1 confirmed the allegation of misappropriation of resident funds was substantiated for Resident 6. On 8/31/22 at 12:32 PM Staff 11 indicated she became "really attached" to Resident 6 and vise versa. Staff 11 state she assisted residents with needs the facility did not provide such as clothes. Staff 11 stated Resident 6 requested "specific items" be purchased, and the resident would occasionally write her a check with any change given back to the resident. Staff 11 stated she was going to Florida and was busy preparing for the trip and accepted the check for $900 from Resident 6. Staff 11 stated the $900 was never used and never went into her account. Staff 11 stated she accepted the check because Resident 6 was "upset and felt neglected." Staff 11 stated the situation went "too far." Staff 11 acknowledged there was a process in place regarding shopping for residents and indicated she followed the process until she accepted the $900. Staff 11 stated she "knew better" but felt "pressured" by Resident 6 to accept the money. Staff 11 stated she never accepted money from other residents. Refer to F602.

1) Resident # 2 resolved 2) After resident interviews, no other resident affected by employees using or obtaining, gifts, gratuities, and staff accepting checks or banking for resident. Resident council educated. Staff 11 is no longer employed at the facility. 3) Staff educated on F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) with an emphasis on not being allowed to receive any gifts or gratuities or perform banking duties from resident or their families. Employee handbook reviewed on hire for accepting gifts or gratuities. 4) The Administrator/designee will conduct weekly reviews of 5 resident abuse interviews to ensure professional standards are met around giving of gifts and gratuities. 5) Weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these reviews will be reported in the next Risk Management/QA/QAA/QAPI Committee meeting for 3 months then, until committee determines substantial compliance has been met and recommends quarterly monitoring. 6) Administrator/Social services Responsible. Date of compliance 9/29/22

Based on observation, interview, and record review it was determined the facility failed to ensure adequate nursing staff to meet resident needs for 4 of 4 halls reviewed for staffing. This placed residents at risk for delayed care and unmet care needs. Findings include: A list provided by the facility on 9/2/22 indicated the facility had 15 residents who required a mechanical lift for transfers and 20 other residents who required two staff assistance for transfers. Resident Council Notes reviewed from 6/2022 through 8/2022 indicated the following: *6/24/22: No staffing concerns. *7/22/22: CNAs do not come when asking for help and eggs are served cold. *8/26/22: Food is always served cold. Facility Staff indicated the following concerns: - On 8/31/22 at 6:08 AM Staff 4 (CNA) stated the night prior she had 12 residents to care for independently on evening shift. Staff 4 stated the only reason she was able to complete showers was because both residents wanted a bed bath. Staff 4 further stated evenings were the hardest for staffing and she had to work a lot of double shifts. - On 8/31/22 at 6:08 AM Staff 22 (CNA) stated there were not enough staff for night shift and he often worked double shifts. Staff 22 stated on night shift Resident 13 waited "a while" for incontinence care and the resident needed to be changed when he responded to her/his room. Staff 22 further stated often times nurses would not answer call lights and CNA staff had to answer all of the call lights. - On 8/31/22 at 9:20 AM Staff 7 (LPN) stated due to staffing concerns nurses had to do CNA work. Staff 7 stated weekends for staffing were "just horrible." Staff 7 stated there were times it was just one CNA and her for one hall and the facility had a lot of "needy residents" that required two staff for changing, toileting, dressing, and transferring. Staff 7 stated she had to tell CNA staff that she did not have time to assist them as she was doing medications and blood sugars, and there were less nurses on the floor. - On 8/31/22 at 12:20 PM Staff 25 (CNA) stated during 5/2022 the facility was short staffed on evening shift and all call lights took longer to be answered. - On 8/31/22 at 1:48 PM Staff 24 (CNA) stated in 5/2022 the facility was short staffed and call lights took longer to be answered due to a lack of staff. Facility Residents indicated the following concerns: - On 8/30/22 at 1:25 PM Resident 6 stated call lights took a long time (over an hour) and was worse during day shift. Resident 6 stated staff forget to help and she/he will have to yell out for assistance. - On 9/2/22 at 10:24 AM Resident 18 stated the facility was always short CNA staff. Resident 18 stated day shift and the weekends were the worst. The resident stated sometimes there was only one CNA for the whole hall. Resident 18 stated call light times varied and could ranged from 10 minutes to almost an hour. The resident stated she/he usually called for assistance to use the bathroom. The resident stated even her/his daughter called the facility to get assistance for her/him when the call light was not being answered. Resident 18 stated one time both she/he and her/his roommate called for assistance and waited for 45 minutes. Resident 18 stated all meals were late. - On 9/2/22 at 10:25 AM Resident 19 stated call light times took a long time depending on the day, especially weekends. Resident 19 stated when she/he pressed her/his call light she/he had to wait over half an hour for toileting assistance. Resident 19 stated if she/he waited a long time her/his roommate would call the front desk. Resident 19 further stated all facility meals were late, especially lunch that was scheduled to be served at 12:30 PM but did not arrive until 1:00 PM through 2:00 PM. 1. Resident 13 admitted to the facility in 3/2021 with diagnoses including anxiety disorder. The 6/15/22 Quarterly indicated Resident 13 was cognitively intact. On 8/31/22 at 6:08 AM Staff 22 (CNA) stated there were not enough staff for night shift and he often worked double shifts. Staff 22 stated on night shift Resident 13 waited "a while" for incontinence care and the resident needed to be changed when he responded to her/his room. Staff 22 further stated often times nurses did not answer call lights and CNA staff had to answer all of the call lights. On 8/31/22 at 6:53 AM and 7:20 AM Resident 13 stated during night shift she/he was incontinent earlier that morning, and pushed her/his call light. Resident 13 stated she/he waited almost two hours for incontinence care and her/his sheets and pajamas were "soaked." Resident 13 stated she/he has waited up to two hours for her/his call light to be answered and the facility was short staffed, especially on weekends. Resident 13 stated she would like to get up in her/his wheelchair during the day, go back to bed and then get up again, but due to staffing issues she gets up in her/his chair and stays up all day. A review of the call light logs indicated on 8/31/22 the call light was activated at 3:49 AM and Resident 13 waited two hours and 8 minutes for the call light to be answered. On 9/2/22 at 11:49 AM Staff 1 (Administrator) acknowledged the call light time on 8/31/22 was over two hours and the expectation was for staff to answer call lights immediately. 2. Resident 3 admitted to the facility in 11/2021 with diagnoses including heart failure and anxiety disorder. On 12/30/21 Witness 2 (Complainant) stated Resident 3 reported she/he waited two hours for her/his call light to be answered. A review of Resident 3's call light logs from 12/1/21 through 12/31/21 revealed 107 instances when Resident 3 waited over 30 minutes for the call light to be answered. On 9/2/22 at 11:49 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated the expectation is that staff answer call lights immediately and acknowledged the identified long call light times. , 3. Resident 8 admitted to the facility in 2021 with diagnoses including chronic pain and congestive heart failure. A concern was reported in April 2021 which indicated the facility was short staffed resulting in long call light times. Review of Resident 8's Call Light Logs for April, 2021 indicated the following call light times over 20 minutes for needs including transfers and bathroom assistance: - 4/3/21: 26 minutes - 4/8/21: 25 minutes - 4/9/21: 30 minutes - 4/11/21: 20 minutes - 4/12/21: 30 minutes and 20 minutes - 4/17/21: 37 minutes On 9/2/22 at 9:15 AM Staff 1 (Administrator) and Staff 2 (RNCM) confirmed the long call light times for the identified dates for Resident 8. , 4. Resident 1 admitted to the facility in 10/2021 with diagnoses including a left below the knee amputation. The resident discharged 5/25/22. The 4/21/22 Quarterly MDS indicated the resident was cognitively intact, was always incontinent of bowel and bladder, and required two person assistance with bed mobility and toileting. On 5/6/22 and 8/30/22 Witness 1 (Complainant) stated Resident 1 often waited a long time for incontinence care and call lights took "forever" to be answered by staff. A review of Call Light Logs for Resident 1 for 5/2022 indicated the following dates the resident waited more than 20 minutes for her/his call light to be answered for "bathroom" assistance: *5/1/22: 30 minutes. *5/2/22: 53 minutes and then one hour and 41 minutes. *5/3/22: 45 minutes and then 38 minutes. *5/4/22: 42 minutes. *5/5/22: 37 minutes. *5/7/22: 41 minutes and then 55 minutes. *5/9/22: 34 minutes. *5/10/22: One hour and 16 minutes and then one hour and 43 minutes. *5/12/22: 26 minutes and then 41 minutes. *5/14/22: 32 minutes. *5/15/22: Two hours and 37 minutes. *5/16/22: 42 minutes. *5/17/22: One hour and 15 minutes. *5/18/22: 48 minutes. *5/19/22: 50 minutes. *5/20/22: 49 minutes. *5/23/22: 58 minutes. On 8/31/22 at 12:20 PM Staff 25 (CNA) stated during 5/2022 the facility was short staffed on evening shift and all call lights took longer to be answered. Staff 25 further stated there were times Resident 1 had to wait longer to get up with the Hoyer (mechanical lift) as it took two staff to assist the resident. On 8/31/22 at 1:48 PM Staff 24 (CNA) stated in 5/2022 the facility was short staff and there was a "good chance" Resident 1's call light would have taken longer to be answered. On 9/1/22 at 9:54 AM Staff 1 (Administrator) acknowledged the identified dates Resident 1's call light took 20 minutes or longer to answer. Staff 1 stated the expectation was for call lights to be answered "immediately."

1) Resident #13 interviewed to ensure that needs are being met and has no further concerns. 2) Interviews conducted with resident and no resident identified as having further concerns with cares and call lights. 3) New call light procedure started with the electronic call bell system. New procedure includes excepting one call light at a time on the call bell system. Staff educated on F725 Sufficient Staff CFR(s): 483.35(a)(1)(2) and the new call light procedure. More handheld call light devices purchased. CNA class started in the building. Class of new CNA graduates 9/23. More CNA classes to follow. 4) The Nursing Director/designee will conduct weekly reviews of call light times to ensure response times are met x 4 weeks, and then every 2 weeks x 2 months. The findings of these reviews will be reported in the next Risk Management/QA/QAA/QAPI Committee meeting for 3 months then, until committee determines substantial compliance has been met and recommends quarterly monitoring. 5) Administrator Responsible. Date of compliance 9/29/22

Based on interview and record review it was determined the facility failed to ensure a resident received specialized rehabilitative services (physical and occupational therapy) for 1 of 3 sampled residents (#8) reviewed for therapy. This placed residents at risk for a physical decline. Findings include: Resident 8 admitted to the facility in 3/2021 with diagnoses including chronic pain and congestive heart failure. Resident 8 discharged from the facility 5/12/21. A physician order dated 3/18/21 indicated PT and OT to evaluate and treat Resident 8. Resident 8's 3/18/21 Care Plan indicated the resident was at risk for falls with PT and OT to evaluate and treat as ordered. The 3/25/21 Admission MDS indicated Resident 8 was working with therapy on strengthening, balance and transfers. Review of PT and OT records for March, April and May 2021 revealed the following missed sessions related to staffing: - 4 missed sessions in March. - 14 missed sessions in April. - 3 missed sessions in May. On 8/31/22 at 8:47 AM Staff 10 (PT Assistant) stated Resident 8 was scheduled to have PT and OT five times a week. Staff 10 confirmed Resident 8 missed both PT and OT sessions due to therapy staffing for the dates identified.

1) Resident #8 was discharged from the facility. 2) DOR interviewed and reviewed current residents to ensure on other residents affected. 3) Education and training provided to DOR on importance of obtaining timely services. 4) The Rehab Director/designee will conduct weekly reviews of start of therapy times to ensure times are met x 4 weeks, and then every 2 weeks x 2 months. The findings of these reviews will be reported in the next Risk Management/QA/QAA/QAPI Committee meeting for 3 months then, until committee determines substantial compliance has been met and recommends quarterly monitoring. 5) Administrator Responsible. Date of compliance 9/29/22

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were accurate for 15 of 30 days reviewed. This placed residents at risk for inaccurate staffing information. Findings include: A review of the facility's Direct Care Staff Daily Reports from 8/1/22 through 8/30/22 revealed the following dates when the reports were completed inaccurately: - 8/7/22 - 8/9/22 - 8/10/22 - 8/14/22 - 8/15/22 - 8/16/22 - 8/17/22 - 8/20/22 - 8/22/22 - 8/24/22 - 8/25/22 - 8/27/22 - 8/28/22 - 8/29/22 - 8/30/22 On 9/1/22 at 1:33 PM Staff 1 (Administrator), Staff 2 (RNCM/Interim DNS) and Staff 23 (DNS) confirmed the identified dates Direct Care Staff Daily Reports were completed inaccurately.

No Residents Cited The Current daily staff posting accurately reflects the number of staff members in the facility. The Regional Director of Operations re-educated the Administrator on the Daily Staff Public Posting requirement. The Administrator re-educated responsible team members on the Daily Staff Public Posting requirement. The Administrator will Audit the Daily Staff Public Posting within Stand-Up meeting for 2 weeks then weekly for 3 weeks. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee.

Based on interview and record review it was determined the facility failed to ensure the minimum CNA staffing ratio was met for 11 of 30 days reviewed. This placed residents at risk for delayed care and unmet care needs. Findings include: A review of the facility's Direct Care Staff Daily Reports from 8/1/22 through 8/30/22 revealed the following dates when the required state minimum CNA staffing ratios were not met for one or more shifts: - 8/4/22 - 8/7/22 - 8/8/22 - 8/10/22 - 8/13/22 - 8/16/22 - 8/20/22 - 8/22/22 - 8/27/22 - 8/28/22 - 8/29/22 On 9/1/22 at 1:33 PM Staff 1 (Administrator), Staff 2 (RNCM/Interim DNS) and Staff 23 (DNS) confirmed the identified dates the facility was staffed below the CNA staffing ratio.

1) There have been no residents identified to be at risk related to this citation. 2) Facility will utilize our emergency staffing plan when there is possibility of falling under mandated staffing ratio. 3) The Administrator re-educated leadership team and floor nurses on CNA staffing ratios and Emergency Staffing Plan. The staffing ratio and plan to maintain compliance has been reviewed in QAPI. The facility has ongoing NA classes held at the facility. We continue to promote and recruit candidates that we can put through CNA school so that we are able to continue meeting the staffing ratio. We encourage picking up extra shifts with bonuses and we do not have a cap on overtime hours. We offer sign on bonuses and have stayed flexible for various scheduling needs, making our facility appealing to work with. 4) The Administrator will Audit CNA staffing ratios within Stand-Up daily for two weeks and then weekly for 3 weeks. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure ongoing compliance.

***************************** 411-085-0360 Abuse Refer to F600, F602 and F610 ***************************** 411-086-0110 Nursing Services: Resident Care Refer to F658 ***************************** 411-086-0100 Nursing Services: Staffing Refer to F725 ***************************** 411-086-0220 Rehabilitative Services Refer to F825

Based on observation, interview and record review it was determined the facility failed to ensure residents' safety with dining for 3 of 6 sampled residents (#s 2, 3, and 6) reviewed for safety with dining. This placed residents at risk for a lack of safety with dining. Findings include: 1. Resident 3 admitted to the facility 12/2022 with diagnoses including blindness and hemiplegia. Resident 3 was cognitively intact. Resident 3's current Face Sheet and meal card indicated she/he had an allergy to pineapple. Review of the menu from 3/7/22 through 4/8/22 revealed three documented opportunities when the resident was at risk of being served a meal with pineapple. On 4/8/22 at 10:20 AM Resident 3 stated she/he was served pineapple but did not eat it. The resident stated when she/he ate pineapple, her/his tongue would swell. On 4/8/22 at 11:02 PM Staff 8 (Activities Director) stated he was aware Resident 3 was allergic to pineapple and had been served pineapple. Staff 8 stated when fruit cups were served at meals they often contained pineapple. On 4/8/22 at 3:36 PM Witness 1 (Complainant) stated Resident 3 was blind and allergic to pineapple. Witness 1 stated the resident had recently been served pineapple but did not consume it. On 4/8/22 at 8:45 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Dining Service Specialist) and Staff 11 (Regional Director of Operations) were notified of the concerns. 2. Resident 2 admitted 6/17/20 with diagnoses including schizophrenia and diabetes and had a BIMS of 11 (moderately impaired cognition). Resident 2's current meal card indicated she/he was allergic to fish. Review of the facility's menu from 3/7/22 through 4/8/22 indicated the following: -On 3/8/22 the dinner meal included a fish sandwich. -On 3/11/22 the lunch meal included stuffed baked fish. -On 3/18/22 the dinner meal included grilled fish. -On 3/25/22 the lunch meal included her and lemon fish. -On 3/28/22 the lunch meal included fried fish. -On 4/4/22 the dinner meal included baked fish in butter. -On 4/8/22 the dinner meal included tuna noodle casserole. On 3/28/22 Witness 1 (Complainant) stated she/he had first hand knowledge staff attempted to serve Resident 2 fish. The witness did not indicate what staff member attempted to serve the resident fish. On 4/8/22 at 9:40 AM Resident 2 indicated staff had attempted to serve her/him meals with fish more than once over the last month. Resident 2 was unable to recall what staff attempted to serve her/him the meals with fish. The resident then stated she/he could have any fish other than salmon or tilapia, and was notserved anything other than that in the last few weeks. On 4/8/22 at 3:36 PM Witness 1 (Complainant) stated she/he had knowledge Resident 2 was allergic to and recently was almost served fish. She/he stated the incident was caught during a routine tray cart audit, and Staff 6 (Former Dietary Manager) intervened before the tray was served. On 4/8/22 at 8:45 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified Resident 2 had a documented fish allergy and was served a meal tray with fish. 3. Resident 6 admitted to the facility 3/2021 with diagnoses including a hip fracture and was cognitively intact. The resident's current meal card and face sheet indicated she/he was allergic to bell peppers and onions. Review of the facility menu from 3/7/22 through 4/8/22 indicated green peppers or onions were documented to be served as follows: - 3/9/22 - chopped pepper with steak. - 3/12/22 - green peas with pearl onions. - 3/14/22 - sauteed onions. - 3/19/22 - sauteed onions and peppers. -3/20/22 - onion roasted potatoes. -3/23/22 - stuffed peppers. -3/25/22 - cucumber onion salad. -3/26/22 - potatoes and onions. -3/31/22 - peas and pearl onions. A 3/22/22 facility grievance form filed by Resident 6 was signed by Staff 1 (Administrator). The resident indicated she/he continued to receive peppers and onions on her/his meal tray despite having allergies listed on her/his meal card. Resident 6 specified she/he received allergens on her/his meal tray on 3/18/22 and 3/19/22. The Administrative Review portion completed by Staff 1 indicated he met with the Staff 6 and asked her to meet with the dietary department to educate them on the importance of tray card accuracy. The follow up section of the document indicated staff training was completed on 3/29/22. On 4/8/22 at 10:15 AM Resident 6 stated she/he had recently received a stuffed bell pepper, and that she/he often had onion in her/his meals. Resident 6 stated Staff 6 (Former Dietary Manager) would often be helpful to try and ensure she/he didn't get peppers or onions, but she/he would still received meals with them. The resident further stated she/he had stomach upset when she/he was served bell peppers or onions. The resident stated/he would usually just leave the tray alone and wouldn't eat a meal. On 4/8/22 at 10:56 AM Staff 7 (CNA) stated he was aware Resident 6 received meal trays with green peppers. Staff 7 further stated the resident complained on multiple occasions about this. Staff 7 stated he knew the resident couldn't have "peppers" and he would try and get her/him a replacement if he saw them on her/his tray. On 4/8/22 at 8:45 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified Resident 6 had a documented green pepper and onion allergy and served her/him a meal tray with green peppers and/or onions.

F-806 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #2, #3 and #6  The resident has been interviewed regarding his/her food allergy and the care plan has been updated with interventions related to his/her documented allergies. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All current residents care plan and meal tray card have been audited and updated for food allergies and dislikes by the dietary and clinical department. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Facility Administrator and/or designee have in-serviced facility staff and agency staff on tray card accuracy, dislikes, and allergies. Administrator, facility management staff, nursing staff and/or designee, have performed tray card audits on meal delivery for accuracy and corrected any errors prior to any resident receiving his/her meal. Any tray with an error has been corrected by returning the meal to the kitchen for correction and new tray delivered to resident. Kitchen staff will be in-serviced by dietary manager and/or designee on meal consistencies and food(s) that contain gluten and gluten free food(s). The Activity Director and/or designee will document resident grievances during resident council meeting and give the grievance to the specific department manager for investigation and resolution. 4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what program will be put into place to monitor the continued effectiveness of the systemic change. Tray card audits performed by company dietitian, facility management, nursing staff and/or designee will continue to be performed 3 X daily for 30 days. Findings will be reviewed at monthly QAPI meeting X 3 months or until the QAPI committee feels the deficient practice is in substantial compliance.

OAR 411-086-0250 Dietary Services

Refer to F806

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/24/2022 and 01/30/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.