Green Valley Rehabilitation Health Center

-á Resident 8 was admitted to the facility in 2/2026 with diagnoses including dementia. -á Review of a Resident 8's Care Plan dated 2/13/26 indicated the resident had an ADL self-care performance deficit and limited physical mobility. Interventions included ambulation with a four-wheeled walker. The care plan also indicated the resident was at risk for elopement due to Alzheimer's, with the goal to ensure the resident did not leave the facility unattended. The resident's care plan also indicated the resident wished to be discharged to her/his home where a family member lived with the resident. Interventions including to discuss the discharge planning process with the family. -á Review of Resident 8's BIMS Evaluation dated 2/17/26 documented the resident scored a 5 out of 15 (indicating severe cognitive impairment). -á A Physician Assistant's (PA) Note dated 5/11/26 indicated discharge planning concerns for failure to thrive at home. Resident 8 was being discharged home (65 miles away) despite clinical reservations given past concerns at home. Cognitive status appeared to be at baseline. -á A Discharge Readiness form dated 5/11/26 at 3:24 PM, indicated the resident was to be discharged to home approximately 65 miles from the facility. The resident was to be transported home via public transportation. -á A Nurse's Note dated 5/12/26 at 2:51 PM, indicated the resident was discharged from the facility at 2:45 PM. -á A train ticket dated 5/12/26 indicated Resident 8 was to depart via bus from the local train station to a grocery store in the resident's hometown one mile from the resident's home. The bus was scheduled to leave at 3:45 PM and arrive at 5:26 PM. -á A Nurse's Note dated 5/12/26 at 7:53 PM, documented the resident arrived back at the facility after missing the bus to her/his hometown. The note indicated the resident's family was informed. -á A Physician Assistant's Note dated 5/13/26 at 9:21 PM, indicated the resident was seen for readmission to the facility after being sent to the bus stop via taxi to take a bus back home where family were to meet Resident 8. The note indicated the resident did not get on the bus due to a severe cognitive impairment and the inability to find the correct bus on her/his own. -á In an interview on 5/20/26 at 12:15 PM, Resident 8, who was alert, stated the facility treated her/him well and had no concerns with care. Resident 8 wanted to go home to her/his family on the coast but did not know what city she/he resided. The resident stated she/he was currently at a hospital but did not know which hospital. The resident stated she/he was recently sent home via a car, there was an accident on the way home and the car brought her/him back to the facility. Resident 8 did not remember being at the bus stop. -á In an interview on 5/20/26 at 12:25 PM, Staff 3 (RCM) stated Staff 4 (RCM) made a suggestion during a pre-discharge meeting the facility should send a staff person with the resident to the bus stop and not be sent alone. Staff 3 stated no staff went with the resident to the bus station. Staff 3 stated an attendant at the bus station called the facility to report the resident missed the bus. -á In an interview on 5/20/26 at 12:42 PM, Staff 5 (Social Services) stated Staff 4 had concerns regarding the resident's cognition and being dropped off at the bus station to catch a bus to go home. Resident was sent alone by the facility via taxi to the local bus stop. Staff 5 stated Witness 8 (Family Member) member was supposed to meet the resident in their hometown when the resident arrived and had called the facility to let them know the resident did not get on the bus.-á -á In an interview on 5/20/26 at 1:27 PM, Staff 6 (LPN) stated on 5/12/26 he received a call from Witness 8 who stated a bus station attendant had called her to tell her Resident 8 had missed the bus to go home. Staff 6 stated the resident was found by the bus station attendant, confused, and the bus station attendant had called Witness 8 to let them know. Staff 6 immediately called Staff 1 (Administrator) and Staff 2 (DNS) and an ambulance was sent to pick up the resident at the bus station who was taken back to the facility. -á In an interview on 5/20/26 at 1:40 PM, Staff 1 and Staff 2 stated Resident 8 was sent via taxi to the bus station on 5/12/26 with a prepaid bus ticket to go home. Resident 8 was not accompanied by staff and failed to get on the scheduled bus to go home. Resident 8 was found by a bus attendant who called Witness 8 who then notified the facility. Staff 2 was present at the pre-discharge meeting and was aware of the concerns by Staff 4. The facility did not feel sending the resident to the bus station alone would be a problem. -á In an interview on 5/21/26 at 7:13 AM, Witness 8 stated she received a call from the local bus station who informed her the resident had missed the bus to go home. Witness 8 called the facility who dispatched EMS to pick up the resident.-á -á -á

Corrective Action 1) Resident #8 discharged the facility on 5/25/26 via Ride Source directly to her home. Identification of others at risk 1) Social Service/Designee will complete baseline audit of cognitively impaired residents who discharged in the past 30 days to verify safe discharge was conducted. Systemic Changes 1) The corporate Social Service (SS) Consultant provided education on 5/28/26 to the facility Interdisciplinary team (IDT) regarding appropriate discharge planning process including expectation of correlating documentation. Monitoring 1) Audits will be conducted by NHA/Designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

1. Resident 3 was admitted to the facility in 1/2026 with diagnoses including pneumonia.-á -á A Discharge Planning Questionnaire dated 2/23/26 indicated Resident 3 was to be discharged home on 2/24/26. The form did not include a recapitulation of the residentGÇÖs stay or the residentGÇÖs functional status upon discharge. -á In an interview on 5/21/26 at 8:10 AM, Staff 5 (Social Services) stated the facility used the Discharge Planning Questionnaire for all discharges from the facility. Staff 5 acknowledged Resident 3's discharge summary did not include the resident's recapitulation of stay and the resident's functional status. -á 2. Resident 2 was admitted to the facility in July 2025 with diagnoses including kidney cancer. -á A Discharge Planning Questionnaire dated 9/12/25 indicated Resident 2 was discharged home on 9/15/25. The form did not include a recapitulation of the residentGÇÖs stay or the residentGÇÖs functional status upon discharge. -á In an interview on 5/21/26 at 8:10 AM, Staff 5 acknowledged Resident 2's discharge summary did not include the resident's recapitulation of stay and the resident's functional status. -á 3. Resident 8 was admitted to the facility in 2/2026 with diagnoses including dementia. -á A Discharge Planning Questionnaire dated 5/11/26 indicated Resident 8 was to be discharged home on 5/12/26. The form did not include a recapitulation of the residentGÇÖs stay or the residentGÇÖs functional status upon discharge. -á In an interview on 5/21/26 at 8:10 AM, Staff 5 acknowledged Resident 8's discharge summary did not include the resident's recapitulation of stay and the resident's functional status. -á

Corrective Action 1) Residents #3, 2, and 8 have discharged the facility. Identification of others at risk 1) Social Service/Designee will complete baseline audit of residents who have discharged from the facility over the past 30 days to determine if appropriate discharge summary was in place including recapitulation of stay. Systemic Changes 1) The corporate Social Service (SS) Consultant provided education on 5/28/26 to the facility Interdisciplinary Team (IDT) regarding appropriate discharge planning process including expectation of correlating documentation. Monitoring 1) Audits will be conducted by NHA/Designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 13 was admitted to the facility in 7/2025 with diagnoses including right femur fracture and visual hallucinations.-á Resident 13GÇÖs 1/2026 Physician Orders indicated the resident was prescribed risperidone for dementia with behaviors ordered on 8/18/25 and trazodone for insomnia ordered on 11/17/25. Resident 13GÇÖs consent for risperidone was verbally obtained on 9/26/25 and no consent was found for trazadone. A review of Resident 13GÇÖs 1/2026 MAR revealed the resident received risperidone twice a day and trazadone daily in the evening.-á On 1/30/26 at 2:10 PM Staff 2 (DNS) acknowledged Resident 13 was not informed of the risks and benefits of the use of risperidone and trazodone prior to use.-á

Corrective Action 1) Resident #13 will have verified informed consent in place for currently ordered psychotropic medications. Identification of others at risk 1) DON/Designee will complete baseline audit of current residents to verify consents for psychotropic medications are present. Systemic Changes 1) DON/Designee will provide education to licensed nurses regarding process to obtain informed consent with use of psychotropic medications. Monitoring 1) Audits will be conducted by DON/Designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

3. Resident 10 was admitted to facility in 6/2018 with diagnoses including calcific tendinitis of left shoulder (a painful condition caused by calcium deposit buildup within the rotator cuff tendons) and pneumonia.-á The quarterly MDS with an ARD of 10/31/25, revealed Resident 10 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment, and experienced occasional severe pain.-á Observations on 1/26/26 at 3:35 PM and 1/27/26 at 3:28 PM revealed Resident 10 had lidocaine cream on her/his nightstand and a bottle of 3% hydrogen peroxide first aid antiseptic spray on her/his shelf. Resident 10 stated she/he had the lidocaine cream and antiseptic for a few months.-á On 1/27/26 at 3:28 PM, Resident 10 applied lidocaine cream onto her/his left neck, shoulder and wrist. Resident 10 also demonstrated the use of the first aid antiseptic by holding the spray to her/his mouth. Resident 10 stated she/he sprayed the antiseptic into her/his mouth before rinsing it out with mouthwash.-á A review of Resident 10's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer topical lidocaine or first aid antiseptic spray. On 1/28/26 at 11:46 AM, Staff 11 (CNA) stated she was not aware of Resident 10 having medications in her/his room or if Resident 10 had been authorized to have medications at her/his bedside.-á On 1/29/25 at 8:38 AM, Staff 12 (CNA) stated she was not aware of Resident 10's ability to self-administer medications or if Resident 10 had been authorized to have medications at her/his bedside. Staff 12 stated if medications were found by a resident's bedside, she would inform the nurse.-á On 1/29/26 at 8:52 AM, Staff 13 (CMA) stated Resident 10 was known to purchase a variety of her/his own medications and keep the medications in her/his room. Staff 13 stated she has taken medications from Resident 10's room in the past and reported the incident to the nurse. Staff 13 stated there was a process for residents to self-administer their own medications. On 1/29/26 at 9:20 AM, Staff 7 (LPN) stated he was not aware of Resident 10 having authorization to self-administer medications. Staff 7 stated as of 1/28/26 at 1:32 PM, an order was received for Resident 10 to have lidocaine cream at her/his bedside. Staff 7 stated there was no order for Resident 10 to use antiseptic in her/his mouth.-á On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they expected an evaluation and orders to be in place for residents to self-administer medications. 4. Resident 68 was admitted to the facility 7/2023 with a diagnosis of Alzheimer's disease.-á The quarterly MDS with an ARD of 1/3/26, revealed Resident 68 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Observations on 1/27/26 at 11:57 AM and 1/28/26 at 4:05 PM revealed Resident 68 had a tube of Ammonium Lactate cream by her/his bedside and two tubes in her/his shelf. Resident 68's name and instructions were observed on the prescription label.-á On 1/27/26 at 4:04 PM, Resident 68 stated staff did not assist with applying the cream to her/his feet. Resident 68 stated the cream was for the gangrene on her/his feet. On 1/28/26 at 4:05 PM, Resident 68 could not explain the quantity or frequency of the cream's use and stated staff did not assist her/him with the application.-á A review of Resident 68's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer ammonium lactate cream to her/his feet. On 1/29/26 at 8:49 AM, Staff 10 (CNA) stated she was not aware of Resident 68 having medications at her/his bedside. She stated if she saw medications at Resident 68's bedside, she would let the nurse know. On 1/29/26 at 8:52 AM, Staff 13 (CMA) stated she was not aware of Resident 68 having the ability to self-administer medications. Staff 13 stated there was a process for residents to self-administer their own medications. On 1/29/26 at 9:40 AM, Staff 7 (LPN) acknowledged the ammonium lactate cream by Resident 68's bedside and shelf. Staff 7 stated he was not sure what the cream was for and confirmed it was not on Resident 68's orders, and the resident did not have skin issues on her/his feet. On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they expected an evaluation and orders to be in place for residents to self-administer medications. 5. Resident 108 was admitted to facility 6/2023 with diagnoses including muscle weakness and chronic pain. The quarterly MDS with an ARD of 12/1/25, revealed Resident 108 had a BIMS score of 15, which indicated the resident was cognitively intact. Observations on 1/26/26 at 1:21 PM revealed Resident 108 had antifungal powder, Aspercreme, and Icy Hot on her/his shelf. Resident 108 stated she/he sometimes used the products on her/himself.-á Observations on 1/27/26 at 3:39 PM revealed Resident 108 had antifungal powder at her/his bedside and the Apsercreme on her/his shelf.-á A review of Resident 108's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer Aspercreme, antifungal powder, or Icy Hot.-á On 1/29/26 at 8:41 AM, Staff 10 (CNA) stated she was not aware of Resident 108's ability to self-administer medications.-á On 1/29/26 at 9:00 AM, Staff 7 (LPN) stated Resident 108 and her/his family were known to purchase over-the-counter medications and bring them to her/his room.-á On 1/29/26 at 9:34 AM, Staff 7 confirmed there was no order for Resident 108 to self-administer medications.-á On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they expected an evaluation and orders to be in place for residents to self-administer medications. , 2. Resident 12 was admitted to the facility in 4/2025 with diagnoses including acute respiratory failure and chronic obstructive pulmonary disease.-á The facilityGÇÖs 3/2023 Right to Self-Administer Medication outlined the following criteria for a resident to self-administer medications:-á 1. -á -áIf a resident has requested to self-administer medications, it is the responsibility of the interdisciplinary team to determine it is safe before the resident exercise the right. A resident may self-administer medications after the interdisciplinary team has determined which medications be self-administered. 2. -á -áConsiderations in determining of the resident is clinically appropriate to self-administer include: -á a. -á -áWhich medications are appropriate and safe for self-administration. b. -á -áThe resident physical capacity to swallow without difficulty and to open medication packaging. c. -á -áThe residentGÇÖs cognitive status, including ability to correctly identify medications and know for which conditions s/he is taking medication.-á 3. -á -áAppropriate documentation of the determinations will be documented in the residentGÇÖs medical record and care plan.-á Resident 12 was admitted to the facility in 4/2025 with diagnosis including acute respiratory failure and chronic obstructive pulmonary disease.-á A review of Resident 12GÇÖs 10/30/25 Quarterly MDS revealed she/he was cognitively intact. On 1/27/26 at 2:41 PM a Breyna inhaler (also known as Symbicort, a combination of budesonide and formoterol fumarate, a corticosteroid and long-acting agonist) and Albuterol Sulfate inhaler (a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) was observed on Resident 12's bedside table. Resident 12 stated the blue inhaler (Breyna) was her/his medicine which her/he took one or two times a day and the green (albuterol) inhaler was her/his rescue inhaler and she/he used when needed. A review of Resident 13GÇÖs 1/2026 MAR indicated the resident was approved by her/his provider to keep Symbicort and Albuterol Sulfate at bedside. An 8/15/25 Self-Administration of Medication assessment revealed Resident 13 was evaluated for wanting to self-administer medication, the list of medications approved to self-administer, and location of storage was not assessed.-á On 1/28/26 at 3:59 PM Staff 26 (LPN) stated Resident 13 did not have any inhalers at bedside and she/he was not capable of accessing the nightstand drawer to lock/unlock to get the medications. On 1/28/26 at 4:07 PM Staff 25 (CMA) stated Resident 13 had one inhaler (Symbicort) at bedside and would use it twice a day.-á On 1/30/26 at 9:30 AM Staff 4 (LPN) stated Resident 13 had one inhaler (Albuterol Sulfate) at bedside and would use it as needed.-á On 1/30/26 at 11:03 AM Staff 3 (RN, Unit Manager) stated she was aware Resident 13 had Symbicort inhaler at bedside and was not aware the resident had Albuterol Sulfate or did not have a lockbox. Staff 3 stated she expected any residents who had medications at their bedside to have a completed self-administration assessment which includes the names of the medications and a lock box for the medication.-á On 1/30/26 at 2:10 PM Staff 2 (DNS) stated she expected staff to be aware of all residents who are allowed to have medications at bedside, the specific medications, and have the medications secured in a lockbox.-á , 1. Resident 5 was admitted to the facility in 3/2024 with a diagnosis of heart failure.-á Resident 5's 3/11/24 Self-Administration of Medication form revealed she/he was capable but did not want to self-administer medications.-á Resident 5's Order Details form revealed Salonpas was to be administered PRN left knee pain. The order indicated the medication could be kept at Resident 5's bedside.-á Resident 5's 12/17/25 Quarterly MDS revealed she/he had moderate cognitive and memory problems.-á Resident 5's clinical record revealed there was no assessment to ensure she/he was safe to administer Salonpas. On 1/28/26 at 10:50 AM Staff 4 (LPN) stated a resident could have medications at the bedside after an assessment was completed.-á Staff 4 stated Resident 5 had orders to keep the medication at the bedside.-á On 1/28/26 at 10:57 AM Staff 3 (RNCM) stated If a resident was to have medications at the bedside there needed to be a physician order, the medication was to be kept in a secure location, and a self-medication assessment was to be completed before allowing medications at the bedside. Staff 3 stated Resident 5 was not assessed to ensure she/he was able to self-administer medications.-á On 2/2/26 at 10:08 AM Staff 2 (DNS) stated if a resident had medications at the bedside, a resident was to be assessed to ensure she/e was capable of self-administration, the medication was to be in a secure location, and orders were to be obtained.-á

Corrective Action 1) Resident’s #5, #10, #12, #68, and #108 will have completed self-administration of medication evaluation completed to determine capacity to self-administer medications. Order and care plan will be updated to reflect if residents are able to self-administer medications. Identification of others at risk 1) DON/Designee will complete baseline audit of current residents to determine if medications are being kept at bedside. Audit will ensure residents have self-administration of medication evaluation completed that supports safe ability to self-administer medications. Systemic Changes 1) DON/Designee will provide education to licensed nurses and CMA’s regarding process to ensure residents are able to self-administer medications. Monitoring 1) Audits will be conducted by DON/Designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

-á 2. Resident 30 was admitted to the facility in 9/2025 with a diagnosis including heart failure. A 12/17/25 signed Advance Directive Resident Information form revealed Resident 30 had an advance directive.-á The 1/10/25 revised Care Plan indicated Resident 30 did not have an advance directive. On 1/29/26 at 4:13 PM, Staff 9 (Director of Social Services) acknowledged Resident 30 did have an advance directive and there was no copy on file. Staff 9 stated the resident's care plan was not revised to reflect accurate information about her/his advance directive and a copy of her/his advance directive was not obtained within a week as expected. , The facility's policy and guidelines for Advance Directives dated 3/2023 included the following: - If the resident has not formulated an advance directive, the facility will determine if the resident wishes to formulate an advance directive and provide assistance to the resident in the development of advance directives in accordance with state law. Documentation in the medical record will reflect the discussion of advance directives occurred, that assistance has been offered to the resident, and the resident's acceptance or declination of assistance.-á - The facility will periodically review the advance directives with the resident and/or the resident's representative.-á 1. Resident 10 was admitted to facility in 6/2018 with diagnoses including calcific tendinitis of left shoulder (a painful condition caused by calcium deposit buildup within the rotator cuff tendons) and pneumonia. The quarterly MDS with an ARD of 10/31/25, revealed Resident 10 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. On 1/27/26 at 3:28 PM, Resident 10 stated she/he had an advance directive, and staff did not discuss the details of her/his advance directives with her/him.-á A review of Resident 10's clinical record revealed on 6/19/18 she/he indicated having an advance directive, but the copy was not on file and there were no subsequent notes to indicate any attempts at obtaining the document.-á On 1/29/26 at 2:58 PM, Staff 8 (SSD) stated he expected a copy of a resident's advance directive to be on file when a resident indicated to have one. Staff 8 confirmed Resident 10 indicated to have an advance directive, but it was not on file.-á On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated it was expected for staff to obtain a copy of a resident's advance directive if the resident indicated to have one.-á 3. Resident 108 was admitted to facility 6/2023 with diagnoses including muscle weakness and chronic pain. The quarterly MDS with an ARD of 12/1/25, revealed Resident 108 had a BIMS score of 15, which indicated the resident was cognitively intact. On 1/27/26 at 11:40 AM, Resident 108 stated the facility had not talked to her/him about an advance directive and she/he did not know what an advance directive was.-á On 1/30/26 at 2:58 PM, Staff 8 (SSD) stated if a resident did not have an advance directive, he expected staff to follow up and educate and offer information to the resident every quarter. Staff 8 confirmed Resident 108 did not have an advance directive and confirmed there were no notes to indicate she/he was educated and offered one. On 1/30/26 at 3:02 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated it was expected for staff to educate, offer and assist residents with an advance directive when residents indicate to not have one.-á -á

Corrective Action 1) Residents #30 discharged the facility on 1/29/26. Residents #10 and #108 have a new signed advanced directive acknowledgement dated 2/17/26 and 2/20/26 respectively. Identification of others at risk 1) Administrator/ Designee will audit current residents to ensure advanced directive assistance was offered and acknowledgement is uploaded to the EMR. Systemic Changes 1) Administrator/ Designee will educate Social Service staff to ensure an advanced directive or acknowledgements are in place for all new residents and offered periodically upon change of condition. Monitoring 1) Audits will be conducted by Administrator/Designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

1. On 1/26/26 at 10:44 AM a treatment cart was observed with a computer screen unlocked. Resident 82's information was visible including her/his code status, allergies, and care to be provided. Staff were not at the cart.-á On 1/29/26 at 10:51 AM Staff 15 (IP) was observed to lock the computer screen. On 1/29/26 at 10:51 PM Staff 7 (LPN) stated she/he was in charge of the treatment cart, and the computer screen should be locked.-á On 2/2/26 at 10:08 AM Staff 2 (DNS) stated staff were to lock the computer screens before leaving the cart.-á -á 2. On 1/26/26 at 4:10 PM a medication cart computer screen was observed with Resident 105's medication list visible. Staff were not within sight of the cart. Staff 16 (CMA) was observed to exit a resident room. Staff 16 stated the computer screen was to be locked when not in use. Staff 16 stated he was called away from the computer and did not lock the computer screen before leaving the cart.-á On 2/2/26 at 10:08 AM Staff 2 (DNS) stated staff were to lock the computer screens before leaving the cart.

Corrective Action 1) Staff were corrected immediately upon discovery unattended computer screen for residents #83 and #105 information. Identification of others at risk 1) DON/ Designee will do daily and periodic rounds to ensure resident information is protected. Systemic Changes 1) DON/Designee will provide education to licensed nurses and CMA’s regarding privacy and confidentiality and keeping resident information secure. Monitoring 1) Audits will be conducted by DON/Designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 115 was admitted to the facility in 3/2025 with a diagnosis of chronic lung disease. Resident 115's Significant Change MDS revealed she/he was cognitively intact.-á On 1/26/26 at 12:24 PM Resident 115 stated when the toilet flushed at night, it made a really loud noise, and it ""scared [her/him' to death."" On 1/28/26 at 12:10 PM Staff 16 (CNA) stated Resident 115's toilet was very loud when flushed and was loud for approximately two months. Staff 16 stated if equipment needed to be repaired maintenance was notified with an online communication system.-á On 1/28/26 at 12:12 PM with Staff 6 (Maintenance) Resident 115's toilet was flushed and was heard to make a loud foghorn like noise. Staff 6 stated he was not aware and was not notified by staff that Resident 115's toilet was loud when flushed.

Corrective Action 1) The identified noisy toilet was fixed prior to survey exit. Resident #115 discharged the facility on 2/11/26 Identification of others at risk 1) Administrator/Designee will round all residents’ bathrooms to ensure toilets are functioning properly. Systemic Changes 1) Administrator/Designee will re-educate staff on how to place work orders in the facilities maintenance program TELS. Monitoring 1) Administrator/Designee will audit the facility TELS system weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 92 was admitted to the facility in 12/2025 with diagnoses including alcohol abuse and encephalopathy (a disease in which the brain is affected by toxins or infection in the blood). Resident 92GÇÖs 12/16/25 Admission MDS indicated Resident 92 was at risk for isolation, depression, and further decline. he MDS further indicated Resident 92 will be referred to activities to avoid isolation. The 1/11/26 revised care plan failed to address Resident 92's preferences, likes, dislikes, and activities to avoid isolation. On 1/26/26 at 3:57 PM Resident 92 stated she/he was not aware of any activities in the facility and would like to participate. On 1/28/26 at 3:19 PM Resident 92 was observed sitting in the hallway alone. On 1/29/26 at 12:30 PM Resident 92 was observed eating lunch in her/his room alone. Random observations from 1/29/26 through 2/2/26 on day and evening shifts revealed Resident 92 sitting in her/his room or walking the halls alone. On 1/26/26 at 10:38 AM Staff 39(CNA) stated the resident did not participate in the facility but did mention she/he would like to try the music exercise. Staff CNA stated she did not know if the resident actually went. On 1/26/26 at 3:57 PM Resident 92 stated she/he was not aware of any activities in the facility and would like to participate. On 1/30/26 at 10:57 AM Staff 42 (LPN) stated she was not aware if Resident 92 participated in the activities provided in the facility but was aware she/he walked around the facility. On 1/30/26 at 1:50 PM Staff 23 (Activities Director) acknowledged the care plan was not comprehensive. On 1/30/26 at 2:04 PM Staff 2(DNS) stated her expectation was for the (RCMs) and Staff to work together to provide preferences and activities for the residents and have a comprehensive care plan to reflect the residentGÇÖs preferences. -á -á -á -á -á -á -á

Corrective Action 1) Resident #92 discharged the facility on 2/25/26. Identification of others at risk 1) DON/Designee will complete baseline audit of current residents to ensure activities care plan is in place and reflective of the resident’s preferred activities. Systemic Changes 1) DON/Designee will provide education to activities regarding development of a person-centered care plan. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

-á 2. Resident 30 was admitted to the facility in 9/2025 with diagnoses including heart failure and diabetes. The 9/22/25 and 11/15/25 IDT (Interdisciplinary Team) Care Plan Conference Evaluations revealed Staff 18 (Assistant Social Worker) was present at the meeting, social services needs were addressed with Resident 30, no additional staff were present at the meetings, and no nursing subject matter was documented as discussed. The 1/7/26 Quarterly MDS revealed a BIMS assessment score of 12 (moderate cognitive impairment) for Resident 30.-á A 1/10/26 Hemoglobin A1c (a laboratory test measuring the average glucose level over three months) Clinical Report revealed Resident 30's diabetes was well controlled.-á On 1/27/26 at10:28 AM, Resident 30 stated she/he wanted to address concerns regarding heart medication changes and a desire for a Hemoglobin A1c but did not. Resident 30 could not recall any IDT meetings to discuss medical concerns when a nurse was present. Resident 30 stated she/he was not aware of any Hemoglobin A1c results which was necessary to understand changes in her/his diabetic medications. On 1/30/26 9:45 AM, Staff 18 stated invitations for Resident 30's care conferences were not sent out timely to those staff who were to attend her/his meetings. The expectation was for concerns of residents to be addressed at care conference and for team members to attend to address issues and resident questions.-á-á -á On 1/30/26 at 10:08 AM, Staff 19 (Unit Manager-LPN) acknowledged she did not attend the last two care conferences for Resident 30. Staff 19 expected any medical concerns to be addressed and documented during care conferences and communicated to those who could not attend.-á -á On 1/30/26 at 10:39 AM, Staff 2 (DNS) stated Unit Mangers and other IDT team members were to attend care conference meetings and, if unavailable, a representative needed to attend the meetings to address the resident's care concerns.-á , 1. Resident 5 was admitted to the facility in 3/2024 with a diagnosis of heart disease.-á Resident 5's Care Plan updated on 9/19/25 revealed she/he was at risk for ADL self-care. Interventions included bilateral bed canes for mobility.-á On 1/27/26 at 3:14 PM Resident 5 was observed in a recliner. Resident 5 did not have a bed in her/his room.-á On 1/29/26 at 2:53 PM Staff 3 (RNCM) stated Resident 5 did not have a bed for a while, and the care plan was not updated to reflect the changes.-á On 2/2/26 at 10:08 AM Staff 2 (DNS) stated care plans were to be updated at least quarterly, with a change of condition, and as needed to reflect current care.-á 3. Resident 71 was admitted to the facility in 8/2023 with a diagnosis of kidney disease. On 1/27/26 at 9:27 AM Resident 71 stated she did not have dentures and was observed to not have teeth.-á Resident 71's Care Plan revised on 10/14/25 revealed she/he did not have teeth, and staff were to assist with denture care.-á On 1/30/26 at 8:36 AM Staff 31 (CNA) stated he never saw Resident 71's dentures. On 1/29/26 at 2:53 PM Staff 3 (RNCM) stated she was not aware Resident 71 did not have dentures and indicated the care plan did not reflect her/his current dental status needs.-á-á On 2/2/26 at 10:08 AM Staff 2 (DNS) stated care plans were to be updated at least quarterly, with a change of condition, and as needed to reflect current care.-á

Corrective Action 1) Resident #5 will have updated care plan to accurately reflect use of bed rails and current primary use of recliner for sleeping/reclining. 2) Resident #30 discharged the facility on 1/29/26. 3) Resident #71 will have updated care plan to accurately reflect dentition status. Identification of others at risk 1) DON/Designee will complete baseline audit of current residents to ensure care conference has been completed in correlation with their most recent quarterly or comprehensive MDS. 2)  DON/Designee will complete baseline audit of residents to ensure dentition status and use of bed mobility assistive devices is accurately reflected on the resident care plans. Systemic Changes 1) Director of Social Services and Activities provided education to social services regarding completion of routine care conferences. 2) DON/Designee will provide education to unit managers and MDS coordinators regarding process to accurately reflect resident dentition and device use for bed mobility on resident care plan. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 55 was admitted to the facility in 9/2024 post joint replacement.-á Resident 55's Care Plan revised on 9/26/25 revealed she/he had limited mobility, and interventions include a nursing restorative program. The program included walking.-á Resident 55's 12/22/25 Quarterly MDS revealed she/he was cognitively intact.-á On 1/26/26 at 11:22 AM Resident 55 stated she/he received exercises and then it suddenly stopped.-á-á Resident 55's clinical record did not have documentation to indicate she/he currently received a restorative program or a rationale for discontinuation.-á On 1/29/26 at 10:29 AM Staff 5 (Director of Rehabilitation) stated Resident 55 was not on the current list of residents who received restorative services.-á-á On 1/29/26 at 11:05 AM Staff 33 (Restorative Aide) stated Resident 55 had a respiratory illness and restorative was discontinued. Staff stated she informed the RNCM.-á On 1/30/26 at 1:39 PM Staff 3 (RNCM) stated Resident 55 had a respiratory illness and Staff removed her/him from services. Staff 3 stated if a resident's restorative program was discontinued there should be a note for the rationale. Staff 3 stated there was no assessment or rationale for the discontinuation of Resident 55's restorative program.-á On 2/2/26 at 10:08 AM Staff 2 (DNS) stated after therapy develops a restorative program for a resident, it is then nursing driven and the RNCM should be involved with the decisions to discontinue a resident's program.-á

Corrective Action 1) Resident #55 will be reviewed to determine if restorative services are clinically indicated. Identification of others at risk 1) DON/Designee will complete baseline audit of residents who have current care plans in place for restorative services to determine if restorative services have been provided according to care plan. Systemic Changes 1) DON/Designee will provide education to restorative CNA regarding provision of restorative services as care planned. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 55 was admitted to the facility in 9/2024 with a diagnosis of joint replacement.-á Resident 55's 12/22/25 Quarterly MDS revealed she/he was cognitively intact.-á Resident 55's Care Plan last revised on 9/26/25 revealed she/he had an ADL self-care performance deficit and interventions included she/he was dependent on staff for personal hygiene.-á On 1/26/26 at 11:17 AM Resident 55 stated she/he needed assistance to shave and preferred to be clean shaven. Resident 55 also stated she/he did not receive many showers. Resident 55 was observed in bed and was not shaved. Resident 55's facial hair was approximately 0.25 inches long.-á An undated facility shower schedule revealed Resident 55's shower days were scheduled for Tuesday and Thursday mornings.-á Resident 55's 12/31/25 through 1/21/26 shower documentation and Progress Notes revealed the following: -12/31/25- Resident 55 refused a shower. There was no progress note to indicate nursing communicated with her/him. -1/2/26- Resident 55 was offered two times, and a progress note indicated she/he would accept a shower on another day. -1/3/26 (Saturday) Resident 55 received a shower-á -1/5/26 (Monday) Resident 55 refused a shower. There was no progress note to indicate nursing communicated with her/him. -1/6/26 Resident 55 refused a shower. There was no progress note to indicate nursing communicated with her/him. -1/7/26- Resident 55 refused a shower on two occasions.-á There was no progress note to indicate nursing communicated with her/him. -1/9/26 Resident 55 refused a shower on two occasions. There was no progress note to indicate nursing communicated with her/him. -1/14/26 Resident 55 received a shower -1/21/26 Resident 55 refused a shower. -áThere was no progress note to indicate nursing communicated with her/him. Resident 55 received two showers in 30 days.-á On 1/30/26 at 8:33 AM Staff 34 (CNA) stated if a resident refused a shower, the resident was to be offered assistance two more times that day. If a resident refused a shower after the third offer, the nurse was notified, and the nurse was to communicate with the resident. Staff 34 stated residents were usually shaved on shower days.-á On 1/30/26 at 8:39 AM Staff 34 (LPN) stated if a resident refused a shower, the CNA was to notify the nurse, and the nurse was to communicate with the resident to offer an alternative shower day and was also to encourage the resident to bathe.-á On 1/30/26 at 1:39 PM Staff 3 (RNCM) stated Resident 55 often refused showers and her/his shower days were changed. Staff 3 stated Resident 55's care plan did not address her/his shaving preference and acknowledged if staff shaved residents on shower days, Resident 55 would not be shaved often.-á On 2/2/26 at 10:08 AM Staff 2 (DNS) stated a resident's shower, and shaving preferences were to be determined upon admission. If a resident refused a shower the nurse should find out the reason for the refusal and document in the resident's clinical record. Staff 2 stated she did not see documentation for shower refusals.-á-á

Corrective Action 1) Care plan will be updated for resident #55 to include preferences for personal hygiene. Identification of others at risk 1) DON/designee will complete baseline audit of all residents to ensure care plan includes personal hygiene preferences. 2) DON/designee will complete baseline audit of all residents that showers have been offered per resident preference/shower schedule and appropriate documentation is present for any refusals, including attempts to reapproach. Systemic Changes 1) DON/designee will educate Nurses and CNAs on the need to document showers and for any refusals, ensure that attempts to reapproach are also documented. 2) DON/designee will educate nurses and CNAs on the need to ensure the care plan accurately reflects resident preferences, including for personal hygiene, and the process for getting the care plan updated if needed. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations

-á Resident 61 was admitted to the facility in 11/2025 with diagnoses including dementia, post-traumatic seizures, and anxiety.-á The 11/11/25 Admission MDS indicated a BIMS assessment score of 15 (cognitively intact) and Resident 61 was unable to complete her/his interview for her/his Preferences for Routine and Activities. The MDS indicated staff knew it was important for Resident 61 to participate in religious activities, spend time outdoors and do things with groups of people. A 11/14/25 Care Plan indicated staff were to invite the resident to leisure programs. No information about Resident 61's preferences for activities were identified.-á The 12/28/25 through 1/27/26 Task: Activity Involvement document revealed Resident 61 was not offered activities during the last 30 days. On 1/27/26 at 9:40 AM, Resident 61 was observed sitting alone on her/his bed in her/his room, the resident indicated no staff interviewed her/him regarding her/his preferences for activities, and the resident was interested in bingo.-á On 1/28/26 at 11:39 AM, Staff 21 (CNA) stated no information about Resident 61's preferences for activities were in her/his care plan and the resident ""liked"" to stay secluded in her/his room. On 1/28/26 at 11:47 AM, Staff 24 (Activity Assistant) stated she was ""not surprised"" she did not know Resident 61. Staff 24 revealed she offered books to residents who were on the skilled wing. Staff 24 stated when residents decline books or room activities, we ""move on."" On 01/28/26 at 12:01 PM, Staff 23 (Activity Assistant) stated she interviewed Resident 61 about her/his activities preferences, and the resident was able to answer all the questions. Staff 23 stated she did not complete care plans for activities and was aware she did not correctly complete Resident 61's Admission MDS due to lack of training. Staff 23 stated she perceived Resident 61 was anxious during her/his interview, religious and group activities were important to the resident, and acknowledged follow-up with Resident 61 for activities did not occur. Staff 23 expected CNAs to offer activities and communicate when a resident was interested to attend. Staff 23 acknowledged improved communication between CNAs and activity staff was necessary.-á On 1/29/26 at 3:02 PM, Staff 1 (Administrator) acknowledged training was needed for activity staff. Staff 1 expected correct information about Resident 61's activities and preferences in the MDS, and care plan and activities offered to Resident 61 based on those preferences.

Corrective Action 1) Care plan will be updated for resident #61 to include preferences for activities. Identification of others at risk 1) Administrator/designee will complete baseline audit of all residents to ensure care plan includes activities preferences. Systemic Changes 1) Administrator/Designee will educate Activities staff on the need to document activity preferences to provide meaningful activities to all residents. Monitoring 1) Audits will be conducted weekly by Administrator/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 71 was admitted to the facility in 8/2023 with a diagnosis of paraplegia.-á Resident 71's 1/2/26 BIMS revealed she/he was cognitively intact. 1. A Smoking -Supervised Smokers policy last revised 12/2025 revealed residents who wish to smoke were to be evaluated. Smoking paraphernalia would be managed by nursing staff and made available during smoking times.-á Resident 71's Care Plan last revised on 12/31/25 revealed she/he was an independent smoker. Interventions included cigarettes and lighters were ""required"" to be stored at the nurse's station.-á On 1/27/26 at 9:32 AM Resident 71 was observed in the smoking area. Resident 71 had a black bag in her/his lap. When Resident 71 opened her/his bag one pack of cigarettes and one lighter was observed.-á On 1/29/26 8:45 AM Staff 38 (CNA) stated Resident 71 smoked in the morning with other residents. Staff 38 stated Resident 71 was allowed to smoke without supervision. Staff 38 stated Resident 71 kept her/his lighter in her/his black bag.-á On 1/29/26 at 9:14 AM Staff 3 (RNCM) stated Resident 71 was assessed to be able to smoke independently. Staff 3 was not aware Resident 71 kept her/his lighter and cigarettes in her/his black bag, but stated it was likely the reason she never saw Resident 71 obtain her/his smoking paraphernalia from the nurses station.-á On 2/2/26 at 10:02 AM Staff 1 (Administrator) stated staff were to monitor residents who smoke. The designated smoking area had locked boxes for residents to store their smoking paraphernalia. Staff 1 stated residents were not always compliant with storing smoking supplies.-á 2. Resident 71's Power Wheelchair or Scooter Safety Skills Assessment Supplement form revealed she/he was safe to use a power wheelchair.-á Resident 71's 12/31/25 Unwitnessed Fall investigation revealed she/he fell on 12/31/25. Resident 71 was in her/his power wheelchair and reported she/he unbuckled her/his seatbelt prior to the fall. The investigation revealed she/he sustained a brain bleed. Actions taken to prevent further occurrences were to have OT evaluate Resident 71 in her/his chair to see if a different type of chair or adjustments to the current chair were appropriate for her/his safety.-á Resident 71's 1/7/26 OT Evaluation and Plan of Treatment revealed she/he was referred to OT after a fall from her/his wheelchair after she/he removed the seal belt resulting in a brain bleed and leg fracture. Resident 71 also reported left shoulder pain. The OT assessment evaluated the resident's ability to sit at the edge of the bed. The assessment did not include an evaluation of the wheelchair to see if adaptations could be made for safety. The assessment indicated continued OT services were not needed.-á Resident 71's 1/7/26 PT Evaluation and Plan of Care revealed she/he was assessed after she/he fell two times after unbuckling her/his seat belt. The first fall resulted in facial fractures and the second fall resulted in a small brain bleed and a left hip fracture. The evaluation indicated resident 71 was not able to use her/his leg for six weeks and no ROM or exercise program was appropriate. The evaluation also indicated Resident 71 had extensive education by staff to use the seatbelt when in the chair. It was determined continued PT services were not indicated. The evaluation did not include an assessment to determine if additional adaptations could be made to Resident 71's power wheelchair for safety.-á On 1/29/26 at 9:14 AM and at 2:53 PM Staff 3 (RNCM) stated Resident 71 fell two times in 12/2025 because she/he unbuckled her/his seatbelt. After the fall OT was to evaluate the power chair to see if there was anything which could increase her/his safety.-á On 1/29/26 at 2:31 PM Staff 5 (Director of Rehabilitation) stated in 2025 Resident 71 was evaluated for the use of her/his power wheelchair and was assessed to be safe. Staff 5 stated after the falls therapy evaluated Resident 71, but the order did not indicate it was to evaluate wheelchair safety, and she/he was assessed for physical needs.-á

Corrective Action 1) Resident #71 will not have smoking paraphernalia stored in her room in between smoking sessions. Education will be provided to resident regarding not having smoking paraphernalia in her room. Identification of others at risk 1) DON/Designee will complete baseline audit of residents who smoke to verify smoking paraphernalia is not in the residents’ rooms. Systemic Changes 1) DON/Designee will provide education to nursing staff regarding smoking policies, including residents not keeping paraphernalia in their room. 2) DON/Designee will provide education to residents who smoke to ensure understanding of policies regarding not storing smoking paraphernalia in resident rooms. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 66 was admitted to the facility in 2022 with diagnoses including severe osteoarthritis (a disease which destroys the cartilage protecting bones and cause pain, stiffness and reduced mobility) and chronic pain.-á The resident's 11/2025 BIMS revealed a score of 14 (cognitively intact). A review of the resident's pain monitoring (1-10 scale of pain level with 10 indicating the worst pain possible) in the TAR for the previous 12 months revealed the following: 2/2025: Pain levels of 6-10 reported on 26 of 28 days. 3/2025: Pain levels of 6-9 reported on 27 of 31 days. 4/2025: Pain levels of 6-10 reported on 28 of 30 days. 5/2025: Pain levels of 6-10 reported on 30 of 31 days.-á 6/2025: Pain levels of 6-8 reported on 25 of 30 days.-á 7/2025: Pain levels of 6-8 reported on 25 of 31 days. 8/2025: Pain levels of 6-8 reported on 30 of 31 days. 9/2025: Pain levels of 6-9 reported on 23 of 30 days. 10/2025: Pain levels of 6-9 reported on 28 of 31 days. 11/2025: Pain levels of 6-8 reported on 25 of 30 days. 12/2025: Pain levels of 6-8 reported on 26 of 31 days. 1/2026: Pain levels of 6-7 reported on 26 of 28 days.-á Resident 66's clinical record revealed orders for Tylenol, Lyrica (a medication used to treat nerve pain), lidocaine patches, and cyclobenzaprine (a muscle relaxer) for pain.-á In a Pain Assessment completed 12/23/25 by Staff 7 (LPN) the resident reported severe pain that interfered with sleep, activity, and participation in therapy. The report indicated the resident reported an acceptable pain level would be a level five. On 1/27/26 at 8:25 AM, Resident 66 stated she/he had chronic, unrelieved pain and the only thing she/he could do was lay completely still as movement usually exacerbated the pain. The resident stated she/he received opioid pain medication in the past but was taken off of it due to using a marijuana gummy. The resident stated she/he used the marijuana gummy because she/he was desperate to stop the pain and nothing was working. The resident stated she/he had no quality of life and felt frustrated, trapped and hopeless.-á On 1/28/26 at 8:45 AM, the resident was observed in her/his room with ice packs on her/his right shoulder. The resident was in tears and stated the shoulder pain was severe.-á On 2/1/26 at 12:49 PM, Staff 39 (CMA) stated Resident 66 had chronic pain in her/his shoulders and back and she sometimes found Resident 66 crying from pain.-á On 2/1/26 at 3:17 PM, Staff 7 stated he did a Pain Assessment for Resident 66 on 12/23/25 and was very familiar with the resident. Staff 7 stated in the past year Resident 66 experienced pain experienced significant pain 4 out of 5 days.-á Staff 7 stated he wrote an SBAR (an internal communication which does not become part of the clinical record) sometime after the assessment as the resident had reported a pain level of ten out of ten. He stated he was aware she/he was chronically in pain and did not think her/his pain regimen of Tylenol and Lyrica was alleviating her/his pain. Staff 7 stated Resident 66 was more independent in the past but now was dependent on staff for most of her/his care.-á On 2/1/26 at 4:45 PM, Staff 16 (CMA) stated Resident 66 experienced was in a lot of pain chronically. Staff 16 stated he saw Resident 66 in tears from pain frequently and she/he would cry out in pain when she/he tried to move. Staff 16 stated he spoke to the Unit Manager about Resident 66's pain. On 2/1/26 at 6:47 PM, Staff 38 (CNA) stated Resident 66 was chronically in pain and she would see Resident 66 crying or grimacing in pain. She stated Resident 66 rarely left her/his room and wanted to be left alone when she/he was in a lot of pain. She stated she would attempt comfort measures with Resident 66 and sometimes she could distract her/him but didn't really think anything was helping alleviate Resident 66's pain.-á On 2/2/26 at 11:18 AM, Staff 37 (Physician's Assistant) stated the resident had severe osteoarthritis. She stated Resident 66 was on a pain contract from a previous provider and refused a urinalysis which meant she/he was weaned off opioids. Staff 37 stated Resident has severe osteoarthritis and a hernia and was not a candidate for corrective surgery due to her/his weight. Staff 37 stated Resident 66 could find another provider, but she was not going to risk her license by prescribing Resident 66 opioids since she/he violated the pain contract.-á On 2/2/26 at 11:28 AM, Staff 8 (Social Services Director) stated Resident 66's last interdisciplinary team conference was in 2/2025. Staff 8 stated he did not assist Resident 66 to obtain an appointment with a pain management clinic. On 2/2/26 at 11:38 AM, Staff 28 (LPN/Unit Manager) stated Resident 66 reported her/his pain was not managed but when Staff 28 asked staff they reported Resident 66 did not present symptoms of pain. Staff 28 stated staff did not inform her Resident 66's pain regimen was not effective and she did not interview Resident 66 about her/his pain. Staff 28 stated she had heard Resident 66 used methamphetamine and violated her/his pain management contract. Staff 28 stated she did not request Resident 66 be evaluated for substance use disorder (SUD) and was not aware there was no diagnosis for SUD in Resident 66's clinical record.-á On 2/2/26 at 11:50 AM, Staff 2 (DNS) stated the facility had an obligation to provide oversight and care of residents and collaborate regularly on the effectiveness of resident care. Staff 2 stated the facility needed to review Resident 66's situation and to assist Resident 66 to reach her highest practicable level of wellbeing.-á -á -á -á -á -á -á -á

Corrective Action 1) Resident #66 will have updated pain assessment. Identification of others at risk 1) DON/Designee will complete baseline audit of residents to ensure pain assessment is in place. Audit will include care plan review for those identified to have pain to ensure interventions for pain are in place, and monitoring of pain is conducted per established routine. Systemic Changes 1) DON/Designee will provide education to licensed nurses regarding completing pain monitors per ordered routine, and ensuring care plan is in place which identifies appropriate interventions for pain. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 66 was admitted to the facility in 2022 with-ádiagnoses including severe osteoarthritis (a disease-áwhich destroys the cartilage protecting bones and cause-ápain, stiffness and reduced mobility) and chronic pain. The resident's 11/2025 BIMS revealed a-áscore of 14 (cognitively intact). A review of the resident's pain monitoring (1-10 scale-áof pain level with 10 indicating the worst pain-ápossible) in the TAR for the previous 12 months-árevealed the following: 2/2025: Pain levels of 6-10 reported on 26 of 28 days. 3/2025: Pain levels of 6-9 reported on 27 of 31 days. 4/2025: Pain levels of 6-10 reported on 28 of 30 days. 5/2025: Pain levels of 6-10 reported on 30 of 31 days. 6/2025: Pain levels of 6-8 reported on 25 of 30 days. 7/2025: Pain levels of 6-8 reported on 25 of 31 days. 8/2025: Pain levels of 6-8 reported on 30 of 31 days. 9/2025: Pain levels of 6-9 reported on 23 of 30 days. 10/2025: Pain levels of 6-9 reported on 28 of 31 days. 11/2025: Pain levels of 6-8 reported on 25 of 30 days. 12/2025: Pain levels of 6-8 reported on 26 of 31 days. 1/2026: Pain levels of 6-7 reported on 26 of 28 days. Resident 66's clinical record revealed orders for Tylenol, Lyrica (a medication used to treat nerve pain), lidocaine patches, and cyclobenzaprine (a muscle relaxer) for pain. In a Pain Assessment completed 12/23/25 by Staff 7(LPN) the resident reported severe pain that interfered with sleep, activity, and participation in therapy. The report indicated the resident reported an acceptable pain level would be five. On 1/27/26 at 8:25 AM, Resident 66 stated she/he had-áchronic, unrelieved pain and the only thing she/he-ácould do was lay completely still as movement usually-áexacerbated the pain. The resident stated she/he received-áopioid pain medication in the past but-áwas taken off of it due to using a marijuana gummy. The-áresident stated she/he used the marijuana gummy because-áshe/he was desperate to stop the pain and nothing was-áworking. The resident stated she/he had no quality of-álife, felt frustrated, trapped and hopeless. On 1/28/26 at 8:45 AM, the resident was observed in-áher/his room with ice packs on her/his right shoulder.-áThe resident was in tears and stated the shoulder pain-áwas severe. On 2/1/26 at 12:49 PM, Staff 39 (CMA) stated Resident-á66 had pain in her/his shoulders and back and she-ásometimes found Resident 66 crying from pain. On 2/1/26 at 3:17 PM, Staff 7 stated he did a Pain-áAssessment for Resident 66 on 12/23/25 and was very-áfamiliar with the resident. Staff 7 stated he wrote an-áSBAR (an internal communication which does not become-ápart of the clinical record) sometime after the-áassessment as the resident reported a pain level of-áten out of ten. He stated he was aware she/he was-áchronically in pain and did not think her/his pain-áregimen of Tylenol and Lyrica was alleviating her/his-ápain. Staff 7 stated Resident 66 was more independent-áin the past but now was dependent on staff for most of-áher/his care. On 2/1/26 at 4:45 PM, Staff 16 (CMA) stated he saw Resident 66 in tears from pain, and she/he would frequently cry out in pain when she/he tried to move.Staff 16 stated he spoke to the Unit Manager about Resident 66's pain. On 2/1/26 at 6:47 PM, Staff 38 (CNA) stated Resident 66 was chronically in pain and she would see Resident 66 crying or grimacing in pain. She stated Resident 66 rarely left her/his room and wanted to be left alone when she/he was in a lot of pain. She stated she attempted comfort measures with Resident 66 and sometimes she could distract her/him but didn't really think anything was helping alleviate Resident 66's pain. On 2/2/26 at 11:18 AM, Staff 37 (Physician's Assistant) stated Resident 66 had severe osteoarthritis. She stated Resident 66 was on a pain contract from a previous provider and refused a urinalysis which meant she/he was weaned off opioids. Staff 37 stated Resident 66 also had a hernia and was not a candidate for corrective surgery due to her/his weight.-áStaff 37 stated Resident 66 could find another-áprovider, but Staff 37 was not going to risk her-álicense by prescribing Resident 66 opioids since she/he-áviolated the pain contract. On 2/2/26 at 11:28 AM, Staff 8 (Social Services-áDirector) stated Resident 66's last interdisciplinary-áteam conference was in 2/2025. Staff 8 stated he did-ánot assist Resident 66 to obtain an appointment with a-ápain management clinic. On 2/2/26 at 11:38 AM, Staff 28 (LPN/Unit Manager)-ástated Resident 66 reported her/his pain was not-ámanaged but when Staff 28 asked staff they reported Resident 66 did not present symptoms of pain. Staff 28-ástated staff did not inform her Resident 66's pain-áregimen was not effective and she did not interview-áResident 66 about her/his pain. Staff 28 stated she heard Resident 66 had used methamphetamine and violated her/his pain management contract. Staff 28-ástated she did not request Resident 66 be evaluated for substance use disorder (SUD) and was not aware there-áwas no diagnosis for SUD in Resident 66's clinical-árecord. On 2/2/26 at 11:50 AM, Staff 2 (DNS) stated the-áfacility had an obligation to provide oversight and-ácare of residents and to collaborate regularly on the-áeffectiveness of resident care. Staff 2 stated the-áfacility needed to review Resident 66's situation and-áassist Resident 66 to reach her highest practicable-álevel of wellbeing.

Corrective Action 1) Resident #66 will have updated pain assessment Identification of others at risk 1) DON/Designee will complete baseline audit of residents to ensure pain assessment is in place. Audit will include care plan review for those identified to have pain to ensure interventions for pain are in place, and monitoring of pain is conducted per established routine. Systemic Changes 1) DON/Designee will provide education to licensed nurses regarding completing pain monitors per ordered routine, and ensuring care plan is in place which identifies appropriate interventions for pain. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 61 was admitted to the facility in 11/2025 with diagnoses including insomnia, post-traumatic seizures, and anxiety.-á The 11/11/25 Admission MDS indicated a BIMS score of 15 (cognitively intact) for Resident 61.-á The 11/11/25 ACTs My Way assessment indicated Resident 61 was sensitive to loud noises due to military service and Staff 23 (Activity Assistant) conducted the interview. A 11/14/25 Care Plan revealed no information about Resident 61's PTSD (Post Traumatic Stress Disorder) triggers.-á The 1/2026 Monitors revealed Resident 61 slept from two to 11 hours per day during the month. -á On 1/27/26 at 10:05 AM, Resident 61 stated she/he had PTSD and no one was aware he/she required a particular environment to sleep well. Resident 61 sat at the side of her/his bed with the television on and stated she/he needed sound in the room with the television on and the drapes tucked against the window to ensure no person was looking in from the outside. Resident 61 stated it was helpful to the resident for staff to know that information in order to feel safe. On 1/27/26 at 4:13 PM, Staff 20 (CNA) stated she was aware Resident 61 was afraid of the dark, needed the shades closed, and she reported the issue to nursing.-á -á On 1/28/26 at 12:01 PM, Staff 23 acknowledged Resident 61 was GÇ£uneasyGÇ¥ when she interviewed the resident about her/his PTSD. Staff 23 did not report any concerns to nursing and was unsure how information was communicated to CNAs in order to improve care for Resident 61. -á -á On 1/29/26 at 4:13 PM, Staff 9 (Director of Social Services) stated he expected communication from staff when Resident 61 indicated she/he had triggers related to PTSD. Staff 9 acknowledged Resident 61 lacked a thorough assessment and expected interventions in the residentGÇÖs care plan to ensure the resident felt safe.

Corrective Action 1) Resident #61 will have updated behavior/trama assessment Identification of others at risk 1) DON/Designee will complete baseline audit of residents to ensure trauma assessment is in place. Audit will include care plan review for those identified as at risk to ensure interventions for are in place, and monitoring is conducted. Systemic Changes 1) DON/Designee will provide education to licensed nurses regarding completing trauma assessment, and ensuring care plan is in place which identifies appropriate interventions. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 5 was admitted to the facility in 3/2024 with a diagnosis of diabetes.-á Resident 5's 3/19/25 health care provider summary revealed Resident 5 was seen for chronic conditions and her/his dental status. The summary indicated Resident 5 requested to see a dentist for possible implants.-á Resident 5's 1/20/26 NP Wound Note reveals she/he had mild cognitive impairment.-á Resident 5's 1/27/26 Care Plan revealed she/he did not have teeth, and staff were to refer to a dentist for evaluations.-á On 1/26/26 at 3:58 PM Resident 5 stated she/he did not have teeth and wanted implants. Resident 5 stated no one spoke to her/him ""forever"" regarding dental services.-á On 1/29/26 at 2:53 PM Staff 3 (RNCM) stated Resident 5 was able to be transported to dental appointments, but she did not see any dental referrals in her/his clinical record.

Immediate Corrective Action 1) Resident #5 will be referred for dental follow-up. Identification of Others at Risk 1) DON or designee will complete baseline audit for all residents to determine if dental follow-up is needed. Systemic Changes 1) DON/designee will educate Nurses and CNAs on dental services policy, specifically the process for requesting dental follow-ups for residents and requirement to document measures implemented to ensure that residents are still able to eat and drink while awaiting follow-up. 2) DON/designee will educate social services and unit managers on dental services policy, specifically the need to document activities related to dental follow-up requests in the resident's medical record. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months to review current residents and new admissions to ensure appropriate dental follow-up if indicated. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

3. Resident 57 was admitted to the facility in 4/2025 for muscle wasting and diabetes. The 1/25/26 Quarterly MDS revealed a BIMS score of 14 (cognitively intact) for Resident 57. Resident 57 was on a CCD (controlled carbohydrate diet) regular texture diet.-á On 1/29/26 at 12:40 PM several lunch meals were observed to be plated without metal warming plates and loaded on to the cart.-á On 1/29/26 at 12:43 PM the lunch cart was sent out from the kitchen to Sequoia Hall. On 1/29/26 at 1:04 PM Staff 35 (CNA) delivered Resident 57's lunch tray to her/his room. Resident 57 ordered a three-ounce pork chop, Italian pasta salad, tossed salad with dressing and dinner roll. Resident 57 received one pork chop on the plate and tossed salad. The resident stated there was no food warmer under the plate and the pork chop did not feel warm. Resident 57 stated food is often served cold.-á On 1/29/26 at 1:08 PM Staff 35 stated she went to the kitchen to request the missing items for Resident 57. Staff 35 stated the dietary staff stated the Italian pasta salad and dinner roll had run out. Staff 35 stated residents frequently complained about cold food served in the residentsGÇÖ rooms and the kitchen running out of food.-á On 1/30/26 at 1:19 PM Staff 1 (Administrator) acknowledged Sequoia Hall had complaints of cold food complaints and food running out.-á , 2. Resident 29 was admitted to the facility in 12/2025 with diagnosis including heart disease. A 12/13/25 Care Plan indicated Resident 29 required staff to assist with the set-up of her/his meals. The 12/19/25 Admission MDS revealed a BIMS assessment score of 14 (cognitively intact) for Resident 29.-á On 1/26/26 at 12:36 PM, meal trays were loaded on a cart from the dining room and taken to Resident 29's hall. On 1/26/26 at 12:41 PM, Resident 29 was observed with her/his meal in her/his room and stated the food was not warm. An unidentified CNA in the resident's room did not offer to address her/his cold food. On 1/27/26 at 10:49 AM, Resident 29 stated her/his meals were often late and cold and reheated food took too long to be returned. On 1/28/26 at 1:23 PM, Resident 29 was observed in her/his room with a lunch tray and napkin on her/his plate. Resident 29 stated she completed her/his meal and acknowledged her/his meal was half eaten. Resident 29 stated her/his lunch arrived 10 minutes earlier and her/his potato arrived cold and could not melt butter. Resident 29 stated the meal was late and she/he expected food to arrive around noon.-á On 1/30/26 at 9:01 AM, Staff 27 (CNA) stated residents frequently complained about cold food when served in the residents' rooms and food was often cold from the beginning of service. Staff 27 stated meals were late two to three times each week and there was no effective method to reheat residents' food. Staff 27 stated any lack of staffing impacted the ability for meals to be delivered timely.-á On 1/30/26 at 12:10 PM, Staff 22 (Regional Dining Director) acknowledged the facility was aware of cold food complaints by residents and sufficient food delivery equipment was required to address the cold food concerns. , 1.Resident 11 was admitted to the facility in 1/26 with diagnoses including anemia (low red blood cell count) and kidney failure. The 1/18/26 Admission MDS revealed a BIMS assessment revealed a score of 15 for Resident 11. On 1/26/26 at 9:41 AM, Resident 11 was observed with her/his breakfast in her/his room. Resident 11 stated the food was not warm and she/he refused to eat it. Staff 32 (CNA) entered the room and Resident 11 stated her/his eggs, toast, and oatmeal were cold. Staff 32 did not offer to address her/his cold food. On 1/26/26 at 12:36 PM, meal trays were loaded on a cart from the dining room and taken to Resident 11's hall. On 1/29/26 at 10:49 AM, Resident 11 stated her/his meals were often cold. Resident 11 stated she/he would ask for an alternative, but staff did not return with warm food. Resident 11 stated the food was always cold; therefore, she/he had family bring snacks to the facility. Resident 11 stated she/he informs the staff daily the food is cold, but nothing changes regarding her/his breakfast of scrambled eggs, toast, and oatmeal. On 1/29/26 12:37 PM, Staff 23 (CNA) stated the residents complain frequently about cold food. Staff 23 stated it was difficult to warm all the trays for the residents and still perform work duties. Staff 23 stated management needed to ensure the residents had hot meals. Staff 23 stated staff do the best they can to get meal trays out, but it does not take long for the food to become cold. On 1/30/26 at 12:10 PM, Staff 2 (DNS) and Staff 22 (Regional Dining Director) acknowledged the facility was aware of cold food complaints by residents. Staff 2 and Staff 22 stated sufficient food delivery equipment was required to address the cold food concerns. -á

Corrective Action 1) Residents #29, #57, and #11 have been notified of facility changes to keep food warm and palatable. Identification of others at risk 1)Administrator/Designee will complete a base line audit for specific food temperatures. Systemic Changes 1) A steam table was ordered on 1/30/ 26 to better maintain food temperatures. 2) Administrator/Designee will educate Dietary and Nursing staff on proper food temperatures and reheating food as necessary. Monitoring 1) Audits will be conducted weekly by Administrator/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

1. Resident 9 admitted to the facility in 1/2023 with diagnoses including paralysis of the left side following a stroke and diabetes. An 10/23/25 Quarterly MDS indicated Resident 9 was cognitively intact. A review of Resident 9's medical record indicated she/he received an influenza vaccine on 10/2/25. No consent for the influenza vaccine was found in Resident 9's medical record.-á On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered influenza vaccines when they were available, and a consent was signed prior to receiving the vaccine. She verified Resident 9 did not have a signed consent for the influenza vaccine she/he received on 10/2/25. On 2/2/26 at 1:04 PM, Staff 2 (DNS) stated she expected all nursing staff to obtain a signed consent prior to giving any vaccinations.-á 2. Resident 62 admitted to the facility in 6/2024 with diagnoses including end stage renal disease and paralysis of the left side following a stroke. A 12/21/25 Quarterly MDS indicated Resident 62 was cognitively intact.-á A review of Resident 62's medical record indicated she/he received an influenza vaccine on 10/7/25. No consent for the influenza vaccine was found in Resident 62's medical record.-á On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered influenza vaccines when they were available, and a consent was signed prior to receiving the vaccine. She verified Resident 62 did not have a signed consent for the influenza vaccine she/he received on 10/7/25. On 2/2/26 at 1:04 PM, Staff 2 (DNS) stated she expected all nursing staff to obtain a signed consent prior to giving any vaccinations.-á

Corrective Action 1) Residents #9 and #62 will have documented consent in the medical record for subsequent vaccinations received. Identification of others at risk 1) DON or designee will complete baseline audit of residents to determine if documented consent is present for influenza or pneumococcal vaccinations that have been received in facility during the past 90 days. Systemic Changes 1) DON/Designee will provide education to licensed nurses regarding ensuring resident consent is obtained and documented prior to administration of a vaccine. Monitoring 1) Audits will be conducted by DON or designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

The facility Infection Prevention & Control COVID-19 Immunization policy with revision date 1/7/25 indicated all residents would be offered the COVID-19 vaccine when available and the resident's medical record would contain documentation of an acceptance or refusal of the vaccine.-á 1. Resident 9 admitted to the facility in 1/2023 with diagnoses including paralysis of the left side following a stroke and diabetes. An 10/23/25 Quarterly MDS indicated Resident 9 was cognitively intact. A review of Resident 9's medical record indicated she/he received a COVID-19 vaccine on 10/2/25. No consent for the COVID-19 vaccine was found in Resident 9's medical record.-á On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered COVID-19 vaccines when they were available, and a consent was signed prior to receiving the vaccine. She verified Resident 9 did not have a signed consent for the COVID-19 vaccine she/he received on 10/2/25. On 2/2/26 at 1:04 PM, Staff 2 (DNS) stated she expected all nursing staff to obtain a signed consent prior to giving any vaccinations.-á 2. Resident 62 admitted to the facility in 6/2024 with diagnoses including end stage renal disease and paralysis of the left side following a stroke. A 12/21/25 Quarterly MDS indicated Resident 62 was cognitively intact. A review of Resident 62's medical record indicated she/he received a COVID-19 vaccine on 10/7/25. No consent for the COVID-19 vaccine was found in Resident 62's medical record.-á On 1/29/26 at 2:44 PM, Staff 15 (RN/IP) stated all residents were offered COVID-19 vaccines when they were available, and a consent was signed prior to receiving the vaccine. She verified Resident 62 did not have a signed consent for the COVID-19 vaccine she/he received on 10/7/25. On 2/2/26 at 1:04 PM, Staff 2 (DNS) stated she expected all nursing staff to obtain a signed consent prior to giving any vaccinations.-á

Corrective Action 1) Residents #9 and #62 will have documented consent in the medical record for subsequent vaccinations received. Identification of others at risk 1) DON or designee will complete baseline audit of residents to determine if documented consent is present in each resident’s medical record for covid vaccinations that have been received in facility during the past 90 days. Systemic Changes 1) DON/Designee will provide education to licensed nurses regarding ensuring resident consent is obtained and documented prior to administration of a vaccine. Monitoring 1) Audits will be conducted by DON or designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations

The Direct Care Staff Daily Reports from 11/25/25 through 1/25/26 revealed the facility did not have an RN charge nurse on duty for eight consecutive hours between day and evening shifts for the following dates:-á 11/26/25 11/27/25-á 11/28/25 11/29/25 12/6/25 12/7/25 12/11/25 12/13/25 12/14/25 12/20/25 12/21/25 12/22/25 12/25/25 12/26/25 12/27/25 12/28/25 1/1/26 1/2/26 1/3/26 1/4/26 1/9/26 1/10/26 1/11/26 1/12/26 1/13/26 1/14/26 1/16/26 1/21/26 1/22/26 1/23/26 On 1/30/26 at 11:07 AM, Staff 14 (Scheduling Coordinator) confirmed RNs were not available on the discrepant dates. On 1/30/26 at 3:02 PM, Staff 1 (Administrator) acknowledged the requirement for eight hours of RN staffing between day and evening shifts were not met.

Corrective Action 1) Facility will have RN scheduled for the required 8 hours of continuous coverage. Identification of others at risk 1) DON/Designee will complete baseline audit for the past 30 days to determine if facility has had 8 hours of RN coverage between 6 am and 10 pm as required. Systemic Changes 1) DON/Designee will provide education to staffing coordinator, nurse managers and licensed nurses regarding staffing ratio and required 8 hours of RN coverage.  Education will include steps to take if scheduled staff do not arrive for their scheduled shift. 2) Daily staffing meeting will be conducted to confirm RN is schedule to meet required RN coverage. 3) Facility will continue weekly recruiting calls to facilitate hiring additional RN staff. Monitoring 1) Audits will be conducted by DON or designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

A revised Resident Rights Grievances Policy and Procedure (revised in 3/2023) indicated the grievance officer with assistance of Social Services, responsibility to oversee the grievance process, receive and track grievance through conclusion, lead any necessary investigations, maintain confidentiality, and issue written grievance decisions. Staff will immediately report to the Grievance Officer any grievance alleging violations related to misappropriation of resident property. The Grievance Officer will make reports available within seven business days of filing. A summary report of the investigation will be available to the resident, and a confidential file will be maintained on grievance decisions and investigations for three years. -á Resident 23 was admitted to the facility in 2/2025, with a diagnosis including depression. -á An 8/26/25 Resident Council meeting minutes indicated residents reported missing items from their room. Resident 23 attended the meeting. -á An 8/31/25 MDS revealed Resident 23 BIMS was 15 (cognitively intact). -á Review of the Grievance List report for 7/2025 and 8/2025 revealed no grievances submitted for Resident 23. -á On 1/12/26 at 12:46 PM, Resident 23 stated in 8/2025 she/he was missing jewelry, an oximeter, a set of colored pencils and gel pens. Resident 23 stated she/he reported the missing items to staff and at the resident council meeting. -á On 1/14/26 at 11:49 AM, Staff 26 (CNA) stated Resident 23 reported in 8/2025 she/he was missing a set of earrings and an oximeter. Staff 26 stated she reported the missing items to the charge nurse. Staff 26 stated Resident 23 had completed a grievance form the day before, so she did not assist with completing one. -á On 1/15/26 at 9:13 AM and 11:19 AM, Staff 11 (Director of Social Services and Recreation) stated he did not remember any grievances for Resident 23 regarding missing items. Staff 11 stated no grievances were found for Resident 23 for 8/2025. Staff 11 stated there had been ""confusion"" due to multiple staff members in 8/2025 and the grievance was possibly submitted but became lost. -á On 1/15/26 at 11:49 AM, Staff 1 (Administrator) stated he would expect staff to complete a grievance and to be resolved in five days.

Corrective Action 1) Resident #23 will have further grievances resolved in a timely manner. Facility will initiate and complete the grievance process surrounding previously reported missing items. Identification of others at risk 1) NHA/Designee will complete baseline audit of current residents to verify that residents with missing items in the past 30 days have had a grievance initiated and follow-up has been completed with the resident. Systemic Changes 1) NHA/Designee will provide education to staff regarding process to report missing items via grievance process and timeframe to resolve the grievance. Monitoring 1) Audits will be conducted by NHA/Designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 28 was admitted to the facility in 2/2025, with diagnoses including anxiety and cognitive communication deficit (difficulty in expressing or understanding language). -á A 3/7/25 Elopement Investigation Report revealed on 3/6/25 around 4:30 PM, Resident 28 was found approximately a block away from the facility next to a busy street. The investigation stated root cause was Resident 28 was confused and her/his wander guard (electronic monitoring device) was not functioning. -á There was no documented evidence Resident 28's elopement was reported to the State Survey Agency for the elopement incident on 3/6/25.-á -á On 1/14/26 at 9:48 AM, Staff 40 (Former Administrator) stated she could not remember if Resident 28GÇÖs elopement was reported to the state but stated she would not report an elopement because it was no longer listed on the FRI form. -á On 1/13/26 at 10:27 AM and 1/15/26 at 11:55 AM, Staff 1 (Administrator) stated to his knowledge no FRI was completed for the resident's 3/6/25 elopement. Staff 22 (Regional RN) stated if there was an alleged violation it would be expected to submit an FRI for an elopement.

Corrective Action 1) Resident #28 has discharged from the facility. Identification of others at risk 1) Regional Director of Clinical or Regional Director of Operations will complete baseline audit of residents who experienced an incident in the past 30 days to verify any incidents with alleged violation were reported. Systemic Changes 1) Regional Director of Clinical or Regional Director of Operations will provide education to current NHA and DON regarding timely reporting of alleged violations of abuse or neglect. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 28 was admitted to the facility in 2/2025, with diagnoses including anxiety, and cognitive communication deficit (difficulty expressing or understanding language). -á -á A 2/7/25 Admission MDS revealed Resident 28's BIMs score was three (severe cognitive impairment). -á A 3/4/25 Care Plan indicated Resident 28 had episodes of wandering and had a Wander Guard (electronic monitoring device) placed on her/his wheelchair. Interventions included checking placement of Wander Guard on the wheelchair every shift and distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. -á A 3/2025 TAR instructed staff to check Resident 28's Wander Guard placement on the left area of her/his wheelchair every shift with a start date of 3/4/25. -á There was no documented evidence found in Resident 28's clinical record to indicate staff were checking the resident's Wander Guard to ensure it was functioning properly.-á-á -á A 3/7/25 Elopement Investigation Report revealed on 3/6/25 around 4:30 PM, Resident 28 was found approximately one block away from the facility next to a busy street. The investigation indicated the root cause was Resident 28 was confused and her/his wander guard was not functioning. Resident 28 was placed on 15-minute checks, and a 15-minute monitoring sign-up sheet was set up for the staff. -á There was no documented evidence found in Resident 28's clinical record to indicate staff were conducting 15-minute checks after the resident's elopement.-á -á On 1/15/26 at 9:53 AM, Staff 47 (Former Physical Therapist Assistant) stated Resident 28 was very confused. Staff 47 stated he found Resident 28 on 3/6/25 approximately 18 inches from a busy street in a ""precarious"" position. Staff 47 stated Staff 24 (CNA) helped him assist Resident 28 back to the facility. Staff 47 stated the Wander Guard became a ""big thing"" after the resident returned to the facility. -á On 1/15/26 at 1:14 PM, Staff 24 stated he assisted Staff 47 with bringing Resident 28 back to the facility when she/he was found next to a busy street. Staff 24 stated Resident 28 did not have a Wander Guard on her/his wheelchair. -á On 1/14/26 at 8:58 AM and 1/15/26 at 11:55 AM, Staff 1 (Administrator) stated no 15-minute monitoring sheets for Resident 28 were located. Staff 1 stated it would be expected for staff to check Wander Guard placement and functionality.

Corrective Action 1) Resident #28 has discharged from the facility. Identification of others at risk 1) DON/Designee will complete baseline audit of current residents who are identified to be at risk for elopement and have a wander guard device due to evaluated risk. Audit will ensure system is in place to verify placement and functionality and that the use of the wander guard device is reflected in the resident care plan. Systemic Changes 1) DON/Designee will provide education to staff regarding resident factors contributing to risk for elopement. Education will also include  associated protocols to verify placement and functionality of wander guard devices in use. Monitoring 1) Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

A review of the facility's Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025, and 11/2025 indicated there were 21 days without RN coverage for eight consecutive hours. The dates were as follows:-á-á -8/3/25 -8/8/25 -8/10/25 -8/11/25 -8/16/25 -8/17/25 -8/18/25 -8/19/25 -8/24/25 -8/25/25 -8/29/25 -8/31/25 -9/1/25 -9/7/25 -9/15/25 -9/29/25 -10/20/25 -10/25/25 -10/27/25 -10/28/25 -11/3/25 -á -á On 1/15/26 at 9:23 AM, Staff 27 (Staffer) and Staff 23 (LPN) stated they were told to start reporting the RN manager on the Direct Care Staff Daily Report on 1/13/25.-á -á -á On 1/15/26 at 11:52 AM, Staff 1 (Administrator) stated it was the expectation for staff to call off work two hours before their shift to give time for additional staff to be found to cover. Payroll documentation of RN working on the above listed days were requested. No additional documentation was provided.

Corrective Action 1) Facility will have RN scheduled for the required 8 hours of continuous coverage. Identification of others at risk 1) DON/Designee will complete baseline audit of the past 30 days to determine if facility has had 8 hours of RN coverage between 6 am and 10 pm as required. Systemic Changes 1) DON/Designee will provide education to staffing coordinator, nurse managers and licensed nurses regarding  staffing ratio and required 8 hours of RN coverage.  Education will include steps to take if scheduled staff do not arrive for their scheduled shift. 2) Daily staffing meeting will be conducted to confirm RN is schedule to meet required RN coverage. 3) Facility will continue weekly recruiting calls to facilitate hiring additional RN staff. Monitoring 1) Audits will be conducted by DON or designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations

A review of the Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025 and 11/2025 revealed the facility did not have sufficient CNA staff to meet the minimum CNA-to-resident staffing ratios for 14 of 234 shifts on the following days:-á -8/3/25 (day shift) -8/11/25 (evening and night shift) -8/12/25 (night shift) -8/15/25 (evening shift and night shift) -8/17/25 (day and evening shift) -8/24/25 (day shift) -8/30/25 (evening shift) -9/21/25 (day shift) -9/28/25 (evening shift) -11/1/25 (day shift) -11/5/25 (evening shift) -á On 1/14/26 at 10:29 AM, Staff 31 (CNA) stated on evening shifts there would be one CNA to 10 to 12 residents. -á On 1/15/26 at 7:33 AM, Staff 30 (CNA) stated the CNAs have to split up rooms ""quite a bit."" -á On 1/15/26 at 11:52 AM, Staff 1 (Administrator) stated it was the expectation of staff to call off work two hours before their shift to give time for additional staff to be found to cover.

Corrective Action 1) Facility will have CNA’s scheduled to meet mandated ratios. Identification of others at risk 1) DON/Designee will complete baseline audit of CNA staffing ratios for the past 30 days to determine if there has been sufficient CNA staff to meet resident needs according to the established ratios. Systemic Changes 1) DON/Designee will provide education to staffing coordinator, nurse managers and licensed nurses regarding  CNA staffing ratio. Education will include steps to take if scheduled staff do not arrive for their scheduled shift. 2) Daily staffing meeting will be conducted to confirm CNA and RN staff are scheduled to meet established ratios and required RN coverage. Monitoring 1) Audits will be conducted by DON or designee weekly for 4 weeks, then monthly for two months. 2) Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Resident 1 was admitted to the facility in 4/2025 with diagnoses including hip fracture and Fibromyalgia (chronic pain illness). An 4/22/25 Admission MDS revealed she/he was cognitively intact and required moderate assistance from staff for transfers.-á On 10/24/25 at 11:54 AM, Resident 1 stated while speaking with Staff 5 (Speech Therapist) about self-transferring for toileting needs she/he was told to only get up with staff assistance and to urinate in the bed when staff were not available. She/He stated the comment was mortifying and caused her/him to feel degraded. -á On 10/27/25 at 11:45 AM, Staff 5 stated she did not remember Resident 1. She stated she often instructs residents to follow all safety and assistance recommendations to prevent possible injuries. She stated if she was aware a resident was transferring in an unsafe manner to use the toilet, she would instruct them to urinate in the bed rather than get up unassisted.-á On 10/27/25 at 3:50 PM, Staff 3 (Interim DNS) stated he did not remember Resident 1 or any incidences involving Staff 5. He stated had he been made aware of the incident, he would have coached the staff member and spoken with the resident. He stated the expectation of all staff is for them to treat all residents with dignity and respect.

Immediate corrective action Resident #1 is no longer in the facility. Staff #5 was in-service regarding resident dignity. Plan to identify other residents that may be affected. Current facility residents were interviewed regarding dignity and staff approach. No concerns were identified. Systemic Changes Therapy staff and facility staff will be in-serviced regarding Dignity and respect; DSD will provide the same in-service during the next all-staff meeting 12/18/25. Plan to Monitor Administrator/Designee will interview and monitor residents for any dignity related concerns for 3 weeks, then monthly for 2 months until QAPI committee determines substantial compliance. Any concerns or trends will be addressed immediately and brought to the attention of the facility QAPI committee.

The facility Wound Treatment Management policy revised 4/1/25 stated the effectiveness of wound care treatments would be monitored with ongoing assessments of the wound until healed. Resident 1 was admitted to the facility in 4/2025 with diagnoses including hip fracture and Fibromyalgia (chronic pain illness). An 4/22/25 Admission MDS revealed she/he was cognitively intact, had pain daily, and had a surgical wound.-á On 10/24/25 at 11:54 AM, Resident 1 stated the facility ran out of her/his pain medications multiple times and the facility staff did not implement wound observations or treatment after her/his wound care needs changed. She/He stated they were constantly in pain while at the facility and was admitted to the hospital with an infection in their wound. -á On 10/24/25 at 12:05 PM, Witness 2 (Family Member) stated Resident 1 was without pain medication on multiple occasions, and Resident 1GÇÖs wound became infected due to not having any wound observations or treatments in place after the care needs changed. The 4/16/25 provider orders indicated the following:-á - Oxycodone (an opioid pain medication) 5 GÇô 10MG was to be given as needed every four hours. - Tramadol (an opioid pain medication) 1,00MG was to be administered in the AM and at bedtime. The 4/16 - 4/26/25 Medication Administration Records showed: - Oxycodone was administered 29 times-á - Tramadol was not administered on 4/16/25 PM, 4/17/25 AM, 4/21/25 AM and PM, and 4/22/25 AM.-á An 4/17/25 progress note indicated Tramadol was not given on 4/16/25 and 4/17/25 due to the facility not getting the medication from the pharmacy.-á An 4/18/25 provider wound care order indicated treatment was changed to a honeycomb dressing (clear honeycomb shape post-surgical dressing designed to protect the wound and manage drainage). The order indicated it was to be removed 4/26/25 and did not have any instructions for monitoring of the wound after placement of the honeycomb dressing.-á An 4/19/25 progress notes indicated the facility ordered an Oxycodone emergency supply due to running out of the regular shipment.-á An 4/20/25 progress note indicated Witness 1 spoke to staff regarding Resident 1GÇÖs Oxycodone supply running out and her/his pain. The note revealed facility staff contacted the pharmacy who stated the cause of the delivery delay was unknown and the Oxycodone would be sent that night.-á Progress notes from 4/21/25 and 4/22/25 indicated Tramadol was not given because the pharmacy had not delivered the medication. Resident 1GÇÖs April pain level record indicated pain levels ranging seven out of 10 to 10 out of 10 on days medications were missed.-á Shower records for 4/2025 revealed all facility offered showers were refused by the resident and no as needed showers were requested.-á Progress notes from 4/26/25 indicated Resident 1 had complaints of chills, a fever of 103 degrees Fahrenheit, an elevated heart rate, and elevated blood pressure. An assessment of the wound revealed redness, swelling, warmth, and tenderness and Resident 1 was sent to the Emergency Department for treatment.-á On 10/24/25 at 6:47 PM, Staff 9 (Medication Technician) stated she did not remember Resident 1. She stated when residents had scheduled and as needed pain medications, she checked in with the residents throughout the shift for pain levels and medicated as needed. She stated there were times medications were late or got missed altogether. On 10/24/25 at 4:24 PM, Staff 7 (LPN) stated she did not remember Resident 1. She stated medication refills were monitored by the medication technician and nursing staff, and at times medications did not get re-ordered properly which caused residents to miss medications. She stated all wound care treatments and monitoring were initiated and completed by the wound care nurse.-á On 10/27/25 at 2:04 PM, Staff 4 (LPN Unit Manager) stated she did not remember Resident 1. She stated staff have been trained to monitor medication amounts and re-order enough to cover all possible administrations. She stated all medications were expected to be re-ordered prior to the current supply running out. She stated wound care assessments were completed by the wound care nurse, and the expectation for all wounds was for them to be monitored until healed.-á Multiple attempts to reach the wound care nurse were unsuccessful.-á On 10/27/25 at 3:50 PM, Staff 3 (Interim DNS) stated he did not remember Resident 1. He stated pain levels were monitored by multiple staff members throughout the shift and residents were medicated for pain as needed or ordered by the provider. He stated the expectation was for medication refills to be ordered prior to the current supply running out. He stated honeycomb dressings were not touched by staff, and all wounds were expected to be monitored until healed regardless of the wound care dressing in place.-á

Immediate corrective action Resident # 1 no longer resides at the facility. Plan to identify other residents that may be affected Residents with pain medication orders and wound treatment orders have the potential to be affected.  A baseline audit will be conducted to ensure residents with pain medication orders have the ordered medication available. A comprehensive skin assessment was conducted for current residents to ensure residents with wounds have been identified and treatment orders and monitoring are in place. System Change Licensed Nurses will be re-educated on the Volare Wound Treatment Management Policy.                                                                                           Licensed Nurses and Certified Medication Technicians will be re-educated on the pharmacy ordering /reordering policy. Plan to Monitor Director of Nursing/Designee will monitor residents for any medication and treatment orders for 3 weeks, then monthly for 2 months until QAPI committee determines substantial compliance. Any concerns or trends will be addressed immediately and brought to the attention of the facility QAPI committee.

Based on observation, interview and record review it was determined the facility failed to follow physician's orders related to oxygen administration for 1 of 3 sampled residents (#8) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 8 was admitted to the facility in 1/2024, with diagnoses including respiratory failure with hypoxia (lack of oxygen) and asthma. Resident 8's 2/2024 Physician's Orders indicated staff was to administer oxygen continuously at 2 liter per minute via nasal cannula. This order was discontinued when Resident 8 was sent out to the hospital. Resident 8 re-admitted on 12/2024 without an order for oxygen. On 1/31/25 at 12:20 PM, Staff 3 (SSD) confirmed Resident 8 had an appointment on 12/9/24 at summit surgical. Staff 3 remembered her/him coming back upset about the appointment. On 1/31/25 at 10:38 AM, Staff 44 (CNA) stated Resident 8 should have had oxygen when she/he went out to the appointment on 12/9/24. Resident 8 came back and her/his pulse oxygen reading was at 64%. Staff were supposed to send oxygen tanks with residents, which attach to residents' wheelchairs. Staff 4 stated Resident 8 did not have an oxygen tank with her/him during her/his appointment. On 1/28/25 at 10:32 AM, Resident 8 was observed with a nasal canula in place and an oxygen concentrator running at four liters per minute. On 2/3/25 at 10:36 AM, Resident 8 was observed with a nasal canula in place and an oxygen concentrator running at four liters per minute. On 2/3/25 at 10:40 AM, Staff 9 (CMA) confirmed Resident 8 was on four liters of continuous oxygen. Review of Resident 8's clinical record found no order for the resident's continuous oxygen at four liters. On 2/3/25 at 10:43 AM, Staff 2 (DNS) was informed Resident 8 was on oxygen without an order. Staff 2 stated they would look into it.

Resident#8 will have oxygen tank when leaving facility and will have oxygen orders in place. ¿¿ Residents that require oxygen and leave for appointments are at risk. DON/Designee will complete baseline audit of current residents who utilize oxygen to verify it is provided per orders, and identified issues will be addressed. DON/Designee will provide further education nursing staff related to following physician orders related to oxygen use. DON/Designee will conduct random observations of 10 residents who utilize oxygen to verify it is being provided per orders. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to assure there was sufficient nursing staff available to provide nursing and related services to meet the residents' needs safely and timely for 2 of 2 units reviewed for staffing. This placed residents at risk for missed or delayed care, missed or late meals, an increase safety risk for falls and aspiration, and a decline in health status. Findings include: Intermittent call light and staffing observations conducted on 1/29/25 from 8:15 AM to 5:00 PM revealed call light wait times up to 27 minutes. Intermittent call light and staffing observations conducted on 1/30/25 from 5:00 AM to 2:00 PM revealed call light wait times up to 40 minutes. Review of the facility's grievances found the following: - On 11/6/24, staff entered Resident 24's room and found Resident 24 "soaked so bad that it was dripping off of [her/his] bed onto the ground and there was a huge puddle of pee underneath." Additionally, the resident was found laying flat in bed with no oxygen, her/his oxygen saturation was 79% (normal is 93-100%) and the resident stated she/he saw "yellow spots". - On 11/20/24, Resident 18 indicated she/he experienced long call light wait times and soiled linens. - On 12/16/24, staff did not provide timely incontinent care and Resident 5 sat in a soiled brief for an hour and a half before care was received. - On 1/27/25, Resident 31 indicated she/he had waited over two hours for assistance with her/his lunch meal and expressed via a writing board, "I feel sad, no one comes. I'm always last." The facility's 11/2024 and 1/2025 Resident Council Notes revealed concerns related to call lights. The facility's Payroll Based Journal (PBJ) Reports revealed in 11/2024, the facility was short CNA staff for 17 shifts; and in 12/2024 short CNA staff for five shifts. The facility's Direct Care Staff Daily Report from 1/1/25 to 1/26/25 revealed the facility was short eight CNAs for seven shifts. On 1/28/25 at 10:19 AM, Resident 5 stated call light wait times were long and she/he occasionally missed showers because there was not enough staff. On 1/28/25 at 11:58 AM, Resident 4 stated call light wait times were long and she/he did not always get a shower. On 1/28/25 at 3:58 PM, Resident 11 stated the facility was short staffed, call light wait times could be long and she/he sometimes did not get any incontinent care at night. On 1/29/25 at 10:06 AM, Resident 17 stated she/he frequently waited a long time for call lights to be answered and assistance with her/his care needs. Resident 17 further stated meal trays were often delivered late. On 1/29/25 at 10:07 and 2/3/25 at 9:15 AM, Resident 3 stated staff ignored the call lights and she/he would wait for hours. Resident 3 stated she/he needed incontinence care recently, no staff came to provide care and sometimes her/his friend would help with brief changes. Resident 3 stated showers did not always get done, meals were served late, and the resident smoke breaks were missed. On 1/29/25 at 10:12 AM, Resident 16 stated there was not enough staff and had to wait a long time for her/his call light to be answered and her/his care needs were not met in a timely manner. Resident 16 further stated meal trays were delivered late. On 1/31/25 at 10:02 AM, Resident 15 stated there was not enough staff to meet her/his needs and concerns without having to wait a long time and call light wait times were between 45 minutes to "hours" long. Resident 15 stated meal trays were delivered late due to staffing and the food was often cold. Resident 15 further stated staffing and call lights were complained about at every Resident Council meeting with no resolution. On 1/31/25 at 10:09 AM, Resident 14 stated there was not enough staff to meet her/his needs in a timely manner, she/he had to wait over an hour for assistance and needed staff to provide incontinent care more often. Resident 14 further stated meal trays were delivered late and the food was sometimes cold. On 1/31/25 at 11:36 AM, Resident 34 stated staff did not respond to her/his call lights, frequently left her/him in soiled briefs and did not ensure she/he had fresh water to drink. Resident 34 stated she/he was care planned to be a two person assist with the Hoyer (mechanical lift) to transfer, but would be transferred with one staff member at times. Resident 34 further stated call lights could take two hours to be answered, and meal trays were passed late. On 2/3/24 at 9:07 AM, Resident 2 stated the facility missed having resident smoke breaks at least twice a week. On 2/3/25 at 12:24 PM, Resident 1 stated smoke breaks would be late or canceled due to staffing issues. On 1/29/25 at 11:20 AM, Witness 23 (Family) stated she visited Resident 35 daily and observed there was not enough staff to meet her/his basic care needs. Witness 23 stated Resident 35 was left in soiled briefs and bed linens for over one and a half hours, would come in to visit and find multiple soiled briefs in the trash can with a full urinal hung from the side of the can. Witness 23 stated she would empty the urinal and take out the trash during her visits. Witness 23 further stated she brought the family dog for a visit and the dog jumped up on the side of the bed and came down with feces all over his fur. Witness 23 stated the nursing staff were overwhelmed, stretched too far, and the care the facility provided was a failure of basic human decency. On 1/30/25 at 1:18 PM, Witness 25 (Family) stated Resident 18 waited a long time for her/his call light to be answered. Witness 25 stated she visited weekly and another family member visited daily. Witness 25 further stated on many occasions, she would activate the call light and no staff would respond. Witness 25 stated Resident 18 would sit in a soiled brief for 30 - 45 minutes after the call light was activated. Witness 25 further stated on one occasion she activated the call light at 11:25 AM because she wanted Resident 18 up in the wheelchair and taken to the dining room for lunch. After waiting over 25 minutes, she got Resident 18 dressed, into the wheelchair, and took her/him to the dining room herself. On 1/31/25 at 11:46 AM, Witness 26 (Family) stated she visited Resident 24 daily and observed the resident sitting in soiled briefs for an extended length of time due to short staffing. Witness 26 stated staff did not put in Resident 24's hearing aides or assist Resident 24 to brush her/his teeth. Witness 26 stated due to inadequate staffing Resident 24 did not get her/his call lights answered timely, receive timely incontinence care, or get her/his trash taken out of her/his room. Witness 26 stated she now cleaned out Resident 24's drinking cups and took out her/his trash when she visited. Witness 26 stated she had observed staff go in to other resident rooms, shut off the light and not provide care to the residents on multiple occasions. Additionally, Witness 26 stated staff had informed Resident 24 on multiple occasions, they could not provide incontinence care because they were taking other residents out to smoke or they needed to provide eating assistance with meals. On 1/28/25 at 1:33 PM, Staff 44 (LPN) stated staffing could be a nightmare and management had an "I don't care" attitude. Staff 44 stated showers were "haphazard" if they got done; many residents did not get showers. Staff 44 stated call lights on the weekend could be 70 - 90 minutes before they were answered; other days the wait time might average up to 30 minutes. Staff 44 further stated smoke breaks could get missed, meal trays were served late, and residents who needed assistance with meals were served last. On 1/29/25 at 1:24 PM, Staff 45 (CMA) stated medications could be passed an hour or more late on some days due to the workload. On 1/28/25 at 2:35 PM, Staff 18 (CNA) stated the facility's staffing ratios were not sufficient for the acuity needs of the residents. On 1/28/25 at 3:00 PM, Staff 20 (CNA) stated the day shift CNAs frequently double briefed (put two incontinence briefs on at the same time) several residents were not provided incontinent care every two hours as appropriate. Staff 20 further stated showers were not always completed on evening shift because it was hard to fit in a shower. On 1/28/25 at 3:31 PM, Staff 21 (CNA) stated resident call light wait times were long and it was difficult to complete resident showers so they were not completed on many occasions. On 1/29/25 at 9:00 AM, Staff 5 (Unit Manager) stated the majority of the intermediate care facility (ICF) residents were a two person assist with a high acuity level. Staffing was unacceptable, not safe for the acuity level, and an ongoing problem that turned into an every day problem. Staff 5 stated resident showers were missed, residents did not get repositioned, and when she arrived in the morning she often found residents soaked in urine because the night shift did not have enough staff to complete their last rounds. Staff 5 further stated documentation often got missed because there was not enough time to complete it, meals were served late, and the residents who required assistance to eat were assisted last. On 1/29/25 at 9:05 AM, Staff 25 (CNA) stated the facility worked short staffed a lot and some residents did not want to wait for assistance. On 1/29/25 at 9:16 AM, Staff 6 (CNA) stated she was regularly assigned nine or ten residents, was not able to complete the residents care per their individual plans of care, and would "let some things go." Staff 6 stated she would not get everyone's teeth brushed, miss resident showers and not able to perform personal hygiene. Staff 6 further stated this occurred almost daily. On 1/29/25 at 9:19 AM, Staff 33 (CNA) stated she was unable to get Resident 10 up in the morning when the facility was short staffed which would cause her/him to get very upset. Staff 33 stated when she was assigned 13 residents to care for she was unable to complete showers or provide care per the residents' care plan. On 1/29/25 at 9:24 AM, Staff 7 (CNA) stated when the facility was short staffed she was responsible for eight to 13 residents on day shift. When this occurred call lights were not answered timely, showers would not get done, and it was hard to meet residents' needs. Staff 6 stated many residents were a two person assist for care and those residents waited a long time for assistance. Staff 6 stated when she arrived for her shift she would find residents soaked in urine, with one time a resident's entire bed was wet. Staff 6 further stated meal trays were passed late and residents who needed supervision with meals were brought to the dining room for meals, however, no staff were available to supervise them. These situations occurred at least once or twice a week. On 1/29/25 at 9:28 AM, Staff 26 (CNA) stated staffing levels were not good and Resident 11 was usually soaked with urine every morning when she arrived on shift. Staff 26 stated showers did not get done and residents complained about it. On 1/29/25 at 10:17 AM, Staff 3 (SSD) stated, "staffing is sickening to me", and it's a consistent problem. Staff stated residents complained of staffing and call lights at every Resident Council meeting. Staff 3 stated residents did not receive showers, brief changes or bed linen changes because one CNA to nine residents was not feasible with the high acuity level. Staff 3 stated she had recently received facility Grievance Forms for a resident's bed that was not changed for two weeks, a two hour wait time for the call light to be answered and general call light and staffing concerns. Staff 3 further stated one to two days a week residents who need assistance and supervision in the dining room were not observed by staff; especially on evening shift. On 1/30/25 at 10:26 AM, Staff 11 (CNA) stated due to short staffing she had to rush resident care, omit showers, teeth brushing and personal hygiene, give untimely incontinent care and perform two person Hoyer transfers by herself because no staff was available to help her. Staff 11 stated when she arrived on day shift she would often find residents "soaked" with urine due to low CNA staffing levels on night shift. Staff 11 stated meal trays were delivered late, residents who required assistance to eat either received late assistance or sometimes not get to eat, and residents who required supervision with meals were left unsupervised. Staff 11 further stated she was told the nurses at the nurses' station would supervise the residents (there was an obstructed view into the dining room from the nurses' station.) On 1/30/25 at 10:52 AM, Staff 10 (CNA) stated it was difficult to provide adequate care due to staffing levels. Staff 10 stated he was unable to provide care per the residents care plan, showers were constantly missed and he was unable to reposition the residents who needed repositioning every two hours. Staff 10 stated the hardest part was when a continent resident would activate the call light for toileting assistance and because he was unable to answer the call light timely they would soil themselves. Staff 10 further stated meal trays were usually passed late and the residents who required assistance were assisted very late. There were multiple occasions when breakfast did not get passed until after 9:00 AM, which then delayed lunch, and because lunch was late he could not get to his last resident round and had to pass off the residents' afternoon care to the next shift. On 1/30/25 at 11:15 AM, Staff 12 (Staffing Coordinator) stated she utilized a matrix to determine staffing levels and looked at both the facility census and number of residents who received the bariatric rate. Staff 12 stated she did not staff to the residents' acuity, needs or diagnoses. Staff 12 verified the facility was short staffed on several shifts in 11/2024, 12/2024 and 1/2025. On 1/30/25 at 11:50 AM Staff 2 (DNS) and Staff 4 (Assistant DNS) stated the facility determined staffing levels off the census based on the regulations and the minimum state staffing levels for the bariatric rate.

Resident #24 will have care needs meet timely Resident #18 no longer resides at the facility. ¿ Resident #5 will have care needs meet timely. ¿ Resident #31 will have care needs met timely. Resident #4 will have care needs met timely. Resident #11 will have care needs met timely. Resident #17 will have care needs met timely. Resident #3 will have care needs met timely. Resident #15 will have care needs met timely. Resident #14 will have care needs met timely. ¿ Resident #2 will have care needs met timely. Resident #1 will have care needs met timely Resident #35 will have care needs met timely Current residents have the potential to be affected¿¿ Residents will receive a timely response to a call light.¿ Residents will receive timely incontinence care. Residents will receive timely meal service. Residents will receive showers. Residents will receive supervised smoke breaks. NHA/Designee will complete baseline interviews of current residents with BIMS of 9 or higher to verify if call light is responded to timely. Identified issues will be addressed.¿¿ The DON/Designee will complete a baseline audit for the last 14 days to validate sufficient staff were scheduled for each shift. NHA/Designee will provide further education to staff related to call light response and responding to resident requests for assistance timely.¿ The DON/Designee will provide further education to nurse managers and staffing related to scheduling sufficient staff for each shift.¿ NHA/Designee will conduct ongoing random interviews of 15 residents with BIMs of 9 or higher to verify if the call light is responded to timely. DON/Designee will complete weekly audits to validate sufficient staff are working for each shift.¿ Audits will be conducted weekly for 4 weeks, then monthly for 2 months.¿¿ Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.¿

Based in interview and record review it was determined the facility failed to ensure minimum state CNA staffing ratios were met for 3 of 3 months reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: The facility's Payroll Based Journal (PBJ) Reports revealed the facility was short 20 CNAs for 17 shifts in November 2024 and six CNAs for five shifts in December 2024. The facility's Direct Care Staff Daily Report from 1/1/25 to 1/26/25 revealed the facility was short eight CNAs for seven shifts. On 1/30/25 at 11:15 AM, Staff 12 (Staffing Coordinator) verified the PBJ Reports revealed the facility was short 20 CNAs for 17 shifts in 11/2024, six CNAs for five shifts in 12/2024, and the Direct Care Staff Daily Report from 1/1/25 to 1/26/25 revealed the facility was short eight CNAs for seven shifts.

Facility will have sufficient CNA staff according to established minimum ratios.¿¿ DON or designee will complete baseline audit of CNA staffing ratios for the past 30 days to ensure there is sufficient nursing staff to meet resident needs.¿¿ Sufficient nursing staff will be available to meet resident needs.¿ Audits will be conducted by DON or designee weekly for 4 weeks, then monthly for two months.¿ Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.¿

************************* OAR 411-086-0110 - Nursing Services: Resident Care Refer to F695 ************************* OAR 411-086-0100 - Nursing Services: Staffing Plan Refer to F725 ************************

Based on interview and record review it was determined the facility failed to provide the risk and benefits for the use of an antipsychotic medication to a resident/responsible party prior to administration for 4 of 5 sampled residents (#s 55, 87, 164, and 165) reviewed for medications. This placed resident responsible parties at risk for lack of informed consent. Findings include: 1. Resident 55 admitted to the facility in 7/2024 with diagnoses including pulmonary embolism (blockage of a lung artery). A review of the 9/2024 MAR instructed staff to administer sertraline (to treat depression) one time a day for depressive episodes with a start date of 7/27/24. The MAR instructed staff to administer lorazepam (to treat anxiety) every four hours as needed for nausea and agitation with a start date of 8/29/24. No information was found in the record to indicate the resident or responsible party were provided risk and benefits information for the use of sertraline or lorazepam. On 9/13/24 at 8:36 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated they knew there was a system issue related to the provision of risks and benefits information. , 2. Resident 87 admitted to the facility in 3/2024 with diagnosis which included bipolar (mood swings) disorder. A 6/15/24 Quarterly MDS revealed Resident 87 was cognitively intact. The 8/2024 MAR indicated Resident 87 received duloxetine (antidepressant medication) daily since 7/30/24 related to her/his bipolar depression. Review of Resident 87's clinical record indicated no documentation the resident or responsible party were provided risk and benefit information for the use of duloxetine. On 9/10/24 at 4:39 PM Staff 4 (Unit Manager-LPN) acknowledged Resident 87 was not provided the the risk and benefits for the use of duloxetine. , 3. Resident 164 readmitted to the facility in 8/2024 with a diagnosis of surgical repair of leg fractures. An 8/31/24 NSG (Nursing) Admission/Readmission Evaluation form revealed Resident 164 was cognitively intact. A 9/2024 MAR revealed Resident 164 was to be administered haloperidol (antipsychotic medication to treat mental health disorders) PRN for restlessness. No doses were administered. The MAR also indicated she/he was to be administered Ativan (antianxiety medication) PRN for nausea, anxiety, and restlessness. One dose was administered on 9/9/24. Resident 164's clinical record revealed no consents were obtained related to the haloperidol and Ativan. On 9/10/24 at 8:59 AM Staff 22 (Social Services) stated the social service staff were to obtain consents for psychotropic medications. If the resident admitted to the facility and social services was not in the building, the nursing staff did not obtain consents. Staff 22 acknowledged consents were not obtained for Resident 164's psychotropic medications. 4. Resident 165 admitted to the facility in early 9/2024 with a diagnosis of a stroke. A 9/6/24 NSG (Nursing) Admission/Readmission Evaluation form revealed Resident 165 was alert and oriented to person and situation. The form indicated Resident 165's family was present on admission. A 9/2024 MAR revealed Resident 165 was to be administered Lexapro (for anxiety and depression) daily. The MAR indicated Lexapro was administered daily starting on 9/7/24. Resident 165's clinical record revealed no consent was obtained for the use of Lexapro. On 9/10/24 at 8:59 AM Staff 22 (Social Services) stated she was responsible for obtaining consents for psychotropic medications. Staff 22 also stated the nursing staff did not obtain consents for psychotropic medications prior to administering psychotropic medications to residents. Staff 22 acknowledged a consent was not obtained from Resident 165 or her/his representative prior to medication administration.

Resident#55 no longer resides at the facility. Resident #165 no longer resides at the facility. Resident #164 no longer resides at the facility Resident #87 risk and benefit of Duloxetine was reviewed with resident Residents utilizing psychotropic medications have the potential to be affected. The DON/Designee will complete a baseline audit on current residents with orders for psychotropic medications to validate consent for medication in place. The DON/Designee will provide further education to Licensed Nurses related to obtaining consent for psychotropic medications prior to initiation of a new psychotropic medication. The DON/Designee will complete weekly audits on residents who were newly admitted or have had a new order for psychotropic medication to verify consent was obtained. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations

Based on interview and record review it was determined the facility failed to ensure a safe system for a resident's self-administration of medication for 1 of 6 sampled residents (#44) reviewed for accidents. This placed residents at risk for adverse medication reactions. Findings include: Resident 44 admitted to the facility in 2021 with a diagnosis of heart disease. An 4/22/24 annual MDS revealed Resident 44 was cognitively intact. A 5/12/23 Self-Administration of Medication form revealed Resident 44 was assessed to be capable of self-administration of medications. The form did not indicate which medications Resident 44 was able to self-administer. A care plan initiated 9/2023 revealed Resident 44 was not able to walk and propelled in a wheelchair with staff assistance. The care plan also indicated Resident 44 self-administered over-the-counter supplements which were kept at her/his bedside. The care plan did not identify which medications she/he could self-administer. A 9/2024 MAR revealed Resident 44 had orders to self-administer supplements which were kept at the resident's bedside. A 9/6/24 Provider Note revealed Resident 44 had an "old" skin graft donor site to the left thigh. The resident reported she/he put Desitin on the site by "accident" and the site worsened significantly. Progress Notes revealed on 9/6/24 Resident 44's thigh donor site was assessed to be open, had slough, and bled. The note indicated the wound nurse evaluated the site. On 9/7/24 the site was "much better" but Resident 44 reported the site was still very painful. On 9/8/24 at 12:09 PM Resident 44 stated she/he applied Desitin to her/his skin donor site and it worsened. On 9/9/24 at 8:42 AM and 9/10/24 an unlocked shelf in Resident 44's room was observed to have one bottle of rubbing alcohol (disinfectant), one bottle of hydrogen peroxide (disinfectant), and nine bottles of oral supplements. The shelf was on the wall at the foot of the resident's bed. On the window sill next to Resident 44's bed one tube of Desitin (barrier cream) was observed. On 9/10/24 at 11:47 AM Staff 17 (CMA) stated medications were not to be left at the bedside unless a resident had physician orders to self-administer specific medications. Staff 17 stated Resident 44 had "a lot" of medications in her/his room. On 9/10/24 at 12:00 PM with Resident 44 and Staff 5 (LPN Resident Care Manager) Staff 5 stated Resident 44 was assessed and had orders for two different supplements to be kept at the bedside. Staff 5 acknowledged there were multiple bottles of supplements, creams and liquid disinfectants in Resident 44's room. Staff 5 stated the medications were to be locked in a secure area and were not. Staff 5 also stated Resident 44 applied Desitin to her/his donor site and it worsened but was now better.

Resident #44 will be interviewed to determine which medications she would like to self-administer. A Self-Administration of Medication Evaluation will be completed to determine if she is safe to self-administer medications. An order for self-administration of medications will be obtained. The care plan will be updated to reflect which medications she is self-administering. Residents who prefer to self-administer medications may be affected. The DON/Designee will complete a baseline audit of current residents with BIMS of 9 or higher to determine which residents prefer to self-administer medications. Residents who prefer to self-administer medications will have a Self-Administration of Medication Evaluation completed to determine if they are safe to self-administer medications. If it is determined the resident is safe to self-administer medications, orders to self-administer medications will be obtained and their care plan will be updated. The DON/Designee will provide further education to licensed nurses on the requirements for clinically appropriate self-administration of medications. The DON/Designee will complete weekly audits on five random residents and new admissions to validate the requirements for clinically appropriate self-administration of medications have been completed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to provide a response to Resident Council grievances for 1 of 1 resident group reviewed for grievances. This placed residents at risk for a decline in psychosocial well-being. Findings include: A grievance policy revised 3/2023 indicated the grievance officer (administrator) would take immediate action to prevent further potential violations of any resident right while a grievance was investigated. Review of Council Minutes notes dated 7/16/24 revealed : -"CNAs: No improvement-getting worse." - Council members also wanted reimbursement for lost or stolen items and voiced concern about menus not being followed. -Call light response time was "awful". -Head phones being used 8/2024 Council Agenda notes revealed: -CNAs not knocking on bathroom doors -CNAs have attitudes -Meals were up to 1.5 hours late -Resident laundry being delivered to wrong rooms. During a resident council meeting on 9/10/24 at 2:51 PM, residents stated the facility staff did not respond to concerns or grievances voiced by resident council. Residents voiced the following concerns: 1. Staff wore earphones on (NOC) night shift. 2. Day shift CNAs used their phones and ignored resident call lights. 3. Not enough help or staff to meet their needs and long call light responses up to 60 minutes. 4. Residents unanimously reported they received no follow-up for their concerns or grievances. 5. Clothing and personal items were missing, and no staff addressed the concerns. 6. A lack of variety of snacks. On 9/12/24 at 1:02 PM Staff 7 (Activities Director) stated there were several changes in administrators (three in the last year) and this made it more difficult for consistency with communication between staff members regarding who was responsible to respond to grievances. Staff 7 stated for the last six months grievances were given to department heads who were not aware of what to do with them. The grievance process did not propagate from the department heads to the administrator. Staff 7 also stated residents voiced their discouragement with the lack of acknowledgement, and it negatively impacted their mood and sense of dignity. An 8/2024 online grievance log revealed a brief description of grievances, but the form did not have a follow-up section and did not identify who would address the concern. On 9/13/24 at 1:44 PM, Staff 7 confirmed there was no follow-up section included on the online grievance log. On 9/12/24 at 3:02 PM Staff 1 confirmed there were no grievance resolutions.

Will follow up on resident counsel grievances from 7/16 council minute notes. Residents who submit grievances have the potential to be affected. The Administrator/Designee will review Resident Council notes for August and September. Any grievances and/or recommendations will be followed up verbally to the Resident Council and in writing. The Administrator/Designee will provide further education to department heads on verbal and written follow-up for Resident Council per requirements. The Administrator/Designee will complete monthly audits on grievances and/or recommendations from Resident Council to validate verbal and written follow-up has been completed per requirements. Audits will be conducted monthly for 3 months. Audit trends will be reported to facility QAPI X 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure a resident was assisted with formulating an advance directive for 1 of 3 sampled residents (#164) reviewed for advance directives. This placed residents at risk for lack of end-of-life choices being honored. Findings include: Resident 164 admitted to the facility in 2022 with a diagnosis of chronic kidney disease. A 7/30/24 IDT (Interdisciplinary Team) Care Plan Conference/Welcome Meeting Form revealed Resident 164 was able to voice her/his needs but was cognitively impaired. The form also indicated she/he wanted to formulate an advance directive with the assistance of her/his friend. Progress Notes from 7/30/24 to 9/9/24 did not include a follow up note to indicate staff communicated with Resident 164 or her/his friend to assist with formulating an advance directive. On 9/10/24 at 4:01 PM Staff 3 (Social Services) stated she recalled Resident 164 verbalizing she/he wanted to formulate an advance directive. Staff 3 indicated if assistance was provided it would be documented in the progress notes. Staff 3 indicated she would provide documentation if she/he had any additional information. No additional information was provided. ,

Resident #164 no longer resides at the facility. Residents that admit to the facility have the potential to be affected. The Administrator/Designee will complete a baseline audit of current residents to validate residents have been offered/reviewed the choice to formulate an Advance Directive. The Administrator/Designee will provide further education to the social services related to offering/reviewing residents information if they would like to formulate an Advance Directive. The Administrator/Designee will complete weekly audit of new admissions to validate resident was offered/reviewed information if they would like to formulate an Advance Directive. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to notify the physician or resident representative regarding refusals and changes in condition for 3 of 7 sampled residents (#s 55, 86 and 165) reviewed for medications, change of condition and catheter care. This placed residents at risk for delay in treatment. Findings include: 1. Resident 55 admitted to the facility in 7/2024 with diagnoses including chest pain. A review of the 9/2024 TAR instructed staff to administer a lidocaine patch to the affected area one time a day for pain. From 9/1/24 through 9/9/24 Resident 55 refused the patch nine times out of nine opportunities. No documentation was found in Resident 55's clinical record the physician was notified of the refusals from 9/1/24 through 9/9/24. On 9/10/24 at 4:51 PM Staff 1 (Administrator) confirmed the physician was not notified at any time from 9/1/24 through 9/9/24 regarding the lidocaine patch refusals. , 2. Resident 86 admitted to the facility in 3/2024 with diagnosis including UTI and paraplegia (impairment in lower extremities). A 6/18/24 revised care plan indicated to monitor Resident 86 for signs and symptoms of discomfort related to her/his catheter care. A 9/8/24 progress note by Staff 38 (LPN) indicated during routine incontinent care Resident 86's catheter was dislodged during the early morning hours and she/he was transported to the hospital to have the catheter reinserted. Staff 38 indicated she would defer to call Resident 86's emergency contact until later in the morning. On 9/8/24 at 11:36 AM Witness 5 (Complainant) stated she was not notified by the facility Resident 86 was sent to the hospital on 9/8/24. On 9/12/24 at 5:25 PM Staff 38 stated she did not want to notify the family in the middle of the night when Resident 86 went to the hospital to have her/his catheter reinserted. Staff 38 stated she spoke to the nurse on the next shift and conveyed family needed to be notified. On 9/13/24 at 8:35 AM Staff 4 (Unit Manager-LPN) acknowledged Resident 86's family should have been informed immediately when the resident went to the hospital. , 3. Resident 165 admitted to the facility in 9/2024 with a diagnosis of pneumonia. A Progress Note written by Staff 10 (LPN) revealed on 9/8/24 Resident 165 removed her/his oxygen, her/his oxygen levels dropped to the 70's several times at night, and staff made frequent checks on Resident 165. On 9/12/24 at 1:18 PM Staff 2 (DNS) stated if a resident's oxygen level dropped into the 70's Staff 2 expected nursing staff to stabilize the resident and then notify the resident's physician. A request was made to provide documentation Resident 165's physician was notified of the change of condition. No additional information was provided. On 9/12/24 at 7:01 PM Staff 10 stated Resident 165's oxygen level decreased all night the night of 9/8/24. Resident 165 was confused, removed the oxygen, and was a mouth breather. Staff 10 stated he placed the oxygen device near the resident's mouth and the oxygen levels improved. The oxygen levels continued to drop throughout the night because when Resident 165 turned in bed the oxygen tubing was accidentally removed. Staff 3 stated he did not notify Resident 165's physician.

Resident #55 provider was notified of refusal of medication, resident no longer at the facility. Resident # 86 wife was updated 9/10/24 Resident # 165 patient de-saturated 9/8/24, provider was notified on 9/9/24, resident no longer at the facility. Residents that exercise their right to refuse their medication(s), residents that are transferred to the emergency department, and residents that experience a change of condition have the potential to be affected. DON/Designee will complete a baseline audit for the last 14 days to verify provider notified of medication refusals, family notified of ED transport, and family/provider notified timely of change in condition. Family/ representative/providers will be notified if they have not been notified of change of condition previously. DON/Designee will provide further education to the licensed nurses related to notification to family/ representative/physicians related to resident change of condition per requirements. DON/Designee will complete weekly baseline audits to verify family/ representative/physicians are notified timely related to resident change of condition, ED visits, and medication refusals. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to ensure residents' rooms were clean, in good repair and free of clutter for 5 of 5 sampled residents (#s 2, 62, 71, 98, and 162) reviewed for ADLs and environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. Resident 2 admitted to the facility in 5/2016 with diagnoses including chronic pain. On 9/10/24 at 11:44 AM Resident 2's room was observed with the following: -Multiple tissue boxes, paperwork, cups, utensils, books, and a miniature arctic air conditioner on the bedside table. The air conditioner had approximately one half inch of brown dust on the vents and on the internal filters. -Food boxes, pop cans, and paperwork on the floor and the bedside table. Resident 2 stated she/he had the arctic air conditioner for three years and nobody cleaned it for her/him. Resident 2 stated she/he did not like her/his room so cluttered and asked staff to help clean her/his room, but nobody helped her/him. On 9/10/24 at 11:58 AM Staff 4 (Unit Manager-LPN) acknowledged the resident's air conditioner had thick dirt and dust on the vents and on the internal filters, and the resident's room was cluttered and did not appear homelike. 2. Resident 62 admitted to the facility in 6/2022 with diagnoses including chronic pain. On 9/8/24 at 12:30 PM Resident 62 stated housekeeping cleaned her/his bathroom, but it was still dirty with urine and dark brown debris around the toilet bowl and yellow-colored debris on the floor. Resident 62's bathroom was observed with urine and dark brown debris around the toilet bowl and yellow-colored debris on the floor. On 9/8/24 at 12:45 PM Staff 55 (RN) acknowledged Resident 62's bathroom had urine and dark brown debris around the toilet bowl, yellow-colored debris on the floor, and was not clean or homelike. , 3. Resident 98 admitted to the facility in 7/2024 with a diagnosis of a stroke. A 7/19/24 admission MDS revealed Resident 98 was cognitively intact. Resident 98's clinical record indicated she/he resided in her/his current room (Room 123A)since 8/26/24. Resident 71 admitted to the facility in 9/2023 with a diagnosis of a bone infection. A 9/5/24 annual MDS revealed Resident 98 was cognitively intact. Resident 71's clinical record indicated she/he resided in Room 123 from 4/26/24 through 8/15/24. On 9/8/24 at 12:23 PM an area approximately 12 inches high by 12 inches wide of unpainted white wall patching material was observed on the wall below the window in Room 123. On 9/9/24 at 3:06 PM Staff 28 (Maintenance) stated weekly rounds were made of all resident rooms. If a wall was patched it was painted the next day and the patch was likely from rounds the previous week. On 9/12/24 at 10:35 AM Resident 98 stated the patch was on the wall since she/he moved into the room. On 9/12/24 at 10:50 AM Resident 71 stated there was a patch on the wall when she/he resided in Room 123, and she/he "just didn't look at it." 4. Resident 162 admitted to the facility in 4/2024 with a diagnosis of heart disease. Resident 162's clinical record revealed she/he resided in Room 121 while in the facility. An 4/11/24 five day assessment revealed Resident 162 was cognitively intact. On 4/16/24 Resident 162 reported to the State Agency the window blind control wand was broken and the blinds could not be opened in Room 121. On 9/8/24 at 4:38 PM Resident 162 stated the window blind control wand was broken while she/he resided in Room 121. Resident 162 stated she/he reported the issue to staff, but did not recall the name of the staff. On 9/9/24 at 2:56 PM the blind in Room 121 was observed with the control wand missing preventing adjustment. On 9/9/24 at 2:52 PM Staff 62 (Maintenance) looked at the maintenance log and stated there were no reports in 4/2024 related to a broken window blind control wand in Room 121. On 9/9/24 at 2:58 PM Staff 29 (CMA) verified the blind control wand was missing and the slats could not be easily adjusted to let sunlight into the room. Staff 29 stated a work order would be entered into the maintenance computer system to alert maintenance to replace the blind control wand. On 9/9/24 at 3:01 PM Staff 28 (Maintenance) stated maintenance staff conducted weekly room audits but the maintenance department was dependent on the nursing staff to report room concerns via the maintenance computer system.

Resident #2 room was de-cluttered, and air conditioner was cleaned Resident #62 bathroom was cleaned Resident #71 and 98 wall were repaired and painted Resident # 162 no longer resides at the facility, blinds were repaired. All residents have the potential to be affected. The Administrator/Designee will complete a baseline audit on all rooms to verify that rooms are maintained and that walls are without gouges and paint touched up if needed. That blinds are in good repair and have an operatable blind control wand, rooms are free of clutter, and bathrooms are clean. The Administrator/Designee will provide further education to staff related to a safe, clean, comfortable, and homelike environment per requirements and how to place work orders for maintenance repairs. The Administrator/Designee will conduct a weekly audit on five random rooms to verify resident wall is free from gouges and paint to the walls has been touched up if needed. Blinds are in good repair, bathrooms are cleaned, and rooms are free of clutter. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to provide a written grievance, resolution, or communication with a resident or representative for 3 of 17 sampled residents (#s 63, 98 and 162) and 1 of 2 units reviewed for dignity, food, staffing and accidents. This placed residents at risk for unresolved concerns. Findings include: 1. Resident 63 admitted to the facility in 5/2024 with diagnoses including heart failure and chronic kidney disease. Review of a 7/18/24 Discharge MDS indicated Resident 63 was cognitively intact. On 9/11/24 at 3:59 PM Staff 51 (Scheduler) stated Resident 63 reported a missing ring to staff on 8/13/24. She stated a sign was made to alert staff, and a written grievance was given to management. Observation of the sign mentioned by Staff 51 revealed the wording "missing on 8/13/24 silver ring with this symbol (large image of a masonic symbol). Please give to nurse if found!" Review of the 8/2024 grievance log revealed no grievances related to Resident 63. Review of Resident 63's 8/2024 and 9/2024 progress notes showed no entries regarding reports of a missing ring. On 9/12/24 at 11:38 AM Staff 1 (Administrator) stated she interviewed Resident 63 on 8/14/24 and had email communication with her/him regarding the missing ring. She stated the facility ordered a replacement ring, and acknowledged there were no grievances or documentation for the incident in Resident 63's chart. , 2. Resident 98 admitted to the facility in 7/2024 with a diagnosis of a stroke. A 7/19/24 admission MDS revealed Resident 98 was cognitively intact. On 9/8/24 at 12:20 PM Resident 98 stated staff spoke rudely to her/him during the 9/8/24 night shift. Resident 98 reported to Staff 10 (LPN) the CNA told her/him that she/he got upset too easily. Resident 98 stated she/he felt like no one saw or heard her/him. On 9/12/24 at 12:30 PM Staff 1 (Administrator) stated if a resident had a concern about how staff treated her/him a grievance form should be completed in order for administration to verify if the situation occurred. Staff 1 stated she was not aware of a concern related to the manner in which staff provided care to Resident 98. On 9/10/24 at 1:03 PM and 9/12/24 at 7:41 PM Staff 10 stated Resident 98 reported the CNA did not help her/him quickly enough. Staff 10 stated the CNA answered Resident 98's call light and left to find another CNA to assist with Resident 98's care. As the CNA left the room Resident 98's roommate requested to use the bathroom and since the roommate was a one-person assist the CNA assisted the roommate before helping Resident 98. Resident 98 reported the staff did not care for her/his needs and took too long. Staff 10 stated he spoke to the CNA to improve her/his communication skills but did not fill out a grievance. On 9/12/24 at 12:14 PM Staff 13 (Agency CNA) stated she did not recall Staff 10 communicating with her regarding Resident 98. 3. Resident 162 admitted to the facility in 4/2024 with a diagnosis of heart disease. An 4/15/24 Progress Note indicated Resident 162 called the police to report concerns including she/he was served moldy food. An 4/16/24 five day MDS assessment revealed Resident 162 was cognitively intact. On 9/10/24 at 9:28 AM Staff 1 (Administrator) stated she was aware of Resident 162's report of moldy food but did not have a grievance form related to the issue. Staff 1 stated she was not the administrator in 4/2024. On 9/9/24 at 3:45 PM Staff 23 (Former Administrator) stated Resident 162 called the police. Staff 23 stated the facility immediately threw out all the perishable snacks and investigated the incident. Staff 23 stated a grievance form was completed and placed in the grievance binder. Refer to F812 example 1 for additional information. , 4. On 9/3/24 a public complaint was received which indicated staff did not provide timely incontinence care, and a resident's call light was unplugged intentionally. On 9/10/24 at 2:31 PM Witness 4 (Staff) stated when she came onto shift one day in 9/2024 she found one resident with missing blankets, one resident's call light was unplugged in Room 43, and several rooms including Rooms 1A, 1B, 21, 25A, 25B, 26A, and 26B had residents who did not receive incontinent care all night and had skin breakdown. Witness 4 informed the nurse and it was her understanding Staff 33 (LPN) completed a grievance. At times residents had to stay up in their wheelchairs when there needed to be six to 10 full bed changes because there were not enough linens to complete the bed changes. A review of the 9/2024 Grievance Report Log revealed one grievance listed on 9/9/24 completed by Staff 3 (Social Worker) for a care concern for Room 5. No grievances were found for Witness 4's concerns related to resident care. On 9/13/24 at 2:56 PM Staff 1 (Administrator) stated there was only one grievance which was turned in so far in 9/2024. On 9/13/24 at 3:05 PM Staff 33 (LPN) stated Witness 4 notified the Unit Manager about the concerns. Staff 33 stated there were five residents who were "not in great shape." Some of the residents had a pad change but not a fitted sheet and they were "disorganized." Staff 33 stated some residents pulled out their call light cords. On 9/13/24 at 3:12 PM Staff 4 (LPN Unit Manager) and Staff 5 (LPN Unit Manager) stated Staff 33 completed the grievance related to the concerns of residents who did not receive timely incontinent care. The grievances then typically went to Staff 1 or Staff 2 (DNS).

Resident # 63 grievance has been addressed as a new ring has been ordered. Resident # 98 grievance will be followed up on. Resident # 162 no longer resides at the facility. Residents who submit grievances have the potential to be affected. Administrator/Designee will complete a baseline audit to validate all grievances have been addressed with follow-up to the resident/family who completed the grievance. Administrator/Designee will complete baseline audit of residents to ensure that residents are being treated with dignity and respect, will ensure residents food complaints and missing items are followed up on and care concerns are followed up on. Administrator/Designee will provide further education to department heads regarding addressing and follow-up on resident grievances. Facility Staff will be provided with further education on reporting grievances. Administrator/Designee will complete audits on two grievances weekly to validate the grievances that have been addressed and follow up has been completed to the resident/family. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to protect residents' right to be free from physical abuse by staff for 1 of 1 sampled resident (#82) reviewed for abuse. Resident 82 was mistreated by staff resulting in physical injury. Findings include: Resident 82 admitted to the facility in 1/2024 with diagnoses including stroke. A 1/19/24 Admission MDS indicated Resident 82 was moderately impaired with decision making due to aphasia (unable to formulate language). Resident 82 was able to answer yes or no questions and used thumbs up for yes, and thumbs down for no. A 7/24/24 FRI indicated Staff 74 (CNA) showered Resident 82 and bumped the resident's foot on the wall while exiting the shower room. Staff 74 left the hall and left Resident 82 sitting in the shower chair. Staff 75 (CNA) reported the resident's toe was bleeding and no report or communication was given to her. On 9/11/24 at 3:44 PM Staff 34 (LPN) stated Staff 74 was the shower aide on 7/24/24 and gave Resident 82 a shower. Staff 34 stated a staff member did not show up for work and Staff 74 was reassigned to provide direct care to residents. Staff 34 stated Staff 74 became angry, pushed Resident 82's shower chair hard out of the shower room causing the resident's toe to hit the door. Staff 34 stated the toenail was lifted off the toenail bed and was bleeding badly. Staff 34 stated Staff 74 left Resident 82 in the room alone without a call light and did not report to another CNA she was leaving. On 9/11/24 at 4:02 PM Staff 5 (Unit Manager-LPN) and Staff 6 (Unit Manager-LPN) stated Staff 34 reported Staff 74 was pulled from the bath aide position to care for residents, became angry, injured the resident's toe on the shower room door, and left the facility without reporting to another CNA. Staff 5 stated Staff 74 left the resident alone in her/his room in the shower chair without a call light. On 9/11/24 at 4:33 PM Staff 75 (CNA) stated on 7/24/24 she provided showers for residents. Staff 75 stated Staff 74 arrived to help complete showers. Staff 75 stated Staff 74 was told she would be pulled from showers to provide care to residents. Staff 75 stated Staff 74 became angry, walked out of the shower room with Resident 82 still in the shower with the water running and no call light, and started yelling down the hall. Staff 75 stated she came into the hall to see what happened and observed Staff 74 "pull the shower chair roughly and hit the resident's toe on the shower room door." Staff 75 stated the resident's toe was bleeding badly. Staff 75 stated Staff 74 pushed the resident into her/his room and left her/him alone with only a towel on and without a call light. On 9/11/24 at 4:38 PM Staff 2 (DNS) stated Staff 74 did not complete a proper hand-off or report to another CNA she was leaving the floor before she left. Staff 2 acknowledged Resident 82's toe was hit on the shower room door as a result of Staff 74's mistreatment of Resident 82.

Resident #82 incident will be re-investigated Staff #74 is no longer at the facility Residents who reside at the facility have the potential to be affected Abuse and neglect training provided to DON/Administrator by RNC Abuse and neglect training will be provided to facility staff NHA/designee will complete baseline interview with interview able residents to validate they feel safe in the facility. 10 residents will be interviewed by Administrator/Designee weekly to ensure they feel safe in the facility. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to report timely to the State Survey Agency for an allegation of elopement for 1 of 7 sampled residents (#93) reviewed for accidents. This placed residents at risk for elopement. Findings include: Resident 93 was admitted to the facility in 6/2024 with diagnoses including dementia, stroke, alcohol abuse and seizures. A FRI dated 9/9/24 indicated on 9/6/24 Resident 93 left the facility, and it was reported to the State Agency on 9/9/24. On 9/13/24 at 8:37 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated staff did not report the elopement to the facility administration staff until 9/9/24. Refer to F689

Resident #93 has investigation completed for leaving facility AMA. Residents who are at risk for elopement have the potential to be affected DON/Designee will complete baseline audit of residents who had eloped or attempted an elopement in the past 30 days to verify investigation was completed, and any elopement/elopement attempts with alleged violation were reported. DON/Designee will provide education to facility staff regarding investigation completion and timely reporting of elopement/elopement attempts . Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to thoroughly investigate an injury for 1 of 9 sampled residents (#82) reviewed for abuse and accidents. This placed residents at risk for neglect of care. Findings include: Resident 82 admitted to the facility in 1/2024 with diagnoses including stroke. A 7/24/24 FRI indicated Staff 74 (CNA) showered Resident 82 and bumped the resident's foot on the wall while exiting the shower room. Staff 74 left the facility prior to the end of her shift and left Resident 82 sitting in the shower chair. Staff 75 (CNA) reported the resident's toe was bleeding and there was no report or communication given to staff about the resident being left alone. A 7/25/24 facility Investigation completed by Staff 5 (Unit Manager-LPN) specified the following summary of Resident 82's injury on 7/24/24: after Resident 82 was assisted with a shower Staff 74 bumped the resident's foot on the wall while exiting the shower room, but did not realize the resident had an injury to her/his toe. Staff 74 left the resident in her/his room with another CNA. Staff 75 observed the resident's toe bleeding and notified the nurse. Education was provided to Staff 74 to avoid future injury to residents and to ensure reporting to the nurse if an injury occurred. Education was also provided for proper hand-off with teammates when leaving the facility. The investigation provided did not include an interview with the resident, nurses and other CNAs involved. On 9/11/24 at 3:44 PM Staff 34 (LPN) stated Staff 74 was the shower aide on 7/24/24 and gave Resident 82 a shower. Staff 34 stated a staff member did not show up for work and Staff 74 was reassigned to provide direct care to residents. Staff 34 stated Staff 74 became angry, pushed Resident 82's shower chair hard out of the shower room causing the resident's toe to hit the door. Staff 34 stated the toenail was lifted off the toenail bed and was bleeding badly. Staff 34 stated Staff 74 left Resident 82 in the room alone without a call light and did not report to another CNA she was leaving. On 9/11/24 at 4:38 PM Staff 5 (Unit Manager-LPN) acknowledged the investigation did not include an interview with the resident, other CNAs involved or the nurses on duty. ,

Resident #82 Facility will complete thorough investigations on any further incidents Staff #74 is no longer at the facility Residents that experience an injury at the facility have the potential to be affected. DON/Designee will complete baseline audit of resident injury incidents in the past 30 days to verify investigation was thorough including evidence of witness statements, accurate identification of potentially contributing cognitive impairment, and rationale on how the facility ruled out abuse. DON/Designee will provide education to unit managers regarding thoroughness of resident injury investigation including evidence of witness statements, accurate identification of potentially contributing cognitive impairment, and rationale on how the facility ruled out abuse. DON/Designee will complete ongoing audit of new resident incidents to verify investigation was thorough including evidence of witness statements, accurate identification of potentially contributing cognitive impairment, and rationale on how the facility ruled out abuse Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. Audit trends will be reported to QAPI for 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 2 of 2 sampled residents (#s 95 and 262) reviewed for hospitalizations. This placed residents at risk for lack of access to an advocate to inform them of their options and rights. Findings include: 1. Resident 95 admitted to the facility in 7/2024 with a diagnosis of cancer. A Progress Note dated 7/6/24 revealed Resident 24 requested to be sent to the hospital for shortness of breath. Emergency services were called and the resident was transferred to the hospital. Resident 95's clinical record revealed no documentation to indicate the State Long-Term Care Ombudsman was notified. On 9/12/24 at 11:36 AM Staff 63 (Medical Records) stated she worked in her current position for eight years and never sent a message to the State Long-Term Care Ombudsman. On 9/12/24 at 11:54 AM Staff 56 (Regional RN) stated medical records staff were to send resident discharge information to the ombudsman office. , 2. Resident 262 admitted to the facility in 8/2024 with diagnoses including anxiety and a leg fracture. The Admission MDS with and ARD of 8/26/24 revealed Resident 262's BIMS score was 15 which indicated she/he was cognitively intact. An 8/28/24 Nursing Note indicated Resident 262 had a pain level of 10 on a scale from zero to 10. The on-call physician was notified and suggested to call the hospital emergency department to notify them Resident 262 would be sent to the hospital for disimpaction (procedure to remove trapped stool from the rectum). No documentation was found in Resident 262's clinical records to indicate a transfer notice with appeal rights was provided in writing to her/him or the Office of the State Long-term Care Ombudsman was notified of the resident's transfer to the hospital. On 9/12/24 at 11:36 AM Staff 63 (Medical Records) stated she did not complete ombudsman notifications. On 9/12/24 at 11:54 AM Staff 56 (Regional Nurse) stated medical records was designated to complete the ombudsman notifications.

Resident # 95 no longer resides at the facility Resident #262 will have discharge reported to the long-term care ombudsman Residents with facility-initiated transfers have the potential to be affected. The Administrator/Designee will complete a baseline audit to ensure that in the last 30 days all facility initiated discharges to include resident hospitalizations will be reported to the long-term care ombudsman office. Administrator/designee will complete education to medical records on the notification requirements of the regulation. Administrator/Designee will complete weekly audits of all facility-initiated discharges to include residents who are hospitalized to ensure ombudsman office is notified of discharge/transfer Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations,

Based on interview and record review it was determined the facility failed to provide a bed hold policy for 2 of 2 sampled residents (#s 95 and 262) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to their right to return to the facility. Findings include: 1. Resident 95 admitted to the facility 7/2024 with a diagnosis of cancer. A Progress Note dated 7/6/24 revealed Resident 24 requested to be sent to the hospital for shortness of breath. Emergency services were called and the resident was transferred to the hospital. Resident 95's clinical record revealed no documentation to indicate Resident 95 or her/his representative were provided a bed hold policy at the time of discharge. On 9/12/24 at 11:19 AM Staff 22 (Social Services) stated she was not sure who provided residents with a bed hold policy when they were transferred to the hospital. On 9/12/24 at 11:25 AM Staff 58 (LPN) stated when a resident was sent to the hospital she was not sure who provided the resident or representative the bed hold policy. Staff 58 stated at other facilities where she worked the bed hold policy was at the nurses station but she did not see any bed hold policies at this facility. On 9/12/24 11:33 AM Staff 64 (Admissions) stated upon admission residents were provided a bed hold policy. Staff 64 stated Resident 95 did not complete the admission paperwork and a bed hold policy was not provided to her/him. Staff 64 stated if she was not in the facility the nurses had a bed hold policy in the admission paperwork and were to provide it to the resident. Staff 64 stated she did not see a bed hold policy in the resident's record. , 2. Resident 262 admitted to the facility in 8/2024 with diagnoses including anxiety and a leg fracture. The Admission MDS with and ARD of 8/26/24 revealed Resident 262's BIMS score was 15 which indicated she/he was cognitively intact. An 8/28/24 Nursing Note indicated Resident 262 had a pain level of 10 on a pain scale from zero to 10. The on-call physician was notified and suggested to call the hospital emergency department to notify them Resident 262 would be sent to the hospital for disimpaction (procedure to remove trapped stool from the rectum). No documentation was found in Resident 262's clinical records to indicate a bed hold policy was provided in writing to Resident 262 when she/he transferred to the hospital on 8/28/24. On 9/12/24 at 11:59 AM Resident 262 stated she/he did not remember or know anything about a bed hold policy. On 9/12/24 at 12:36 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed no bed hold notice was provided to Resident 262 on 8/28/24 when she/he transferred to the hospital.

Resident #95 no longer resides at the facility Resident #262 will have bed hold policy provided for further transfers to hospital. Residents that have a transfer to the hospital have the potential of being affected. DON/Designee will complete a baseline audit for all residents who transferred to the hospital in the last 14 days to validate the resident/family was provided the notice of bed hold policy prior to or at the time of hospitalization. DON/Designee will provide further education to licensed nurses, UMs, and social services related to providing the bed hold policy to residents/family at the time of hospitalization or leave of absence. DON/Designee will complete weekly audits on residents who were hospitalized from the facility to validate residents/families were provided the bed hold policy prior to or at the time of hospitalization. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to revise care plans related to interventions for personal equipment for 3 of 12 sampled residents (#s 2, 86 and 164) reviewed for ADLs, medications and respiratory care. This placed residents at risk for unmet needs. Findings include: 1. Resident 2 admitted to the facility in 5/2016 with diagnoses including chronic pain. An observation on 9/10/24 at 11:44 AM revealed a mini arctic air conditioner on Resident 2's bedside table and a suction machine on the resident's night stand. A 7/4/24 care plan revealed no information regarding the air conditioner or the suction machine. On 9/10/24 at 11:58 AM Staff 4 (Unit Manager-LPN) acknowledged there was no information regarding the air conditioner or the suction machine on the resident's care plan. , 2. Resident 86 admitted to the facility in 3/2024 with diagnosis including depression and paraplegia (impairment in lower extremities). A 6/18/24 revised care plan indicated the following: -All staff were to involve Resident 86 in decisions about her/his care. -Resident 86 required extensive assistance by one staff for personal hygiene (which including shaving) and was dependent on staff for dressing. -Monitor Resident 86 for symptoms of depression including repetitive anxious or health-related concerns. No details related to interventions for Resident 86's anxiety or preferences for dressing or shaving were indicated. On 9/11/24 at 9:21 AM Staff 80 (CNA) stated Resident 86 needed to receive consistent encouragement to accept care due to her/his anxiety related to her/his depression. Staff 80 stated the resident accepted care and did not refuse if staff understood how to engage her/him. On 9/11/24 at 5:50 PM Resident 86 stated she/he preferred to be clean shaven and choose clothes when leaving the facility. On 9/12/24 at 11:10 AM Staff 8 (CNA) acknowledged shaving for Resident 86 did not occur daily because some staff did not know the resident and her/his preferences for personal hygiene were lacking in the care plan. On 9/12/24 at 11:53 AM Staff 3 (Social Services) confirmed Resident 86's care plan should include specific anxiety interventions and details of her/his preferences for dressing and shaving. Refer to F758 Example #1 , 3. Resident 165 readmitted to the facility in 8/2024 post-surgical reparir of leg fractures. An 8/31/24 hospice Admission Visit Summary revealed Resident 165 was to be administered haloperidol (antipsychotic medication) and Ativan (anti anxiety medication) PRN. A care plan initiated 8/2022 revealed no interventions related to the use of haloperidol and ativan. There were no interventions identified to monitor for medication adverse reactions, what triggered Resident 165's anxiety or need for the PRN medications. There were also no interventions identified to try prior to the use of the PRN haloperidol or Ativan. On 9/11/24 at 2:55 PM Staff 14 (LPN Resident Care Manager) stated social services usually updated care plans related to psychotropic medications and Resident 165's care plan was not updated. Refer to 758 Example #2b.

Resident #2 care plan is updated to reflect mini air conditioner Resident #86 care plan updated to reflect preferences in ADL hygiene and anxiety interventions Resident #164 no longer resides at the facility Residents who have mini air conditioners, dependent on ADL, have DX of anxiety, and require use of psychotropic medications are affected DON/Designee will complete a baseline audit to validate current residents care plans including non-pharmacological interventions and resident care/ADL preferences. The DON/Designee will provide further education to Licensed nurses/UMs/Social services related to revising care plans to reflect residents current care needs and preferences per requirements. DON/Designee will complete weekly audits on five random residents to validate care plans are resident specific related to non-pharmacological interventions and resident care/ADL preferences. Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure staff did not falsify documentation for 1 of 1 staff (#20). This placed residents at risk for adverse medication reactions. Findings include: On 6/25/24 the Past Noncompliance was corrected when the facility identified the cause of the incident and determined vital signs were not obtained by a CMA prior to medication administration resulting in a drop in blood pressure. The plan of correction included: -6/28/24 nurse and CMA education was provided related to the 10 rights of medication administration. -7/3/24 an audit was initiated for residents with blood pressure parameters -7/3/24 the facility reported Staff 20 (CMA) to the Oregon State board of Nursing. -7/3/24 education was initiated to all nurses and CMAs regarding standards and scope of practice related to their licensure and obtaining vital signs prior to medication administration. Resident 41 was admitted to the facility in 8/2023 with a diagnosis of paraplegia (inability to move legs). A 7/10/24 annual MDS revealed Resident 41 was cognitively intact. A 6/2024 MAR revealed Resident 41 was to be administered Baclofen (muscle relaxant) three times a day and the medication was to be held if her/his systolic blood pressure (top number) was less than 100. On 6/25/24 at 3:00 PM Resident 41's BP was documented to be 100/68 and the medication was documented as administered. An investigation initiated on 6/25/24 revealed Resident 41 was administered a muscle relaxant which was to be held if her/his systolic blood pressure was less than 100. Staff 20 documented the blood pressure to be 100/68 for the 3:00 PM dose and the medication was documented as given. Staff 19 (LPN) was notified by a CNA Resident 41's blood pressure was 89/65. When Staff 19 questioned Staff 20 if she took Resident 41's blood pressure Staff 20 stated she looked at the morning blood pressure and "guessed" what the blood pressure would be at 3:00 PM. On 9/12/24 at 3:38 PM Staff 20 acknowledged she did not obtain Resident 41's blood pressure at 3:00 PM and just "made up" a blood pressure to enter into the MAR. Refer to F760

Based on observation, interview and record it was determined the facility failed to provide care and services to maintain good grooming for 3 of 4 sampled residents (# 62, 86 and 98) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: 1 . Resident 62 admitted to the facility in 6/2022 with diagnoses including chronic pain. A public complaint was received on 5/2/24 which alleged Resident 62 received only four showers in the month of 5/2024. The In Room Care Plan instructed staff to shower Resident 62 on Mondays and Fridays. The Documentation Survey Report dated 5/1/24 through 5/31/24 revealed Resident 62 received three showers in the month of 5/2024. On 9/8/24 11:50 PM Resident 62 was observed lying in bed. The resident's hair appeared greasy, and body odor was present. On 9/8/24 at 12:50 PM Resident 62 stated she/he received four showers a month which was not enough. Resident 62 stated she/he was supposed to receive two showers a week but was not getting them. On 9/9/24 at 1:09 PM Staff 36 (CNA) and Staff 68 (CNA) stated there was not enough time or enough staff to get all showers completed for residents. On 9/10/24 at 3:09 PM Staff 35 (CNA) stated there was not enough staff to get showers completed for residents. On 9/13/24 at 8:33 AM Staff 5 (Unit Manager-LPN) confirmed Resident 62 was not receiving her/his showers as care planned. , 2. Resident 86 admitted to the facility in 3/2024 with diagnosis including depression and paraplegia (impairment in lower extremities). An 4/1/24 State Agency public complaint indicated Resident 86 was not assisted with bathing as needed since admission. A 3/2024 Documentation Survey Report indicated Resident 86 refused bathing on two out of eight days when Staff 81 (CNA) provided care. A 6/18/24 revised care plan indicated Resident 86 required extensive assistance by one staff for personal hygiene (including shaving) and two staff were needed to assist the resident with showers, but she/he preferred bed baths. The Shower/Bathe Self Wednesday and Sunday task indicated Resident 86 was scheduled for bathing on 9/8/24 and bathing was "not applicable." On 9/11/24 at 9:21 AM Staff 80 (CNA) stated Resident 86 needed to receive consistent encouragement to accept care due to her/his anxiety related to her/his depression. Staff 80 stated the resident accepted care and would not refuse bathing if staff understood how to engage her/him. On 9/11/24 at 5:50 PM Resident 86 was observed seated in the dining room with quarter inch long facial hair. Resident 86 stated no staff offered to shave her/him on 9/11/24 and she/he preferred to be clean-shaven. On 9/12/24 at 11:10 AM Staff 8 (CNA) stated shaving for Resident 86 did not occur daily because some staff who cared for her/him were inconsistently assigned to Resident 86, did not know the resident and were overwhelmed as newer employees. Staff 8 stated Resident 86 accepted needed care when consistent staff provided care due to her/his anxiety. On 9/13/24 at 8:35 AM Staff 4 (Unit Manager-LPN) stated on 9/13/24 she asked a nurse to shave Resident 86 and acknowledged the resident's preference for shaving was not completed as expected. Staff 4 stated Staff 81 only worked at the facility for a short period of time and Resident 86 would only refuse bathing if staff did not know how to approach her/him. Staff 4 confirmed improved interventions for Resident 86's bathing and personal hygiene care were needed. , 3. Resident 98 admitted to the facility in 7/2024 with a diagnosis of a stroke. A 7/19/24 admission MDS revealed Resident 98 was cognitively intact, had a stroke, and required assistance with most ADLs. A bath task form from 8/11/24 through 9/10/23 revealed Resident 98 was to be showered two times a week. Resident 98 received one bed bath, one sponge bath, refused two showers, and "not applicable" was documented on two days. 8/2024 and 9/2024 Progress Notes included no rationale for the lack of bathing for Resident 98, or if additional attempts to bathe Resident 98 were made when the resident refused. On 9/10/24 at 11:12 AM Resident 98 stated she/he wanted her/his hair washed, but staff stated they did not have enough time. Resident 98 was observed to have oily hair. On 9/10/24 at 11:26 AM Staff 12 (CNA) stated Resident 98 was not scheduled to have a shower on 9/10/24, but the resident reported she/he did not smell good so Staff 12 provided Resident 98 a bed bath. Staff 12 stated it was hard to complete all work due to staffing issues. On 9/11/24 at 6:38 AM Staff 9 (CNA) stated on a shower task "NA" meant bathing did not occur. If a resident refused a bath staff were to document the refusal on the bath audit and give it to the nurse. On 9/11/24 at 5:28 PM a request was made to Staff 2 (DNS) to provide documentation staff attempted to offer Resident 98 additional bathing opportunities. No additional information was provided. On 9/13/24 at 8:52 AM Staff 32 (LPN) stated the CNA was to inform the nurse if a resident refused bathing. Staff were to offer two more times and then a different CNA would approach the resident. If the resident continued to refuse bathing a note was to be made in the progress notes.

Resident #62 will be offered bathing per scheduled preferences Resident #86 will be offered bathing and shaving per scheduled preferences Resident #98 will be offered bathing and hair washes per scheduled preferences Residents who are dependent for grooming (bathing) have the potential to be affected. The DON/Designee will complete a baseline audit of current residents to validate they are receiving showers/bathes per their choice. The DON/Designee will provide further education to nursing staff related to providing bathing opportunities to residents per their person-centered care plan. The DON/Designee will audit 10 residents weekly to validate they are receiving showers as care planned and there is documentation related to resident refusals. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to provide meaningful activities for dependent residents for 2 of 2 sampled residents (#s 14 and 54) reviewed for activities. This place residents at risk for lack of social interaction and isolation. Findings include: 1. Resident 14 admitted to the facility in 2022 with diagnoses including dementia and depression. A 7/8/24 Annual MDS indicated it was very important for Resident 14 to do her/his favorite activity and go outside when the weather was good. Resident 14's mobility device included her/his wheelchair. A 7/8/24 IDT (interdisciplinary team) Care Plan Conference/Welcome Meeting Form indicated Resident 14 had outbursts due to her/his frustrations and no activities staff were in attendance at the care conference. The meeting activity note indicated Resident 87 "has been spending [her/his] time resting/napping in bed, watching tv, using personal cell phone, reading, doing puzzle books, enjoys going outside when the weather is nice in [her/his] power chair, eating meals in [her/his] room and in the dining room and visiting with family and friends." A 7/21/24 revised care plan indicated Resident 14 had no interest in attending group activities and went outside with her/his power chair when the weather was nice and on independent outings to the store. An 8/14/24 through 9/9/24 Task: Activity Participation indicated Resident 14 did not go outside during the time period and attended no group activities. On 9/8/24 at 12:20 PM Resident 14 was observed engaged in no activities and stated she/he often sat in the hall with nothing to do. Resident 14 was observed sitting in the hall in her/his manual wheelchair and stated she/he was bored. On 9/9/24 at 1:38 PM Resident 14 was observed looking out the window on a nice day for an extended period of time while she/he was seated in her/his manual wheelchair by an outside door. On 9/10/24 at 8:48 AM Staff 7 (Activity Director) stated over the last three to four months Resident 14 attended group activities which was beneficial for her/him to continue. Staff 7 stated Resident 14's electric wheelchair was discontinued a month ago due to safety. Staff 7 acknowledged the resident's activity care plan should be updated and she/he should have received assistance to go outside during the last 30 days. On 9/12/24 at 12:02 PM Staff 3 (Social Services) stated resident care conferences lacked representation by activities in order to meet the needs of residents including Resident 14. 2. Resident 54 admitted to the facility in 12/2023 with diagnoses including depression and anxiety. A 12/31/23 Admission MDS indicated it was somewhat important for Resident 54 to engage in her/his favorite activity and very important to go outside when the weather was nice. Resident 54 had no limitations in her/his upper extremities. A 7/1/24 IDT (interdisciplinary team) Care Plan Conference/Welcome Meeting Form indicated no activities staff were in attendance, a discussion occurred related to crochet supplies, and Resident 54 wanted to be asked about activities. A 7/9/24 Activities/Recreation Quarterly/Annual Review indicated Resident 54 enjoyed listening to music, afternoon naps, and knitting, crocheting and sewing. On 9/8/24 at 3:29 PM Resident 54 remained in bed and stated no staff inquired about her/his activity interests, which included crocheting, and she/he requested activity options. On 9/9/24 at 4:05 PM Staff 82 (Activities Assistant) stated quarterly activity assessments may be missed or incomplete and not capture important information of residents. Staff 82 stated she was unaware of Resident 54's interest in crocheting even though a sewing group was recently added to the schedule. On 9/10/24 at 8:48 AM Staff 7 (Activities Director) stated when Resident 54 admitted to the facility it was difficult to engage residents and follow through because of the lack of staffing in the the activities department. On 9/12/24 at 12:02 PM Staff 3 (Social Services) stated resident care conferences lacked representation by activities in order to meet the needs of residents including Resident 54.

Resident #14 was re-interviewed by the Activity Director to assess their activity preferences, and the care plan will be updated. Resident #54 no longer resides at the facility Residents who are dependent have the potential to be affected Administrator/Designee will complete baseline audit of dependent residents of interviewing and obtaining their activity preferences and care plan reflected preferences. Will develop a system to ensure that residents are invited and provided preferred activities of interest. Administrator/Designee completed baseline audit of the last 30 days of all care conference to ensure Activity Department has attended. Administrator/Designee provided education to Activities department on the importance of honoring residents activity preferences as well as updating care plan to reflect. Administrator/Designee will conduct interviews on 5 residents weekly to ensure activities are meeting the preferences of the residents. Administrator/Designee will conduct weekly reviews of 3 care conferences to ensure that activity department is present. Administrator/Designee will review 5 resident care plans weekly to ensure they are reflective of resident preferences. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs. Findings include: The 7/2024 Council Minutes indicated Staff 7 (Activities Director) recorded the minutes as the person responsible. On 9/10/24 at 8:48 AM Staff 7 (Activity Director) stated she worked for the facility in the activities department since 5/2023 and was promoted to the Director position in 7/2024 which included responsibility to organize the Resident Council. Staff 6 acknowledged she did not have an activities certification. On 9/13/24 at 1:07 PM Staff 1 (Administrator) confirmed the certification for Staff 7 was not completed as required.

Current residents have the potential to be affected NHA has enrolled Activity Professional into a class to receive her Activities Accreditation Program. RDO/Designee will provide further education to NHA on qualifications of activity director. Audits will be conducted weekly by NHA/Designee to ensure Activities Director has completed their accreditation. Audit will be conducted weekly for 4 weeks, then monthly for two months. Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to follow through on services to maintain hearing for 1 of 2 sampled residents (#86) reviewed for communication and sensory. This placed residents at risk for lack of adequate hearing. Findings include: Resident 86 admitted to the facility in 3/2024 with diagnoses including depression and paraplegia (impairment in lower extremities). A 5/7/24 IDT (interdisciplinary team) Care Plan Conference/Welcome Meeting Form indicated Resident 87 required hearing services which required orders for her/his ears to be cleaned. A 5/31/24 Quarterly MDS indicated Resident 86 had no hearing aids and her/his hearing was adequate. On 9/11/24 at 9:21 AM Staff 80 (CNA) stated Resident 86 had issues with her/his hearing. On 9/12/24 at 11:53 AM Staff 3 (Social Services) stated she was aware Resident 87 had ongoing wax build-up in her/his ears which was to be addressed through physician orders and acknowledged there was no follow-through by nursing to ensure the orders were in placeand services provided after the 5/7/24 care conference. On 9/13/24 at 8:35 AM Staff 4 (Unit Manager-LPN) confirmed she neglected to obtain the physician orders for Resident 87's ear wax removal.

Resident#87 has had physician order follow up for ear wax removal Residents with ear wax build up are affected DON/Designee will complete baseline audit of current residents to ensure that they do not have wax build up. DON/Designee will provide education to social services and licensed nurses regarding timely coordination for follow up on ear wax removal with provider. Audits will be conducted weekly by DON/Designee to ensure new admits that have wax build up have treatment orders in place. Audit will be conducted weekly for 4 weeks, then monthly for two months. Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Based on observation interview and record review it was determined the facility failed to ensure a pressure ulcer was assessed and provided treatment timely for 1 of 3 sampled residents (#98) reviewed for pressure ulcers. Findings include: Resident 98 admitted to the facility in 7/2024 with a diagnosis of a stroke. A 7/12/24 NSG (Nursing) Admission/Readmission Evaluation form revealed Resident 98 was admitted to the facility with no pressure ulcers. A 7/19/24 admission CAA revealed Resident 98 was at risk to develop pressure ulcers due to incontinence and assistance was required for repositioning. Staff were to reposition the resident every two hours. A 9/2/24 Direct Care Staff Daily Report revealed a RN worked on the the evening and night shifts. A 9/2/24 Progress Note revealed a CNA reported Resident 98 had an open area to her/his coccyx which was the size of the tip of a cotton swab. A request for orders was sent to the physician. Resident 98's clinical record revealed no comprehensive assessment of the pressure ulcer until 9/5/24. A 9/5/24 Wound Evaluation revealed Resident 98 had a Stage 3 (full thickness skin loss but bone, tendon, or muscle is not exposed) pressure ulcer. The ulcer was 0.66 cm long, 0.44 cm wide and was covered with 70 percent slough (dead tissue). The pressure ulcer was identified to be facility acquired. The note indicated the ulcer was cleaned and a foam dressing was applied. A wound consultant agreed with current treatment with an addition of an air mattress. A 9/2024 TAR revealed treatment was not documented as completed until 9/6/24. On 9/10/24 at 3:16 PM Staff 65 (LPN) stated she was the first nurse to assess Resident 98's pressure ulcer. Staff 65 stated she did not stage the ulcer or initiate a skin sheet because it was not in her/his LPN scope of practice to stage a pressure ulcer. On 9/11/24 at 10:33 AM Staff 14 (LPN Resident Care Manger) stated when a pressure ulcer was first identified it should be staged and measured. Staff 14 acknowledged the first comprehensive assessment and documented wound care was completed on 9/5/24 and not 9/2/24. On 9/13/24 at 8:59 AM with Staff 1 (Administrator), Staff 2 (DNS) and Staff 56 (Regional Consultant), Staff 2 stated if a RN was in the building the RN should assess a newly identified pressure ulcer.

Resident # 98 wound was staged, treatments in place, and wound is resolved. Current residents with PU are affected DON/Designee will complete a baseline audit on all current residents with pressure ulcers to ensure wound has been assessed and staged timely and ensure treatment orders are in place. DON/Designee will initiate training for UM and LN related to pressure ulcers, staging, and timely treatment per regulation. DON/Designee will complete audit weekly any new pressure injuries to ensure wound has been assessed and staged timely and ensure treatment orders are in place. Audits will be conducted weekly for 4 weeks, then monthly for two months. Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure supervision for dysphagia, execute fall interventions, and execute elopement interventions for 3 of 8 sampled resident (#s 55, 93, and 164) reviewed for accidents. The facility failed to ensure a safe environment for residents on 1 of 1 unit (skilled) identified during random interviews. Resident 164 fell from an elevated bed resulting in fractured legs. Findings include: 1. Resident 55 admitted to the facility in 7/2024 with diagnoses including dysphagia (difficulty in swallowing) and dementia. Review of Resident 55's care plan revised on 7/29/24 revealed the resident had an ADL self-care performance deficit due to decreased mobility and generalized weakness. Interventions included to have Resident 55 in the dining room for meals with "supervision." On 9/8/24 at 12:56 PM Resident 55 was observed in the dining room with pureed food on a plate. No staff were observed in the dining room. On 9/10/24 at 12:52 PM Resident 55 was observed in her/his room sitting on her/his bed with the bedside table in front of her/him. Resident 55 had pureed food on her/his plate with approximately half the food eaten. No staff were in the room or observed in the hallway within line of sight. On 9/11/24 at 1:10 PM Resident 55 was observed in her/his room with no staff in the room. Food was on Resident 55's plate with approximately half the food eaten. On 9/13/24 at 8:33 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated they expected staff to supervise Resident 55 as care planned. 2. A review of an undated Resident Leaving the Facility policy revealed the following: -Residents who leave the facility are expected to sign out in the sign out book. -Information needed in sign out book: method of contact and expected time of return. -Medications will be provided to the resident or responsible party taking the resident out. -Upon return the resident or responsible party will sign the resident back into the facility. A review of an undated Elopement Preventions Guidelines facility policy revealed the following: -Residents will have a physician order indicating if the resident can leave the facility. The order will indicate if the resident can leave independently or must have supervision. -Each resident who leaves the facility will sign out and sign in upon return. -If employee observes a resident leaving the premises, and the employee does not know if the resident has a physician order allowing the resident to leave independently the employee will stay with the resident and notify another employee to verify the resident has an order. -An employee who intervenes in an elopement attempt will stay with the resident until other staff arrive to assist. -If a resident cannot be located, staff will verify whether the resident was on an authorized leave or pass. -If elopement was suspected the action checklist will be implemented. Resident 93 admitted to the facility in 6/2024 with diagnoses including dementia, stroke, alcohol abuse and seizures. A review of Resident 93's care plan dated 6/10/24 revealed she/he had an ADL self-care performance deficit, a communication problem due to dementia, and an alteration in neurological status due to dementia which required cueing and reorientation as needed. Resident 93 had a seizure disorder and was at risk for injury. The care plan indicated Resident 93 had a history of alcohol abuse and limited physical mobility. The admission MDS with ARD of 6/15/24 revealed Resident 93 had a BIMS score of 15 which indicated the resident was cognitively intact. The cognitive loss CAA indicated Resident 93 had episodes of confusion. Resident 93 was not able to care for herself/himself for quite some time. A review of signed physician orders dated 8/12/24 revealed Resident 93 was approved for therapeutic leave of absence with a responsible person and took prescribed medications. A review of the MAR dated 9/2024 instructed staff to administer hydration of choice four times a day, and on 9/6/24 at 4:00 PM indication Resident 93 was not in facility. A review of 9/6/24 Nursing Notes revealed the following: -10:42 PM Resident 93 was not in the facility all evening shift which was reported to Staff 38 (LPN), and to follow protocol when Resident 96 was considered a missing person. -11:19 PM Resident 93 had not returned to the facility since the morning of 9/6/24. Staff 38 contacted Staff 21 (RN-Staff Coordinator) who was the on-call weekend nurse. Staff 21 instructed to call him again if Resident 93 was not back in the facility by 5:00 AM on 9/7/24. A review of 9/7/24 Nurses Notes revealed the following: -5:12 AM, it was nearly 20 hours since Resident 93 left the facility and she/he did not returned all night. Staff 38 placed another call to Staff 21. Resident 96's emergency contact was called but there was no answer, and then local law enforcement was called on the non-emergent line to report Resident 93 missing. Details of Resident 93's recent alcohol use and volatile behaviors was provided, and law enforcement suggested to call local hospitals. -5:33 AM Local hospitals were contacted, but with no results. -1:02 PM Resident 93 was on alert for behaviors. At approximately 8:00 AM on 9/7/24 local law enforcement arrived to let the facility know Resident 93 was located. Resident 93 was found with a non-functioning power wheelchair.The on-call nurse was alerted and assisted helping the resident back to the building. On 9/8/24 at 4:24 PM Resident 93 stated she/he was lost five miles away from the facility and the police found her/him. Resident 93 stated no one answered when she/he attempted to call. Resident 93 stated she/he was missing overnight, and no staff spoke to her/him about the incident. Resident 93 stated she/he was cold and uncomfortable and she/he missed all her/his treatments. Resident 93 stated she/he did not tell anyone she/he left the facility. Resident 93 felt like no one cared about her/him being missing. A Nursing Facility Reported Incident dated 9/9/24 indicated on 9/6/24 Resident 93 left the facility on the evening shift around 11:00 PM and she/he did not sign out. The facility LPN called the emergency contact and local law enforcement. Law enforcement was able to find Resident 93 approximately six miles away from the facility in her/his powerchair with a failed battery "in the morning" on 9/7/24. Observations from 9/10/24 through 9/12/24 revealed Resident 93 in a manual wheelchair in the facility or outside on facility property. On 9/10/24 at 11:03 AM Staff 44 (LPN) stated Resident 93 was missing for 24 hours. At 2:00 PM on 9/6/24 she/he was not in the facility. At 10:00 PM he/she was still not back and typically Resident 93 would be back in the facility. Staff 44 stated Resident 93 was a danger to herself/himself and to other people. Resident 93 had become violent, aggressive and did not listen to rules. Staff 44 stated she did not check if Resident 93 had signed out in the book to notify staff of her/him leaving the facility. Staff 44 stated she was taught after eight to 10 hours of a resident missing the resident would be reported as a missing person. Staff 44 stated there was "chaos" on her shift and she left the information with the night nurse. On 9/10/24 at 11:21 AM Staff 32 (LPN) stated it was not uncommon for Resident 93 to leave the facility. Resident 93 had dementia and forgot to sign out. On 9/6/24 she/he left the facility around 7:00 AM. Usually if she/he left that early she/he came back around 12:00 PM or 1:00 PM. Staff 32 stated she was not concerned when Resident 93 had not returned to the facility at 2:00 PM and she notified the oncoming nurse. Staff 32 stated when Resident 93 returned to the facility she/he reported she/he had become lost. Staff 32 did not believe Resident 93 was safe to leave the facility. On 9/10/24 at 12:07 PM Staff 38 stated Resident 93 was "absolutely" not cognitively and physically able to be out in the community on her/his own. When Resident 93 first arrived at the facility Staff 38 took 15 to 20 minutes explaining a document so Resident 93 could understand what she/he was signing. Staff 38 stated when she was completed with her shift on 9/7/24 at 6:00 AM Resident 93 was not back to the facility. On 9/11/24 at 9:06 AM and 9/13/24 at 8:41 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated they were working on a discharge plan for Resident 93 and continued to work on the investigation for Resident 93's elopement. Staff 1 confirmed Resident 93 did not sign out of the facility when she/he left on 9/6/24. , 3. Resident 164 admitted to the facility 7/2022 with a diagnosis of high blood pressure. According to the National Library of Medicine, a comminuted fracture was a break or splinter of the bone into more than two fragments. Considerable force and energy was required to fragment bone, fractures of this degree occur after high-impact trauma such as vehicle accidents and falling from a high place. Fractures of this type which may happen with low pressure include cancer and weak bones. An 8/6/24 annual MDS revealed Resident 164 was previously assessed and care planned for cognitive loss. Resident 164 was assessed for further loss of vision, physical safety , "ie (sic) Falls." A care plan was developed to minimize risks, promote socialization, and prevent falls. Resident 164 had limitations which included the inability to walk due to a femur fracture in 2022, decreased ROM to the shoulders and elbows, muscle weakness, reconditioning and balance abnormalities. Resident 164 had "Cognitive: fear of falling" and dementia with moderate cognitive impairment deficits. A care plan initiated 7/28/22 revealed Resident 164 was at risk for falls due to deconditioning, balance problems, incontinence, and her/his unawareness of safety needs. Interventions included ensuring Resident 164's commonly used items were within reach, bilateral bed canes, and non-skid footwear. 8/25/24 Progress Notes revealed Staff 18 (LPN) heard a resident scream from Room 35. Staff 18 entered the room and found resident 164 falling out of bed, her/his body was out of the bed but both arms were hanging onto the bed canes, and she/he was screaming for help. Resident 164's legs were bent in a kneeling position and the left leg was twisted under the bed side table. A large amount of blood was on the floor from a laceration to Resident 164's left leg (shin). Resident 164 reported severe pain and her/his bed was noted to be in the "high" position. The note indicated Resident 164's CNA visualized her/him 30 minutes prior to the fall. An 8/25/24 Unwitnessed Fall investigation revealed Resident 164 fell to the floor "quite hard" landing on both legs. Resident 164 reported she/he attempted to reposition. The investigation indicated the air mattress may have deflated when Resident 164 was close to the edge of the mattress. The air mattress was removed to prevent future slips out of bed. An 8/25/24 hospital New Consult Note Hospital Medicine summary revealed Resident 164 fell out of bed and had fractures of the left and right leg. The right leg fracture was comminuted. The imaging studies were "suggestive" of pathological fractures (fracture caused by weak bones) and metastatic cancer (cancer which spread). An 8/31/24 hospital Discharge Summary did not include a diagnosis of cancer. An 8/31/24 hospice Admission Visit Summary revealed Resident 164 had a fall from her/his "raised" hospital bed. An 8/31/24 NSG (nursing) Admission/Readmission Evaluation form revealed Resident 164's reason for admission was a fall "from a great height", broke both legs, and was to be admitted to hospice immediately. On 9/10/24 at 4:09 PM Staff 69 (CMA) stated Resident 164 kept her/his bed at least waist high so she/he could see the television better. It was never in the normal low position. Resident 164 was able to adjust her/his bed independently. Staff 68 (CNA) stated on 8/25/24 she was not assigned to Resident 164 when she/he fell. Staff 68 heard yelling and went to Resident 164's room. Staff 18 (LPN) was already in her/his room. Resident 164 reported she/he tried to reposition, her/his legs became stuck in a blanket and she/he fell. Resident 164's bed was "high" even for her/his "normal high." Staff 68 stated when she worked with Resident 164 she tried to encourage her/him to lower the bed because it was "always so high up", and propped pillows between the resident and the rail to prevent rolling out of bed. Resident 164 was able to use the bed controls to elevate the bed. The bed should never have been that high. Staff 68 stated Resident 164 did not have mats on the ground even when the bed was in a high position. On 9/10/24 at 8:25 PM Staff 74 (CNA) stated when she arrived on shift at 6:00 AM she observed Resident 164 in bed sleeping. Resident 164 was laying on her/his right side. Staff 18 stated she did not remember the height of Resident 164's bed but she/he liked to elevate the bed. There were no mats on the ground and the call light was activated. On 9/10/24 at 5:02 PM Staff 70 (CNA) stated she worked the day Resident 164 fell. She was in another room at the time and heard a noise and went to Resident 164's room. The nurse and CMA were already in the room. Resident 164 was hanging onto the bed rails and would not let go. eventually Resident 164 was lowered to the floor. Staff 70 stated when she entered the 164's room the bed was at least waist high. Resident 164 liked to have the bed high so she/he could watch television. The resident's bed was at least waist high the dayshe/he fell. Resident 164 was able to adjust the bed, did not have mats on the ground, and had an air mattress. On 9/10/24 at 5:12 PM Staff 71 (CMA) stated at approximately 6:45 AM she administered Resident 164 her/his medicine. Later she heard the nurse call for help. When she entered Resident 164's room the resident was holding onto her/his bed cane and was upright but not standing. Resident 164's legs were contorted and wrapped in a blanket. Resident 164 reported she/he tried to adjust her/his position, her/his legs fell over the side of the bed, and the momentum carried her/him off the bed. Resident 164's bed was "pretty high" and she/he liked it high so she/he could see the television better. Staff 71 stated she did not recall seeing pillows between the resident and the bed rails. On 9/11/24 at 10:53 AM Staff 5 (LPN Resident Care Manager) stated Resident 164 was at risk for falls and liked to keep her/his bed elevated. The resident had an air mattress. Staff 5 stated the standard of care was to keep the bed in a normal or low position and not "high." Staff 5 stated she never reviewed the risks with Resident 164 of keeping her/his bed elevated. After the resident returned from the hospital the bed was care planned to be in a low position and mats on the floor. On 9/13/24 at 1:22 PM Staff 33 (LPN) stated Resident 164 liked to keep her/his bed high and not at a normal height of a bed. After Resident 164 fell staff educated other residents to keep their beds in a low position. Staff 18 stated the resident's bed height was the resident's choice. On 9/13/24 at 1:42 PM Witness 9 (Friend) stated Resident 164's bed was always high. Staff raised the bed to provide care and never lowered it. , 4. On 9/11/24 at 12:39 PM Staff 79 (LPN) stated there was an incident in 5/2024 involving Staff 77 (Former NA) who smoked methamphetamine (controlled stimulant medication) in the staff bathroom while working on shift, and continued to finish the shift after it was reported to management. She stated staff reported Staff 77 hallucinated on the unit, and there was a strong chemical smell in the staff bathroom. Review of Staff 77's 5/28/24 time punch record indicated she clocked in at 1:57 PM, clocked out at 5:53 PM, and did not clock in again until 6/1/24. On 9/12/24 at 6:14 PM Staff 78 (CNA) stated she was working evening shift (2:00 PM until 10:00 PM) on 5/28/24 with Staff 77 as her skilled unit hall partner. She stated Staff 77 was missing for a long stretch of time and was later seen walking down the hallway making swiping motions to her head, mumbling to herself, and shaking her head vigorously. Staff 78 stated when asked if Staff 77 was ok, she replied she was "trying to get it off, get it off, there are screws in my head." Staff 78 stated she reported to her charge nurse and wrote a statement about the incident and gave it to management. On 9/13/24 at 12:53 PM Staff 1 (Administrator) stated she received a phone call on 5/28/24 about the reported incident. Staff 1 stated she told Staff 77 to go home and suspended her until an investigation was completed. Staff 1 stated it took two days to create an account with a drug testing center, and Staff 77's drug test results were negative on 5/30/24 so she did not do further investigation. Staff 1 acknowledged the complete investigation for this incident was the drug test dated 5/30/24.

Resident #55 is no longer at the facility Resident #93 will have an updated community outing assessment Resident #164 is no longer at the facility Residents who require assistance with meals, residents who independently leave the facility, and residents who keep bed in high positions are at risk. DON/Designee will complete baseline audit of current residents to verify that community outing assessments are current for any resident going out of the facility independently. DON/Designee will complete baseline audit of current residents that prefer to keep bed in higher position. Risk/benefit will be completed regarding risk for serious injury from falls. DON/Designee will complete baseline audit of current residents who require supervision during meals to ensure that care plan is accurate and is being followed. DON/Designee will initiate training for nursing staff related to keeping residents free from accidents and hazards. DON/Designee will complete an ongoing audit of newly admitted residents to verify that community outing assessments are current for any resident going out of the facility unattended. DON/Designee will complete an ongoing audit of newly admitted residents that prefer to keep bed in higher position. Risk/benefit will be completed regarding risk for serious injury from falls. DON/Designee will complete an ongoing audit of newly admitted residents who require supervision during meals to ensure that care plan is accurate and is being followed. DON/Designee will complete weekly audits x4, then monthly x 2. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to provide adequate catheter and incontinent care for 3 of 15 sampled residents (#s 24, 86 and 164) reviewed for ADLs, accidents and catheter care. This placed residents at risk for unmet incontinent care needs. Findings include: 1. Resident 24 admitted to the facility in 6/2024 with a diagnosis of heart disease. . Resident 24's 6/13/24 annual MDS indicated she/he was cognitively intact. On 9/8/24 at 11:35 AM Resident 24 reported she/he regularly waited 30 minutes for the call light to be answered by staff when she/he needed bowel and bladder care. She/he stated the delayed call light responses by staff caused significant frustration and emotional stress from waiting this length of time with a soiled brief. On 9/9/24 at 8:44 AM call light response observations revealed the following: -Resident 24's call light was activated at 8:44 AM. Staff went to her/his door at 9:06 AM and left the call light activated. -At 9:09 AM staff went to Resident 24's room and turned the call light off. -At 9:19 AM, Resident 24 was interviewed and stated she/he needed a brief change, and it was not changed. Resident 24 stated she/he often fell asleep while she/he waited for assistance with bowel and bladder care and this morning, when she/he awoke, her/his meal tray was on her/his table, the food was cold, and staff did not try and wake her/him to eat or to complete bowel and bladder care which was the reason she/he activated her/his call light. A 9/10/24 at 11:20 AM interview with Staff 6 (CNA) confirmed Resident 24 did not refuse bowel and bladder care and only refused showers if her/his bowels were loose. Staff 6 confirmed she was also frustrated with the low staffing challenges because she could not offer the care the resident needed and deserved. A 9/10/24 at 2:03 PM interview with Witness 7 (Complainant) confirmed Resident 24's bowel and bladder care often was delayed, and she/he was concerned about the integrity of Resident 24's skin because of the delayed ADL care. Currently Resident 24 did not have evidence of skin breakdown, but her/his anxiety was heightened due to waiting for help with a soiled brief. Witness 7 reported Resident 24 experienced this problem several times a week. , 2. Resident 86 admitted to the facility in 3/2024 with diagnoses including depression and paraplegia (impairment in lower extremities). A 2/29/24 Admission Urinary Incontinence and Indwelling Catheter CAA indicated Resident 86 had an indwelling catheter on admission, staff were to check on the resident routinely in anticipation of her/his needs, and the care plan goal was for no trauma or infection related to the use of her/his indwelling catheter. A 7/26/24 physician orders revealed the facility was not to change Resident 86's new suprapubic catheter (tubing surgically inserted into the abdomen for urine drainage.) A 9/6/24 urology provider note indicated Resident 86 had her/his suprapubic catheter changed during an out of facility appointment and the balloon (used to hold the catheter in place) was reinflated. No nursing progress notes or assessment related to the replacement of Resident 86's suprapubic catheter on 9/6/24 were found. A 9/8/24 nursing progress note indicated Resident 86's catheter came out of his abdomen during routine care and she/he was sent to the emergency room to have her/his catheter reinserted. No nursing assessment or hospital notes were found related to the 9/8/24 emergency room visit and catheter reinsertion for Resident 86. On 9/12/24 at 5:25 PM Staff 38 (LPN) stated Resident 86's catheter balloon was already deflated when her/his catheter slipped out on 9/8/24 during routine care. Staff 38 stated she was unaware Resident 86's catheter was replaced on 9/6/24 and she/he was not monitored for her/his new catheter as she expected which could contribute to the issue that occurred on 9/8/24. Staff 38 stated after Resident 86 returned from the emergency room on 9/8/24 there was no paperwork from the hospital and she assumed there were no concerns with Resident 86's catheter procedure by the hospital. Staff 38 acknowledged Resident 86 was not monitored upon her/his return on 9/8/24. On 9/13/24 at 8:35 AM Staff 4 (Unit Manager-LPN) stated emergency room records should be obtained after a resident returns and confirmed Resident 86 should be specifically monitored related to her/his catheter after changes occurred. , 3. Resident 164 readmitted to the facility on 8/31/24 post-surgical repair of fractured legs. Resident 164's clinical record indicated she/he had an allergy to aloe. A care plan revised on 8/27/24 revealed Resident 164 had fragile skin and non-aloe wipes were to be used for incontinent care. On 9/10/24 at 2:15 PM Staff 35 (CNA) stated Resident 164's bottom was very red because staff did not use the correct wipes on her/his skin. Staff 35 stated Resident 164 was allergic to the aloe wipes and had to use a specific type of wipes. Staff 35 stated she worked with Resident 164 on 9/7/24 and the other staff did not use the non-aloe wipes. There were lots of aloe wipes in the room and she removed them. The special wipes were in the resident's closet but there was no sign on the door to remind staff not to use the aloe wipes. Staff 35 stated the hospice nurse was aware of the incident. On 9/10/24 at 3:31 PM Staff 72 (LPN) stated she did not work with Resident 164 when she/he resided on the long term care side. Staff 72 stated when Resident 164 was readmitted to the skilled unit she did not know she/he required special wipes. The wipes were at the bottom of her/his closet. On 9/10/24 at 3:34 PM Witness 10 (Hospice Staff) stated the LPN who assessed Resident 164 on 9/7/24 made a note indicating Resident 164 required special wipes and when staff used the aloe wipes the resident was very painful. On 9/10/24 at 4:11 PM Staff 5 (LPN Resident Care Manager) stated on 8/31/24 she moved the resident's special wipes and put them in the closet. Staff 5 stated the sign may not have been moved to the resident's new room when she/he first readmitted to the facility . On 9/11/24 at 7:30 AM a sign on Resident 164's current room closet door read "Do no use regular wipes on (Resident 164) please use pampers sensitive wipes. Ask unit manager if no wipes are available in room."

Resident#24 will have care needs met timely Resident #86 will obtain notes from 9/8 ER visit and will be monitored post cath changes. Resident #164 no longer resides at the facility Resident with bowel and bladder care needed, catheter changes, and special wipes have the potential to be affected DON/Designee will complete baseline audit to verify that resident care needs are met timely. DON/Designee will complete a baseline audit on current residents with catheter changes to ensure monitoring is in place. Any issues identified will be addressed. Administrator/Designee will conduct a baseline audit on current residents who use special wipes to ensure care plan is updated and is being followed. DON/Designee will conduct education/training to nursing staff related to ensure care needs are met timely, specialty wipes are being provided if necessary, and residents returning from ED are assessed upon return and ED notes are obtained. DON/Designee will complete weekly audits on 5 residents to ensure care needs are met timely. DON/Designee will complete weekly audits on all residents that receive cath changes to ensure monitoring occurred. DON/Designee will complete weekly audits of residents who transfer to the ED to ensure they were e assessed upon return and ED notes were obtained. Administrator/Designee will complete weekly audits on current resident that require special wipes to ensure they are stocked and readily available for resident and being used. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to provide respiratory care and services in accordance with physician orders and standards of practice for 3 of 5 sampled residents (#s 2, 55 and 87) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: 1. Resident 2 admitted to the facility in 5/2016 with diagnoses including chronic pain. An observation on 9/10/24 at 11:58 AM revealed a suction machine on the resident's nightstand covered in dust. There was a yankauer (oral suctioning tool) lying on the nightstand covered with dust, and the canister (collects body fluids such as mucus) was half full of a yellowish liquid with white debris. A physician order dated 2/18/20 indicated to check the suction machine canister weekly on Saturday night, if used that week replace the canister every night shift every Saturday. On 9/10/24 at 11:44 AM Resident 2 stated she/he did not use the suction machine for three or four years. On 9/10/24 at 11:58 AM Staff 4 (Unit Manger-LPN) acknowledged the dirty suction machine and stated the resident had an order for a suction machine on 6/29/20 which was four years ago. Staff 4 acknowledged the resident did not use the suction machine for years and it should have been removed from the resident's room. , 2. Resident 55 admitted to the facility in 7/2024 with diagnoses including pulmonary embolism (PE, blockage of lung artery). A review of Resident 55's care plan revised on 7/29/24 revealed Resident 55 had altered respiratory status and difficulty breathing due to PE and was at risk for complications. Interventions included oxygen therapy as ordered and PRN. Oxygen settings were one to two liters PRN and keep oxygen saturation levels greater than 90 percent. A review of signed physician orders dated 8/7/24 instructed staff to administer oxygen one to four liters per minute and document oxygen saturations and liters per minute every shift with a start date of 7/26/24. A review of the 9/2024 TAR instructed staff to administer oxygen one to four liters per minute and to keep oxygen saturations above 90 percent. Staff were to document oxygen saturations and liters per minute every shift with a start date of 7/26/24. From 9/1/24 through evening shift 9/9/24 liters per minute were documented "NA" with no liter per minute documented. The TAR also instructed staff to administer one to four liters per minute and document oxygen saturations and liters per minute every shift for heart disease with a start date of 8/26/24. From 9/1/24 through evening shift of 9/9/24 the liters per minute was documented as "NA" with no liters per minute documented. Observations from 9/8/24 at 12:56 PM through 9/12/24 at 10:13 AM revealed no instances Resident 55 was administered oxygen. On 9/13/24 at 8:35 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated they would check on orders to determine if orders were PRN. At 11:39 Staff 2 provided a Hospice Medication List. The list instructed staff to provide one to four liters per minute of oxygen PRN, and titrate as needed for dyspnea with a start date of 8/24/24. The list was not a signed physician's order. , 3. Resident 87 admitted to the facility in 3/2024 with diagnoses including respiratory failure and congestive heart failure. A 6/28/24 revised care plan indicated Resident 87 was to receive medications and inhalers as ordered for altered respiratory status and to monitor for effectiveness and side effects. The 9/2024 MAR indicated Resident 87 was to orally inhale her/his Ipratropium-Albuterol (medication to address shortness of breath) solution three times a day as of 9/5/24 for five days. On 9/8/24 at 10:38 AM Resident 87's nebulizer (a device to convert medication into a fine mist to inhale) was observed placed directly on the top of her/his bedside table. On 9/10/24 at 11:19 AM Staff 17 (CMA) stated she worked throughout the facility and was not aware nebulizers for residents were to be stored with a protective barrier until 9/10/24. Staff 17 stated there were no instructions how Resident 87's nebulizer was to be cleaned or serviced although she believed it was necessary. On 9/10/24 at 4:39 PM Staff 4 (Unit Manager-LPN) acknowledged Resident 87's nebulizer should be cleaned after each use and instructions for storage and monthly maintenance of the device should be indicated as a task for nursing.

Resident#2 had suction machine removed from room Resident#55 no longer resides at the facility Resident #87 had protective barrier placed on nebulizer machine Residents with suction machines, physician orders to titrate oxygen therapy, and residents that have nebulizer treatments ordered are at risk. DON/Designee will complete baseline audit of current residents with suction machine to ensure there is current physician orders and that equipment clean and is being changed weekly. DON/Designee will complete baseline audit of current residents with physician order to titrate oxygen to ensure LPM are being documented correctly on TAR DON/Designee will complete baseline audit of all nebulizers in resident rooms to ensure that an appropriate protective barrier is in place. DON/Designee will provide further education to nursing staff related to proper documentation of oxygen use and LPM, proper cleaning and storage for nebulizers, and proper cleaning and storage for suction machines. DON/Designee will conduct random observations of 5 residents who utilize oxygen to verify LPM are being documented accurately., DON/Designee will conduct weekly audit of all residents who are using suction machines to ensure it is being cleaned and stored appropriately DON/Designee will conduct weekly audit of 5 residents with nebulizers to ensure protective barrier is in place. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review the facility failed to provide pain medications as ordered for 1 of 4 sampled residents (#262) reviewed for pain management. This placed residents at risk for uncontrolled pain. Findings include: Resident 262 admitted to the facility in 8/2024 with diagnoses including a leg fracture and pain due to internal orthopedic prosthetic devices. The Admission MDS with an ARD of 8/26/24 revealed Resident 262's BIMS score was 15 which indicated she/he was cognitively intact. Resident 262 had frequent pain presence which effected her/his sleep quality and day-to-day activities occasionally, with a level of eight on a scale of zero to 10. A 9/2024 MAR instructed staff to administer oxycodone (to treat moderate to severe pain) 5 mg tablet every four hours PRN for moderate pain. If the pain level was below two, administer zero mg, pain level from two to five administer five mg, pain level five to 10 administer 10 mg. On 9/7/24 Resident 262 was administered 10 mg for a pain level of eight at 1:07 AM, at 5:14 AM she/he was administered 10 mg for a level of eight pain, and at 12:11 PM for a pain level of 10 pain. A 9/7/24 at 12:11 PM Administration Note by Staff 46 (CMA) revealed oxycodone every four hours PRN for moderate pain. If the pain level was below two, administer zero mg, pain level from two to five administer five mg, pain level five to 10 administer 10 mg. Resident 262 complained of pain. On 9/8/24 at 10:11 AM Resident 262 stated on 9/7/24 she/he activated her/his call light at 9:15 AM. Resident 262 stated a staff member "finally" came in and she/he notified them of the need for PRN pain medication. Resident 262 stated no one came back and she/he did not see any staff until 12:00 PM when they delivered her/his lunch. On 9/12/24 at 7:57 AM Witness 3 (Staff) stated Resident 262 was on PRN pain medication and she/he expected the medication every four hours and most staff who worked with her/him were aware. On 9/12/24 at 9:16 AM and 9/13/24 at 8:06 AM Staff 46 stated she did not remember 9/7/24 or if she received a request for PRN pain medication related to Resident 262. Staff 46 stated it could be "crazy around here." Staff 46 stated the CNA may not have informed her for Resident 262's need for PRN pain medications. Staff 46 stated she was assigned both units and may have not been able to administer the medication. Staff 46 stated the facility was low on staff and staff were "not robots." Staff 46 confirmed Resident 262 was consistent in requesting her/his PRN pain medications. On 9/13/24 at 8:44 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated the expectation was to provide pain medications as physician ordered and to follow through with PRN pain medication requests.

Resident #262 will have pain needs met timely. Residents that have (PRN) orders for pain medication have the potential to be affected DON/Designee will interview current residents with BIMS 9 or higher to ensure that their requests for PRN pain medications are administered timely when requested. DON/Designee will audit pain medications with a dosage parameter based on pain score to ensure it is being administered as ordered. DON/Designee will provide education to licensed nurses and CMAs to ensure they are administering pain medications timely and following parameters for pain levels. DON/Designee will complete ongoing interviews with 5 random residents with BIMS 9 or higher who receive PRN pain medication to verify they receive them timely when requested. Audits will be conducted weekly by DON/Designee for 4 weeks, then monthly for two months. Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure residents received proper dialysis care and services after dialysis for 1 of 3 sampled residents (#58) reviewed for personal property. This placed residents at risk for dialysis complications. Findings include: Resident 58 admitted to the facility in 2/2023 with diagnoses including end stage renal disease (kidney disease) and dependence on renal dialysis (a process of removing waste products and excess fluid from the body). A review of a 6/19/24 Significant Change MDS indicated Resident 58 was cognitively intact. On 9/8/24 at 10:48 AM Resident 58 stated she/he had a fistula (surgically created passage in the arm connecting an artery to a vein) in her/his left arm and she/he had no issues with her/his dialysis treatment on every Tuesday, Thursday, and Saturday. She/he stated staff did not check her/his fistula or vitals upon return from dialysis. Resident 58's 11/8/23 care plan indicated the resident was receiving hemodialysis three times a week. The interventions included monitoring for infection at the fistula site as well as monitoring for bleeding and symptoms of kidney malfunction. The interventions also included checking the fistula thrill and bruit (vibration and rushing sound present in a fistula). The 6/2024 through 9/2024 MARs and TARs included no orders for monitoring for bleeding, infection, or kidney malfunction. The TARs indicated the order to check the thrill and bruit was discontinued on 6/11/24. Review of Resident 58's 6/2024 through 9/2024 progress notes revealed no documented refusals or missed dialysis appointments. Resident 58's records for 6/1/24 through 9/12/24 indicated the resident had 45 opportunities to go to the dialysis center. The resident's record revealed staff completed the pre-dialysis paperwork 35 times and the post-dialysis paperwork four times. On 9/13/24 at 9:49 AM Staff 18 (LPN) stated nursing staff filled out the pre-dialysis form in the computer and sent a printed copy with the resident to the dialysis center. She stated the post-dialysis form was completed on the computer after the resident returned to the facility. On 9/13/24 at 9:57 AM Staff 4 (Unit Manager-LPN) stated she monitored Resident 58's dialysis status through the forms nursing staff filled out on dialysis days. She stated the pre-dialysis forms got lost at times and the dialysis center had very poor communication with the facility. She stated the expectation was for nursing staff to fill out the pre and post-dialysis forms and to check for thrill and bruit every day Resident 58 went to the dialysis center. She acknowledged the missing pre and post-dialysis documentation and the lack of an order for checking the thrill and bruit.

Resident #58 no longer resides at the facility Residents receiving dialysis care could be affected. DON/Designee will complete baseline audit of last 7 days of current residents who receive dialysis to verify pre/post dialysis communication is received/completed and there are orders in place for monitoring fistula. Identified issues will be addressed. DON/Designee will complete baseline audit of last 7 days of current residents who receive dialysis to verify resident has orders in place to monitor dialysis site. Identified issues will be addressed. DON/Designee will provide further education to Licensed Nurses related to facility communication requirements with dialysis center to include pre/post dialysis assessments to be completed and monitoring in place of dialysis site/fistula. DON/Designee will conduct an audit on residents who receive dialysis to verify pre/post communication with dialysis center and that resident dialysis site/fistula is being monitored. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 14 sampled residents (#24) and 2 of 2 units (Skilled unit and long-term unit) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. A review of an 4/15/24 Intake Information revealed a public complaint received by the State Agency indicated the facility was short-staffed for CNAs. Due to inadequate staffing CNAs could not provide showers for all the residents scheduled for the evening shift. A review of Council Minutes dated 4/19/24 revealed call light wait times were up to 30 to 45 minutes, especially on the night shift. A review of Council Minutes dated 7/16/24 revealed call light wait times were "awful." A review of a 7/31/24 Intake Information revealed a public complaint received by the State Agency indicated the facility was short-staffed for both CNAs and nurses. There was difficulty for night nurses to provide care to residents and to complete nursing tasks. On day shift, CNA staff could not provide showers to all assigned residents. A review of a 9/3/24 Intake Information revealed a public complaint received by the State Agency indicated the facility was short-staffed, which caused outcomes such as untimely call light responses, late meal assistance for residents, and not all showers were completed. The following resident interviews occurred on 9/8/24: -10:06 AM Resident 262 stated she/he had to "wait and wait" and had an incontinent episode because of waiting. On 9/7/24 she/he activated her/his call light and she/he did not receive assistance for over two hours. -10:23 AM Resident 78 stated the facility was not good at answering call lights. Resident 78 felt staff ignored her/him on purpose. -10:48 AM Resident 58 stated the facility was slow in answering call lights. -11:32 AM Resident 29 stated call light wait times were "questionable" and when COVID-19 was active in the facility it took staff longer to answer call lights. -11:44 AM Resident 2 stated the facility was always short-staffed on all shifts and staff turnover was high. -11:59 AM Resident 44 stated call light wait times were 30 minutes and last week she/he had loose bowel movements several times. Resident 44 attempted to clean herself/himself and eventually a staff member came in and assisted. -12:28 PM Resident 40 stated her/his breakfast tray was still on the bedside table. At times call light wait times were over 20 minutes. -1:01 PM Resident 97 stated there was not enough staff for the number of residents. Call light wait times were 30 minutes at times. Resident 97 stated there were no staff in the hallway around 9:00 PM. -3:32 PM Resident 54 stated in 8/2024 she/he waited over 30 minute to receive incontinent care. Staff indicated to Resident 54 she/he was not the only one who needed assistance. -4:16 PM Resident 73 stated she/he waited a long time for staff to answer call lights. At times Resident 73 had to call the facility via telephone to have a staff member come into her/his room. On 9/8/24 at 4:37 PM Staff 51 (Scheduler) stated staff did not have time to access snacks for diabetic residents. Staff 51 stated she did call light wait audits which were showing call light wait times of 50 minutes. On 6/18/24 there was a call light wait time of 55 minutes. On 9/9/24 observations revealed: -3:32 AM the call light monitor at the nurses' station indicated Room 104's call light was on for 17 minutes. At 3:36 AM Staff 13 (Agency CNA) went into Room 104 with a 21-minute call light wait time. -6:34 AM the call light monitor in the main dining room revealed Room 121-1 call light wait time at 31 minutes. At 6:42 Room 121-1 call light wait time was at 39 minutes. At 6:47 AM Staff 66 (CNA) and Staff 21 (LPN Staffing Coordinator) stated the facility typically had staffing issues when they had to rearrange the CNAs because staff called off for work. This delayed resident call light wait times. Staff 66 stated she did not normally work the section of Room 121 and she did not know what was occurring, she just went in and answered the call light. On 9/9/24 at 7:40 AM Witness 2 (Staff) confirmed the staffing concerns from the 4/15/24 public complaint. Witness 2 stated there was a problem with staff calling off work with no repercussions. On 9/9/24 at 8:35 AM Staff 67 (CNA) stated the facility was short-staffed every day, and on evening shift she was assigned 11 to 14 residents. On 9/9/24 at 8:39 AM Resident 63 stated she/he waited 45 minutes for her/his call light to be answered. Resident 63 reported 30 minutes was the usual wait time. On 9/10/24 at 11:21 AM Staff 32 (LPN) stated resident acuity was high and in the last six months the facility had 100 resident falls. Staff 32 did not believe there was enough staff to provide the residents the needed care. CNAs complained they were behind and could not get their work done. Staff 32 stated there were a lot of staff who called off of work and there was no accountability for the staff missing work. On 9/10/24 at 2:51 PM during a resident council meeting residents had the following concerns: -Staff wearing earphones on night shift. -Day shift CNAs looking at their phones and ignoring resident call lights. -Not enough staff to meet the needs of the residents. -Long call light response times; 30 to 60 minute wait. On 9/10/24 at 8:08 AM a call light monitor at the nurses station revealed room 26-3 call light wait time was 20 minutes. On 9/10/24 at 2:31 PM Witness 4 (Staff) confirmed the 9/3/24 public complaint. Witness 4 stated there were concerns with staffing with too many call lights to answer, and showers not completed for residents. Witness 4 stated she could not take her breaks as she could not leave the residents with no one to cover while she was on break. Witness 4 stated she saw staff completing two-person transfers by themselves because there was not enough staff to complete the task with the required two people. Witness 4 stated there were no nurses on the floor who could help CNAs when there was a staff shortage. On 9/11/24 at 9:52 AM the call light monitor in the main dining room revealed room 119 call light wait time was 20 minutes. The resident in room 119 stated she/he was waiting for someone to close her/his window as she/he could not reach it. At 9:55 AM the call light wait time was 23 minutes. On 9/12/24 at 7:18 AM Staff 37 (CNA) stated at times she was unable to complete resident showers. Staff 37 stated the residents assigned were not balanced and some residents had a higher acuity than others, so if she was assigned many residents with high acuity then it was difficult to complete all the assignments. Staff 37 stated Sundays were the worst as many staff called off work and it was getting worse. On 9/12/24 at 7:35 Staff 39 (CNA) stated call light wait times was the "biggest" issue. When she came onto her shift at night the call light wait times were 25 to 30 minutes. On 9/11/24 there was one call light wait time which had "maxed" out on the system at 99 minutes. Staff 39 stated staffing shortages occurred off and on. In 4/2024 there was a large turn over in staff which caused a shortage and in 7/2024 there was a shortage in staff. On 9/12/24 at 7:57 AM Witness 3 (Staff) confirmed the 7/31/24 public complaint concerns. Witness 3 stated 9/11/24 was a good example of short staffing as they only had three CNAs on night shift and did not try to find additional staff. There was COVID-19 active in the facility, staff were rushed and there were long call light wait times. Call light wait times were up to 20 minutes when staff had to put on PPE. Pain medications were not provided to residents timely. On 9/12/24 at 10:27 AM the call light monitor in the main dining room indicated the call light wait time for room 118 was 24 minutes. On 9/13/24 the call light monitor at the nurses station revealed Room 17-1 call light wait time was 20 minutes. On 9/11/24 at 8:26 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated the facility had a norovirus (causes severe vomiting and diarrhea) outbreak in 4/2024, the facility had COVID-19 in the facility in 7/2024, 8/2024 and 9/2024, and confirmed there were staffing issues. , 2. Resident 24 admitted to the facility in 6/2019 with a diagnosis of heart disease. Resident 24's 6/13/24 annual MDS indicated she/he was cognitively intact. On 9/8/24 at 11:35 AM Resident 24 reported she/he regularly waited 30 minutes for her/his call light to be answered by staff when she/he needed bowel and bladder care. She/he stated the delayed call light responses by staff caused significant frustration and emotional stress from waiting that length of time with a soiled brief. A 9/9/24 at 8:44 AM call light observation revealed the following: -Resident 24's call light was activated at 8:44 AM. Staff went to her/his door at 9:06 AM and left the call light activated. -At 9:09 AM staff went to Resident 24's room and turned the call light off. -At 9:19 AM, Resident 24 was interviewed and stated she/he needed a brief change, and it was not changed. Resident 24 stated she/he often fell asleep while she/he waited for assistance with bowel and bladder care and this morning, when she/he awoke, her/his meal tray was on her/his table, the food was cold, and staff did not try and wake her/him to eat or to complete bowel and bladder care which was the reason she/he activated her/his call light. A 9/10/24 at 11:03 AM interview with Staff 3 (Social Service Director) revealed Resident 24, as well as other residents, complained on a weekly basis about call lights not being answered in a timely manner and care being delayed or not completed. Staff 3 confirmed delayed care was a common complaint with residents at the facility and as managers they audited the call lights. Staff 3 also stated today there was a 49-minute wait for a call light response on Resident 24's hall. A 9/10/24 at 11:20 AM interview with Staff 6 (CNA) confirmed she was frustrated with the low staffing challenges because she could not offer the care the resident needed and deserved. A 9/10/24 at 2:03 PM interview with Witness 7 (Complainant) confirmed Resident 24's bowel and bladder care often was delayed, and she/he was concerned about the integrity of Resident 24's skin because of the delayed ADL care. Currently Resident 24 did not have evidence of skin breakdown, but her/his anxiety was heightened due to waiting for help with a soiled brief. Witness 7 reported Resident 24 experienced this problem several times a week.

Resident #24 will have her needs meet timely Resident #262 will have needs met timely Resident #78 will have care needs met timely. Resident #58 will have care needs met timely. Resident #29 will have care needs met timely. Resident #2 will have care needs met timely. Resident #44 will have care needs met timely. Resident #40 will have care needs met timely. Resident #97 will have care needs met timely. Resident #54 no longer resides at the facility. Resident #73 will have care needs met timely. Current residents have the potential to be affected Residents will receive a timely response to a call light. NHA/Designee will complete baseline interviews of current residents with BIMS of 9 or higher to verify if call light is responded to timely. Identified issues will be addressed. The DON/Designee will complete a baseline audit for the last 14 days to validate sufficient staff were scheduled for each shift. NHA/Designee will provide further education to staff related to call light response and responding to resident request for assistance timely. The DON/Designee will provide further education to nurse managers and staffing related to scheduling sufficient staff for each shift. NHA/Designee will conduct ongoing random interviews of 15 residents with BIMs of 9 or higher to verify if the call light is responded to timely. DON/Designee will complete weekly audits to validate sufficient staff are working for each shift. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to staff a registered nurse for 8 consecutive hours per day 7 days per week for 7 out of 93 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports dated 4/1/24 through 4/30/24, 7/1/24 through 7/31/24, 8/8/24 through 8/31/24 and 9/1/24 through 9/8/24 revealed there were seven days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period. On 9/13/24 at 8:37 AM and 11:25 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated they would look at the RN coverage. No additional information was provided related to the required RN coverage.

Current residents have the potential to be affected. Facility has current RN Waiver. Facility continues to advertise and recruit additional RNs. The Administrator/Designee will complete a baseline audit for the last 14 days to verify an RN was scheduled daily. The Administrator/Designee will provide further education to central staffing coordinator related to RN staffing requirements. The Administrator/Designee will complete weekly audit to verify an RN was scheduled daily for 8 consecutive hours. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to post accurate and complete staffing information for 6 of 6 days reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include: On the following days and times the Direct Care Staff Daily Report revealed the following : -9/8/24 at 3:00 PM, all three shifts no census was documented for day and evening shift. -9/9/24 at 3:36 AM, 9/8/24 posting for the night shift did not have census documented. -9/10/24 at 9:58 AM, no census documented on day shift. -9/11/24 at 6:57 AM no census documented for day shift; 10:12 AM, no census documented on day shift. -9/12/24 at 10:01 AM, no census documented for day shift. 9/13/24 at 8:20 AM, no census documented for day shift. On 9/13/24 at 8:37 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated staff should document census each shift on the report.

DHS postings will be completed with all required components at the beginning of each shift. Prior Daily DHS staffing sheets have the potential to be affected. DON/Designee will complete baseline audit of DHS postings for the past 30 days to verify they were completed with all the required components. DON/Designee will provide education to licensed nurses regarding completion of the DHS postings with all required components at the beginning of every shift. NHA/Designee will conduct an ongoing audit of daily DHS staffing sheet to verify it is completed accurately and have census attached. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to obtain specialized physician appointments for 1 of 1 sampled resident (#62) reviewed for ADLs. This placed resident at risk for lack of specialized care. Findings include: A public complaint was received on 5/2/24 which alleged the facility failed to arrange the resident's nerve block procedure per physician orders. Resident 62 admitted to the facility in 6/2022 with diagnoses including chronic pain. A 1/13/23 physician order indicated the resident was to have a referral to neurology and cardiology for evaluation and a bilateral ultrasound guided glenohumeral injection (needle into the shoulder joint to deliver an injection). On 9/13/24 at 8:45 AM Staff 3 (Social Services) acknowledged the direction to schedule appointments was not addressed.

Resident #62 will have follow up for any referrals. Residents with physician order for referrals to specialists have the potential to be affected DON/Designee will conduct a baseline audit on current residents with physician order for referral to a speicalist to ensure no appointments/referrals were missed. Areas identified will be addressed DON/Designee will conduct education with UM team to ensure appointments are made for any resident that has physician order for a referral to a specialist. DON/Designee will review any new physician orders for referral to a specialist weekly to ensure that appointments are not missed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to obtain a resident's medication for 1 of 6 sampled residents (#164) reviewed for medications. This placed residents at risk for increased pain. Findings include: Resident 164 readmitted to the facility in 8/2024 with a diagnosis of post-surgical repair of leg fractures. A 9/2024 MAR revealed staff were to apply a fentanyl patch (narcotic pain medication) with a start date of 9/9/24. The MAR indicated the patch was not applied. On 9/11/24 at 8:39 AM Witness 11 (Pharmacy Technician) stated the pharmacy did not receive a valid prescription from the provider. On 9/9/24 the pharmacy requested a new prescription but did not yet receive it. On 9/11/24 at 8:44 AM Staff 31 (LPN) stated if a medication was not available from the pharmacy the CMA was to notify the nurse and the nurse would follow up with the pharmacy. On 9/11/24 at 8:49 AM with Staff 21 (LPN Staffing Coordinator) a fentanyl patch was observed in the automated medication dispensing system. Staff 21 stated if a resident did not have a medication, staff should see if the medication was available in the dispensing machine. If the medication was a narcotic staff would need to call the pharmacy to get permission to remove the medication. If staff had called the pharmacy on 9/9/24 to obtain authorization to remove the a fentanyl patch, they may have found out the pharmacy did not have a valid prescription. On 9/11/24 at 8:50 AM Staff 14 (LPN Resident Care Manager) stated she was not sure the reason staff did not follow up with the pharmacy on 9/9/24 when they did not have a fentanyl patch to administer to Resident 164.

Resident# 164 is no longer at the facility Residents in the facility have the potential to be affected. DON/Designee will conduct a baseline audit of current residents with physicians orders for pain medications to ensure prescribed pain medications are available. DON/Designee will provide further education to LN/CMAs related to the process for ordering medications and steps to take if medication is not available. DON/Designee will conduct an audit weekly that any new pain medications ordered have been received to verify the medication is available Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to monitor residents on psychotropic medications for 2 of 5 sampled residents (#s 87 and 164) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: 1. Resident 87 admitted to the facility in 3/2024 with diagnosis which included bipolar (mood swings) disorder. The 6/28/24 revised care plan indicated Resident 87 used psychotropic medications and to monitor effectiveness and side effects of the medications. The 8/2024 MAR indicated Resident 87 received duloxetine (antidepressant medication) daily as of 7/30/24 related to her/his bipolar depression. An 8/20/24 Psychotropic Medication Review indicated Resident 87's aripiprazole (antipsychotic medication) and quetiapine (antipsychotic medication) were reviewed and were ordered to address hallucinations, delusion and rejection of care. Duloxetine was also reviewed with no indication for the specific use of the medication. The 8/2024 Monitors indicated no monitor was in place for adverse reactions or behaviors related to Resident 87's antidepressant medication. On 9/8/24 at 10:38 AM Resident 87 stated she/he was depressed since she/he came to the facility. On 9/10/24 at 4:39 PM Staff 4 (Unit Manager-LPN) stated it was discussed with interdisciplinary team members the duloxetine was added to address Resident 87's continued depression and rejection of care. Staff 4 acknowledged the monitoring of side effects and behaviors related to Resident 87's duloxetine was not in place and improved documentation was needed to address the use of the resident's antidepressant. , 2. Resident 164 readmitted to the facility 8/2024 with a diagnosis of leg fractures. a. A 9/2024 MAR revealed staff were to administer Ativan (antianxiety) PRN. One dose was administered on 9/9/24. A care plan revised on 9/5/24 revealed Resident 164 was on hospice services. Staff were to administer medications as ordered. A care plan related to the use of an antianxiety medication was not developed. Resident 164's clinical record revealed no documentation to indicate non-pharmacological interventions were provided prior to the Ativan administration. On 9/11/24 at 8:02 AM and 2:55 PM Staff 14 (LPN Resident Care Manager) stated a care plan with non-pharmacological interventions was not developed for Resident 64's PRN Ativan. Staff 14 acknowledged there were no interventions documented prior to the 9/9/24 medication administration. On 9/11/24 at 2:49 PM Staff 31 (LPN) stated she was not sure how to document non-pharmacological interventions for PRN psychotropic medications. Normally the monitor alerted staff to monitor residents for adverse side affects of psychotropic medications. b. A 9/2024 MAR revealed staff were to administer Ativan and haloperidol PRN. One dose of Ativan was administered on 9/9/24 and haloperidol was not administered. A care plan revised on 9/5/24 revealed Resident 164 was on hospice services. Staff were to administer medications as ordered. A care plan related to the use of antianxiety and antipsychotic medications was not developed. Resident 164's clinical record revealed no documentation to indicate staff monitored Resident 164 for side affects of the antianxiety and antipathetic medications. On 9/11/24 at 2:55 PM Staff 14 (LPN Resident Care Manager) stated staff were to monitor for medication side affects on the MAR. Staff 14 stated a monitor for Resident 164's Ativan and haloperidol was not developed.

Resident #87 will have behavior monitoring and adverse side effect monitoring for psychotropic medication use. Will complete updated PHQ9 assessment as states they are depressed. Resident #164 is no longer at the facility DON or designee will complete baseline audit of resident who have physician orders for psychotropic medications to ensure there is behavior monitoring in place and adverse side effects monitor is in place. DON or designee will provide education to staff regarding completing monitoring for adverse side effects of psychotropic medication use. Education will also include completing monitors for presence of behaviors . DON/Designee will complete ongoing audit of newly admitted residents with orders for psychotropic medications or that have new orders for psychotropic medication to verify indication for use, behavior monitoring in place, adverse side effects monitor is in place and that care plan is in place and includes resident centered non-pharmacological interventions. Audits will be conducted by DON or designee weekly for 4 weeks, then monthly for two months. Audit trends will be reported to QAPI for 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to prevent a significant medication error for 1 of 6 sampled resident's (#41) reviewed for unnecessary medications. This placed residents at risk for adverse medication reactions. Findings include: On 6/25/24 the Past Noncompliance was corrected when the facility identified the cause of the incident and determined vital signs were not obtained by a CMA prior to medication administration resulting in a drop in blood pressure. The plan of correction included: -6/28/24 nurse and CMA education was provided related to the 10 rights of medication administration. -7/3/24 an audit was initiated for residents with blood pressure parameters. -7/3/24 the facility reported Staff 20 to the Oregon State board of Nursing. 7/3/24 education was initiated to all nurses and CMAsregarding standards and scope of practice related to their licensure and obtaining vital signs prior to medication administration. Resident 41 admitted to the facility in 8/2023 with a diagnosis of paraplegia (inability to move legs). A 6/2024 MAR revealed Resident 41 was to be administered Baclofen (muscle relaxant) three times a day and the medication was to be held if her/his systolic blood pressure (top number) was less than 100. On 6/25/24 at 3:00 PM Resident 41's BP was documented to be 100/68 and the medication was documented as administered. An investigation initiated on 6/25/24 revealed Resident 41 was administered a muscle relaxant which was to be held if her/his systolic blood pressure was less than 100. Staff 20 documented the blood pressure to be 100/68 for the 3:00 PM dose and the medication was documented as given. Staff 19 (LPN) was notified by a CNA Resident 41's blood pressure was 89/65. When Staff 19 questioned Staff 20 if she took Resident 41's blood pressure Staff 20 stated she looked at the morning blood pressure and "guessed" what the blood pressure would be at 3:00 PM. On 9/9/24 at 3:21 PM Staff 19 stated Resident 41 had chronic low blood pressure. Staff 19 stated a CNA took Resident 41's blood pressure at approximately 3:00 PM and her/his blood pressure was low and a "huge" drop from the morning blood pressure. On 9/12/24 at 3:38 PM Staff 20 acknowledged she did not obtain Resident 41's blood pressure at 3:00 PM and just "made up" a blood pressure to enter into the MAR.

Based on observation, interview and record review it was determined the facility failed to serve foods at appropriate temperatures and store and serve foods in a sanitary manner for 1 of 5 sampled residents (#162) reviewed for foods, 1 of 1 kitchen and 1 of 2 unit refrigerators observed. This placed residents at risk for foodborne illnesses. Findings include: 1. Resident 162 admitted to the facility in 4/2024 with a diagnosis of heart disease. An 4/15/24 Progress Note indicated Resident 162 called the police to report concerns including she/he was served moldy food. An 4/16/24 five day MDS assessment revealed Resident 162 was cognitively intact. On 9/9/24 at 3:45 PM Staff 23 (Former Administrator) stated Resident 162 called the police because she/he alleged the facility served moldy food. Staff 23 stated the facility immediately threw out all the perishable snacks and investigated the incident. Staff 23 did not recall if they verified if the food was moldy. On 9/10/24 at 6:09 PM Staff 30 (LPN) stated she worked when Resident 162 called the police related to moldy food. Staff 30 stated she did not see the food but saw photos of the food. The photo was obviously taken in the facility dining room. The sandwich had green mold on it and the fruit cup had white bumps on it. The bumps which she saw were the bumps that form before food became moldy. , 2. A 9/10/24 Dietary Forms Service Line Temperature Log indicated chicken temperature was recorded at 139 degrees. A 9/11/24 Dietary Forms Service Line Temperature Log indicated poultry temperature was recorded at 151 degrees and the meatloaf was 155 degrees. On 9/11/24 at 3:11 PM recorded temperatures were reviewed with Staff 40 (Dietary Manager). Staff 40 indicated the chicken, poultry and meatloaf temperatures were holding temperatures but did not indicate the temperatures were verified for potentially hazardous food. She stated she did not have a system in place to verify the final cooking temperatures were met. , 3. A 9/8/24 at 9:37 AM interview with Staff 7 (CNA) revealed she reported the ICF unit refrigerator was in unsanitary condition, and the sandwiches had no label for expiration date. Staff 7 reported she did not use the food in the unit refrigerator as she was concerned it was expired and unsafe for consumption. On 9/8/24 at 9:46 AM observation of the unit refrigerator revealed eight sandwiches without date labels and one food-soiled and broken refrigerator shelf (previously taped together). An unsanitary sticky wooden corner shelf was food-soiled and holding peanut butter, syrup, bananas and crackers. The floor surrounding the refrigerator was soiled and sticky. An expired orange and a soiled washcloth sat on top of the refrigerator. On 9/13/24 at 9:18 AM observation of the unit refrigerator revealed no change from initial observation five days earlier except for addition of date labels on sandwiches. A 9/13/24 at 9:34 AM interview with Staff 60 (Infection Prevention Nurse) confirmed the wooden shelf was uncleanable and soiled with sticky food. He stated the shelf was uncleanable and unsanitary and he would replace it with a cleanable surface shelf. Staff 60 also confirmed the unsanitary condition of the refrigerator, surrounding floor, broken refrigerator shelf, expired orange, and soiled washcloth on top of the refrigerator.

Resident #162 is no longer at facility Spoiled, expired, and moldy food will be removed from resident refrigerators. Dietary Service Line Temperature will be updated Resident refrigerators will be cleaned Wooden shelf will be removed Current Residents can be affected The NHA/Designee will complete a baseline audit of the resident fridges to verify cleanliness, all food is labeled, all surfaces are cleanable and that there is no spoiled, expired or moldy food present. The NHA/Designee will provide further education to dietary staff related to dietary service line temperatures, cleanliness of resident fridges, and safe food storage The NHA/Designee will complete a weekly audit to verify the dietary service line temperatures are accurate, resident refrigerators are clean, and there is no spoiled, expired food present. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure residents understood the meaning of an arbitration agreement (disputes resolved with a neutral party and not in court) for 3 of 3 sampled residents (#s 19, 163 and 262) reviewed for arbitration. This placed residents at risk for being uninformed of their legal rights. Findings include: 1. Resident 19 admitted to the facility in 8/2024 with diagnoses including a fracture of the left femur and chronic kidney disease. Review of an 8/7/24 Medicare 5-Day MDS indicated Resident 19 was cognitively intact. Review of a Patient and Facility Arbitration Agreement revealed Resident 19 signed the document on 8/29/24. On 9/11/24 at 10:16 AM Resident 19 stated she/he knew what arbitration meant but did not remember signing an agreement at this facility. On 9/12/24 at 4:37 PM Staff 59 (Admissions Coordinator) stated she told all new admissions they had the right to decline or agree and had 30 days to change their mind. She stated she explained the definition and process of arbitration and offered a copy to all admissions. She stated she gave all admissions her business card and told them to contact her with any questions. 2. Resident 163 admitted to the facility in 8/2024 with diagnoses including kidney failure and respiratory failure. Review of a 9/1/24 Medicare 5-Day MDS indicated Resident 163 was cognitively intact. Review of a Patient and Facility Arbitration Agreement revealed Resident 163 signed the document on 8/28/24. On 9/11/24 at 5:02 PM Resident 163 stated she/he remembered signing the arbitration agreement. Resident 163's spouse stated she/he had further questions about the agreement, and she/he was given a copy of the signed agreement but did not get an explanation about the process as requested. Resident 163's spouse stated she/he still did not know exactly what arbitration meant and was under the impression the facility would not take care of Resident 163 unless the agreement was signed. On 9/12/24 at 4:37 PM Staff 59 (Admissions Coordinator) stated she told all new admissions they had the right to decline or agree and had 30 days to change their mind. She stated she explained the definition and process of arbitration and offered a copy to all admissions. She stated she gave all admissions her business card and told them to contact her with any questions. 3. Resident 262 admitted to the facility in 8/2024 with diagnoses including respiratory failure and gout. Review of an 8/26/24 Medicare 5-Day MDS indicated Resident 262 was cognitively intact. Review of a Patient and Facility Arbitration Agreement revealed Resident 262 signed the document on 8/23/24. On 9/11/24 at 5:12 PM Resident 262 stated she/he did not remember signing an arbitration agreement and arbitration was not explained to them at admission. She/He stated, "when you're not feeling well and people tell you to sign a bunch of papers, you just get it done." On 9/12/24 at 4:37 PM Staff 59 (Admissions Coordinator) stated she told all new admissions they had the right to decline or agree and had 30 days to change their mind. She stated she explained the definition and process of arbitration and offered a copy to all admissions. She stated she gave all admissions her business card and told them to contact her with any questions.

Resident #19 no longer at the facility Resident #163 no longer at the facility Resident #262- Will have arbitration agreement re-explained for understanding All residents that entered an arbitration agreement can be affected NHA/Designee will complete a baseline audit of all residents that have entered an arbitration agreement in the last 30 days to ensure they fully understand the process. NHA/Designee will conduct further education to admission director in regards to arbitration agreements and ensuring residents understand what they are signing. NHA/Designee will conduct a weekly audit of 5 residents who recently signed an arbitration agreement to ensure they understand the agreement. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to ensure appropriate use of PPE and failed to follow infection control standards for 2 of 2 units and 1 of 1 laundry room reviewed for infection control. The facility additionally failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident uses for 1 of 1 sampled resident (#20) reviewed during CBG checks. This placed residents at risk for the spread of infection and placed all residents who required CBG checks at risk for bloodborne illness. Findings include: 1. On 9/9/24 at 3:28 AM Staff 38 (LPN) was observed sitting on a stool across the hall from the nurses' station on the long-term side of the facility with no mask on. Staff 30 (LPN) was observed sitting at the nurses' station with no mask on. At 3:56 AM Staff 38 was observed coming out of an empty resident room with no mask on. Staff 38 stated COVID-19 caused some staffing issues, but CNA staff could still complete their work. On 9/13/24 at 11:14 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) confirmed staff should wear masks while there was COVID-19 active in the facility. 2. On 9/10/24 at 8:49 AM the breakfast cart was observed coming onto the skilled unit. One tray was observed to have no cover on the plate and the food was exposed. At 8:54 AM Staff 67 (CNA) removed the tray from the cart. Staff 67 stated trays came out of the kitchen without covers on the plates. Staff 67 then delivered the tray to room 112. On 9/10/24 at 9:00 AM Staff 60 (RN Infection Preventionist) stated the tray of food should have a cover when going down the hallway. If there was no lid the tray should not be delivered to the resident. , 3. Ongoing observations conducted on 9/8/24 through 9/12/24 between the hours of 3:00 AM and 6:30 PM revealed the following: - Multiple staff members with N95 masks worn improperly or not being worn while in resident care areas and while in COVID-19 positive rooms. - Personal Protective Equipment storage bins outside the rooms of COVID-19 positive residents were missing supplies from each bin. - Multiple staff not wearing proper eye protection while in COVID-19 positive rooms. On 9/12/24 at 4:44 PM Staff 60 (RN Infection Preventionist) stated the facility's current COVID-19 outbreak started on 8/9/24 and was present on both resident care units. He stated the expectation of all staff was to adhere to the Centers for Disease Control infection control guidelines including wearing eye protection when entering rooms that require eye protection and wearing a properly fitted N95 in the correct manner. He acknowledged staff were not always following these protocols when on the units. 4. During an infection control audit of the laundry area on 9/11/24 at 12:50 PM the following was observed: - A wall mounted fan blowing from the dirty to the clean side of the laundry room with visible dirt caked on front grill and all fan blades. - The dirty linen room had no air circulation. - Wet towels around the base of one washing machine with water visibly leaking from a pipe going down the side of the washing machine. - One dryer with a broken heating element. - One washing machine with a broken door requiring the use of a wrench to loosen bolts to get the door open and to seal the door shut. On 9/11/24 at 4:24 PM Staff 54 (Account Manager) stated the broken washing machine was fixed multiple times without permanent resolution of the leaking water and broken door issues. She stated towels were placed around the base of the washing machine to keep the floor dry and staff safe from slipping. She stated the broken heating element for the dryer was fixed multiple times without permanent resolution, and staff used it for non-heat drying only. On 9/12/24 at 12:25 PM Staff 28 (Corporate Maintenance) stated the broken washer replacement parts were on order and that he adjusted the machine every few days to keep it operational. On 9/13/24 at 2:36 PM Staff 54 acknowledged the fan in the laundry room was broken and covered in dirt. She also stated there was very little air flow in the laundry area unless a breeze came through the open windows. 5. Resident 20 admitted to the facility in 2024 with diagnoses including diabetes and infection following a procedure. Review of an 8/23/24 Medicare 5-Day MDS indicated Resident 20 was cognitively intact. On 9/12/24 at 5:42 PM Staff 57 (CNA/Student Nurse) was observed using a CBG glucometer to check Resident 20's blood sugar level. Upon completion of the test, Staff 57 removed the test strip and put the CBG glucometer back into the medication cart drawer without sanitizing the device. On 9/12/24 at 5:45 PM Staff 33 (LPN) confirmed the proper infection control process was not followed by Staff 57 while using the CBG glucometer.

Current residents have the potential to be at risk. IP/Designee will complete observations to ensure licensed nurses are following infection control practices and are cleaning glucometers before and after use. DON/Designee will observe meal service to ensure resident food is covered when served. Fan will be adjusted in laundry room to not blow from dirty to clean, and fan will be cleaned Dirty linen room will have circulation. Dryer element will be obtained and installed. Washing machine will be serviced to try to prevent a leakage. NHA/Designee will provide further education to laundry manager regarding fan maintenance and placement and reporting washing machine leaks and scheduling follow up service weekly DON/Designee will provide further education to staff on appropriate PPE use and glucometer cleaning. IP/Designee will audit 5 PPE use opportunities and 5 glucometer cleanings weekly. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained on 71 of 279 shifts reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of a 4/4/24 Intake Information revealed a public complaint was received by the State Agency indicating the facility stopped using agency staff and there was a shortage of staff on 4/2/24 and 4/3/24. A review of Direct Care Staff Daily Reports from 4/1/24 through 4/30/24, 7/1/24 through 7/31/24, 8/8/24 through 8/31/24 and 9/1/24 through 9/8/24 revealed the facility did not have sufficient CNA staff to meet the minimum CNA staffing requirements for 71 of 279 shifts on the following days: 4/2024: -4/1/24, 4/2/24, 4/4/24, 4/17/24, 4/18/24, 4/20/24, and 4/23/24 evening shift -4/3/24, 4/5/24, 4/6/24, 4/7/24, and 4/19/24 evening and night shift -4/8/24, 4/13/24, 4/14/24, 4/21/24, and 4/22/24 day and evening shift -4/9/24 and 4/28/24 day shift -4/10/24 and 4/27/24 night shift 7/2024: -7/1/24, 7/7/24, 7/24/24, 7/29/24 and 7/31/24 day shift -7/26/24 and 7/28/24 day and evening shift -7/27/24 day and night shift 8/2024: -8/9/24, 8/10/24, 8/18/24, 8/19/24, and 8/20/24 day shift -8/11/24, 8/23/24, 8/25/24, 8/26/24, 8/27/24, and 8/29/24 day and evening shift -8/12/24, 8/22/24, and 8/30/24 evening shift -8/13/24 night shift -8/24/24 day and night shift 9/2024: -9/1/24 day shift -9/3/24 evening shift -9/6/24 and 9/7/24 evening and night shift On 9/13/24 at 8:37 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 56 (Regional Nurse) stated the facility had a norovirus (causes severe vomiting and diarrhea) outbreak in 4/2024, had COVID-19 active in the facility in 7/2024, 8/2024 and 9/2024, and confirmed there was staffing issues.

Facility will have sufficient CNA staff according to established minimum ratios. DON or designee will complete baseline audit of CNA staffing ratios for the past 30 days to ensure there is sufficient nursing staff to meet resident needs. Sufficient nursing staff will be available to meet resident needs. Audits will be conducted by DON or designee weekly for 4 weeks, then monthly for two months. Audit trends will be reported to facility QAPI for 3 months for review and further recommendations.

******************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F552, F565 and F585 ******************************** OAR 411-086-0260 Pharmaceutical Services Refer to F554 and F755 ******************************** OAR 411-086-0040 Admisson of Residents Refer to F578 ******************************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 ******************************** OAR 411-087-0100 Physical Environment: Generally Refer to F584 ******************************** OAR 411-085-0360 Abuse Refer to F600, F609 and F610 ******************************** OAR 411-088-0080 Notice Requirements Refer to F623 ******************************** OAR 411-088-0050 Right to Return from Hospital Refer to F625 ******************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ******************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658, F677, F685, F695, F697, F698 and F760 ******************************** OAR 411-086-0230 Activity Services Refer to F679 and F680 ******************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686, F689, F690 and F758 ******************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725, F727 and F732 ******************************** OAR 411-086-0240 Social Services Refer to F745 ******************************** OAR 411-086-0250 Dietary Services Refer to F812 ******************************** OAR 411-086-0110 Administrator Refer to F847 ******************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880

Based on interview and record review it was determined the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week for 3 of 39 days reviewed for RN staffing coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include: A review of the Direct Care Staff Daily Reports from 1/14/24 through 2/25/24 revealed the following days with no RN coverage for eight consecutive hours: -2/10/24 -2/11/24 -2/18/24 On 2/28/24 at 9:51 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility lacked RN coverage on the identified dates. No additional information was provided.

All residents have the potential to be at risk. Green Valley Nursing and Rehabilitation continues to advertise and recruit additional RNs. DON/Designee will complete a baseline audit for the last 14 days to verify an RN was scheduled daily for at least 8 consecutive hours between the start of day shift and the end of evening shift. DON/Designee will provide further education to nurse managers and the Staffing Coordinator related to requirements for scheduling an RN daily for at least 8 consecutive hours between the start of day shift and the end of evening shift. DON/Designee will complete weekly audits on five random shifts to verify an RN was scheduled daily for at least 8 consecutive hours between the start of day shift and the end of evening shift. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily reports were accurate for 20 of 39 days reviewed for staffing. This placed residents at risk for inaccurate staffing information. Findings include: A review of Direct Care Staff Daily Reports and nursing staff time sheets from 1/14/24 through 2/25/24 revealed the Direct Care Staff Daily Reports were inaccurate for the number of staff on duty and the hours staff worked for the following dates: - 1/18/24 through 1/19/24 - 1/23/24 through 1/25/24 - 1/27/24 - 2/2/24 through 2/7/24 - 2/9/24 - 2/10/24 - 2/12/24 through 2/17/25 - 2/19/24 On 2/29/24 at 12:24 PM Staff 1 (Adminstrator) indicated via email the Direct Care Staff Daily Reports were inaccurate.

All residents have the potential to be at risk. DON/Designee will complete a baseline audit for the last 14 days to validate the Daily Nursing Staff Posting was accurately completed. DON/Designee will provide further education to staff related to completing the Daily Nursing Staff Posting at the start of each shift and updating the posting as necessary to ensure accuracy. DON/Designee will audit the Daily Nurse Staffing Posting weekly for completion and to validate accuracy. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure a Registered Nurse served as charge nurse for eight consecutive hours between day and evening shift for 10 of 39 days reviewed for staffing. This placed residents at risk for unassessed and unmet needs. Findings include: The Direct Care Staff Daily Reports from 1/14/24 through 2/25/24 revealed no Registered Nurse working between day and evening shift for the following dates: - 1/23/24 - 1/24/24 - 1/25/24 - 2/11/24 - 2/18/24 - 2/20/24 - 2/21/24 - 2/22/24 - 2/23/24 - 2/24/24 On 2/28/24 at 9:51 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility was short RN coverage for the identified dates. No additional information was provided.

All residents have the potential to be at risk. Green Valley Nursing and Rehabilitation continues to advertise and recruit additional RNs. The Administrator will request an RN waiver. DON/Designee will complete a baseline audit for the last 14 days to verify an RN was scheduled daily for at least 8 consecutive hours between the start of day shift and the end of evening shift. DON/Designee will provide further education to nurse managers and the Staffing Coordinator related to the requirements for scheduling an RN daily for at least 8 consecutive hours between the start of day shift and the end of evening shift. DON/Designee will complete weekly audits to verify an RN was scheduled daily for at least 8 consecutive hours between the start of day shift and the end of evening shift. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 6 of 39 days reviewed for minimum CNA staffing. This placed residents at risk for delayed care. Findings include: A review of the facility Direct Care Staff Daily Reports for 1/14/24 through 2/25/24 revealed the facility had insufficient CNA staff for one or more shifts to meet the state minimum staffing requirement on the following dates: - 1/14/24 - 1/15/24 - 1/16/24 - 1/17/24 - 1/22/24 - 2/8/24 On 2/28/24 at 9:51 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility was short staffed for the identified dates. No further information was provided.

All residents have the potential to be at risk. Green Valley Nursing and Rehabilitation has CNA classes on site and provides clinical rotations to an offsite CNA class. Green Valley Nursing and Rehabilitation continues to advertise and recruit additional CNAs. DON/Designee will complete a baseline audit for the last 14 days to verify compliance with minimum CNA staffing. DON/Designee will provide further education to staff related to the requirements for minimum CNA staffing. DON/Designee will complete weekly audits to verify compliance with minimum CNA staffing. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

************************************ OAR 411-086-0100 Nursing Services: Staffing Refer to F727 and F732 ************************************

Based on interview and record review it was determined the facility failed to ensure residents were provided bathing for 3 of 6 sampled residents (#s 1, 4 and 9) reviewed for ADLs. This placed residents at risk for a decline in hygiene. Findings include: 1. Resident 1 was admitted to the facility in 2023 with diagnoses including cancer. An 10/2013 bathing record revealed Resident 1 was to receive bathing on Mondays and Fridays. Resident 1 received three of six showers. On 11/14/23 at 2:54 PM a request was made to Staff 2 (DNS) to provide documentation to indicate Resident 1 received two showers a week. No additional information was provided. 2. Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes. A 6/21/23 Annual MDS and CAAs revealed the resident was weak and and was dependent or required extensive assistance with most ADLs. An 10/2023 and 11/2023 bathing report revealed the resident received four of ten showers and the resident refused two showers. The resident was not documented to have a shower for 27 days. An 10/26/23 BIMS Evaluation (cognitive exam) indicated Resident 4 was cognitively intact. On 11/14/23 at 9:59 AM Resident 4 stated if she/he did not want to take a shower, the staff did not always return to provide her/him a bed bath. On 11/14/23 at 11:15 AM Staff 3 (LPN Resident Care Manager) acknowledged Resident 4 frequently refused bathing and there was no indication staff provided a bed bath resulting in multiple missed showers or baths. 3. Resident 9 was admitted to the facility in 2023 with diagnoses including knee surgery. An 10/10/23 Admission MDS and CAAs revealed Resident 9 was cognitively intact and required assistance with all cares. Bathing records revealed the following: -9/2023 two opportunities for bathing and none were provided. -10/2023 eight opportunities for bathing and three were provided. -11/2023 three opportunities for bathing and one was provided. On 11/8/23 at 11:55 AM Resident 9 stated she/he was in the facility for three weeks and did not receive very much assistance with bathing and she was "really stinky." On 11/14/2023 at 3:13 PM Staff 2 (DNS) acknowledged there was limited documentation on bathing provided for Resident 9. A request was made for documentation to indicate Resident 9 was offered bathing at least two days a week. Only one additional day was provided for the month of October to indicate the resident received three and not two baths.

The submission of this plan of correction does not constitute an admission by the facility of any fact or conclusion set forth in the statement of deficiencies. This plan of correction is being submitted because it is required by law. F677: ADL Care Provided for Dependent Residents Residents 1 and 9 no longer reside at the facility Resident 4 has been offered showers twice weekly as per her preference. DON/Designee will complete baseline audit of current residents to verify they have been offered bathing opportunities per their preference over the last 7 days DON/Designee will complete education with CNAs regarding offering bathing per resident schedule, and alternative bathing option if showers are refused. Education will include accurate documentation. Don/Designee will conduct an ongoing audit of 10 residents weekly to verify bathing opportunities being offered per resident preferences Audits will be completed weekly x 4 weeks, then monthly x 3. Findings will be reported to QAPI Committee x 3 months or until a lesser frequency is deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure a resident's medication was administered as prescribed for 1 of 3 sampled residents (#4) reviewed for incontinent care and failed to ensure call lights were answered timely to address bowel care needs for 1 of 10 sampled (#2) residents reviewed for call lights. This placed residents at risk for ineffective medication regimen and unmet needs. Findings include: 1. Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes. A 9/2023 and 10/2023 TAR revealed the resident was to be administered clotrimazole cream (antifungal) for five days from 9/27/23 through 10/1/23. The cream was not available on 9/27/23 and 9/28/23. The cream was subsequently only administered for three days. On 11/14/23 at 11:15 AM Staff 3 (LPN Resident Care Manager) acknowledged the cream was not administered as prescribed. 2. Resident 2 was admitted to the facility in 2023 with diagnoses including paralysis. A 9/21/23 Grievance Form revealed Resident 2 reported concerns including long call light response times. Staff met with the resident and addressed her/his concerns. On 9/26/23 Resident 2 reported there was "some" improvement. An 10/13/23 MDS and CAAs revealed Resident 2 was alert and oriented. Resident 2 struggled to live in the facility because she/he did not cope well with waiting for her/his call light to be answered. On 11/14/23 at 11:39 AM Staff 32 (LPN Resident Care Manager) stated the resident reported concerns of waiting up to 45 minutes for her/his call light to be responded to. On 11/14/23 at 2:15 PM Resident 2 stated in 9/2023 she/he was more dependent and had a colostomy (surgical incision in the abdomen for bowel movements), at times it took staff over 30 minutes to answer her/his call light and the colostomy bag would leak. Resident 2 stated she/he reported the concerns to administration and the issue improved but did not resolve.

F684: Quality of Care Resident 4 fungal infection has resolved. Resident 2 has expressed that wait times are no longer an issue. DON/Designee will complete baseline audit of current residents who had medications ordered with specific duration ending in the last 7 days to verify they were administered for the full duration prescribed. Identified inaccuracies will be addressed. DON/Designee to complete baseline interview of current residents to verify resident needs are being met in a timely manner. DON/designee will provide education to medical records department and LNs regarding processing of orders to ensure correct duration of medication is administered. DON/designee will provide education to staff regarding answering call lights timely. DON/Designee will conduct weekly audits of 5 resident MARs with orders for medications with specific durations to verify medications were administered for the duration ordered. DON/Designee will interview 10 residents weekly to verify needs are being met in a timely manner. Audits will be completed weekly x 4 weeks, then monthly x 3. Findings will be reported to QAPI Committee x 3 months or until a lesser frequency is deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure resident oxygen flow rates were documented for 2 of 4 sampled residents (#s 1 and 10) reviewed for respiratory therapy. This placed residents at risk for lack of documented oxygen needs. Findings include: 1. Resident 1 was admitted to the facility in 2023 with diagnoses including cancer. An 10/16/23 physician order revealed the resident was to be administered one to four liters of oxygen to keep her/his saturation levels greater than 90% and staff were to document the oxygen levels and the liters provided. The order also indicated the oxygen was to be used to maintain an oxygen saturation of 92% or greater. Progress Notes from 10/16/23 through 11/1/23 revealed the following: -10/16/23 oxygen saturation was 92%, the resident wore oxygen but staff did not document how much oxygen was required. -10/20/23 oxygen saturation was 94%, the resident wore oxygen but staff did not document how much oxygen was required. -10/21/23 oxygen saturation was 97%, the resident wore oxygen but staff did not document how much oxygen was required. -10/29/23 oxygen saturation was 93%, the resident wore oxygen but staff did not document how much oxygen was required. -10/30/23 oxygen saturation was 94%, the resident wore oxygen but staff did not document how much oxygen was required. On 11/14/23 at 2:54 PM Staff 2 (DNS) acknowledged staff were to document the amount of oxygen required to maintain Resident 1's oxygen level at prescribed levels on the above dates. No additional information was provided. 2. Resident 10 was admitted to the facility in 2023 with diagnoses including liver disease. 10/27/23 physician orders revealed Resident 10 was to wear oxygen at one to four liters to keep her/his oxygen saturation levels greater than 94 percent. Staff were directed to document the saturation levels and liters of oxygen required. Resident 10's Progress Notes revealed the following: -10/27/23 oxygen saturation was 92%, no oxygen was documented as administered or refused -10/28/23 oxygen saturation was at 94%, no oxygen was documented as administered or refused -10/29/23 oxygen saturation was at 94%, no oxygen was documented as administered or refused -10/30/23 oxygen saturation was 93%, no oxygen was documented as administered or refused -11/2/23 oxygen saturation was 90%, no oxygen was documented as administered or refused -11/3/23 oxygen saturation was at 94%, no oxygen was documented as administered or refused -11/4/23 oxygen saturation was 92%, no oxygen was documented as administered or refused -11/5/23 oxygen saturation was 90%, no oxygen was documented as administered or refused -11/6/23 oxygen saturation was at 94%, no oxygen was documented as administered or refused -11/9/23 oxygen saturation was at 94%, no oxygen was documented as administered or refused On 11/14/23 at 3:29 PM Staff 2 acknowledged the resident's orders were to maintain oxygen saturation levels greater than 94%. A request was made to Staff 2 to provide documentation the resident was provided or refused oxygen to maintain a saturation greater than 94%. No additional information was provided.

F695: Respiratory/Trach Care and Suctioning Residents 1 and 10 no longer reside at the facility Don/Designee will conduct a baseline audit for all residents with orders to titrate oxygen. DON/Designee will complete further education to medical records department and LNs related to proper order entry to include supplemental documentation so that oxygen liters per minute is recorded every shift. DON/Designee will conduct weekly audits on 5 residents with orders to titrate oxygen to verify liters per minute is documented every shift. Audits will be completed weekly x 4 weeks, then monthly x 3. Findings will be reported to QAPI Committee x 3 months or until a lesser frequency is deemed appropriate.

Based on interview and record review it was determined the facility failed to follow physician orders regarding a narcotic pain medication resulting in an excessive dose for 1 of 3 sampled residents (#12) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 12 was admitted to the facility in 7/2023 with diagnoses including heart disease. Review of a physician's order dated 7/18/23 revealed the resident was to receive liquid hydromorphone (narcotic pain medication) 1.5ml (20mg/ml) by mouth every hour for pain. In a written statement on 9/20/23 at 10 AM Staff 13 (LPN) indicated Staff 14 (CMA) realized she had administered too much hydromorphone to Resident 12 and did not confirm the dose prior to administration. Review of a progress note dated 9/20/23 at 3:21 PM revealed Resident 12 was administered 15 ml of hydromorphone instead of 1.5 ml. The note indicated Hospice was notified and told the facility to monitor the resident every 30 minutes for two hours and then once every hour. The note indicated the resident was awake and alert. Review of an ER note dated 9/20/23 revealed Resident 12 was monitored for four hours and had no complications. Review of a Nursing Facility Reported Incident (FRI) form dated 9/21/23 at 5:15 PM revealed a medication error was identified on 9/20/23 regarding Resident 12 was administered 15 mls of hydromorphone instead of 1.5 ml. The form indicated the resident was treated with Narcan (opiod reversal agent), monitored and sent to the ED for evaluation. Hospice and the resident's physician were notified and the resident returned to the facility a few hours later with no injuries. Review of a written statement on 9/25/23 at 10:15 AM Resident 12 indicated administration of the Narcan caused a few minutes of pain but her/his pain was managed. Resident 12 also indicated she/he knew the dose administered was not correct and should have told Staff 14. Review of an incident investigation dated 9/26/23 revealed Resident 12 had received the wrong dose of hydromorphone because Staff 14 had misread the MAR and did not verify the dose prior to administration. The investigation ruled out harm and intentional mistreatment. In an interview on 11/15/23 at 9:51 AM Staff 14 indicated on 9/20/23 a medication error occurred with Resident 12. Staff 14 said she administered to much pain medication to Resident 12 because she misread the dose on the MAR.

F757 Drug Regimen is Free From Unnecessary Drugs Resident 12 no longer resides at the facility. DON/Designee will conduct a baseline audit completed for last 30 days of medication errors, 8/22/23 through 9/22/23 to determine any trends. DON/designee will re-educate LN and Med Techs regarding steps for completing a med pass, including the 6 rights of medication administration. DON/designee will conduct a medication observation with each LN/CMA. DON/Designee will re-educate LNs/CMAs on orientation process. DON/Designee will complete education to newly hired LNs/CMAs on the 6 rights of medication administration and complete medication observation prior to being on their own on the floor. DON/designee will perform medication pass observation on 10% of LN/Med Techs who pass medications weekly x 4 weeks, then monthly x 3 months. DON/Designee will complete audits on new hires to validate education on the 6 rights of medication administration and a medication observation was completed prior to the new hire being on their own. Audits will be completed weekly x 4 weeks, then monthly x 3 months. Findings will be reported to QAPI monthly x 3 months or until a lesser frequency is deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure lab results were reviewed by a physician in a timely manner for 1 of 3 sampled residents (#8) reviewed for UTI. This placed residents at risk for delayed treatment. Findings include: Resident 8 was admitted to the facility in 2023 with diagnoses including heart disease. Progress Notes revealed on 10/4/23 Resident 8's Physician Assistant assessed the resident for reports of "tea" colored urine. Orders were provided to obtain and urine sample and culture if indicated. An 10/2023 TAR revealed staff were to obtain a urine sample to rule out a UTI and the lab was to be notified when the sample was obtained. An 10/9/23 Lab Results Report revealed Resident 8 had a UTI, the urine was cultured and the reported date of the results was 10/9/23. The results included the antibiotics which would be effective against the organism found in the resident's urine. The report indicated the results were faxed on 10/9/23. A Progress Note dated 10/11/23 revealed the resident's Physician Assistant reviewed the urine culture results and started the resident on an antibiotic. This was two days after the lab results were available. An 10/2023 MAR revealed Resident 8 was started on an antibiotic for the UTI on 10/11/23. On 11/27/23 at 7:56 PM Staff 2 (DNS) acknowledged the UA final results were available to review on 10/9/23 and the physician did not review the results until 10/11/23 resulting in a delay in treatment.

F773 Lab Services Physician Order/Notify of Results Res 8 Antibiotic course has been completed and infection has resolved. DON/Designee will conduct baseline audit of current residents who had labs ordered in the last 14 days to verify results were reviewed by a provider. DON/Designee will provide education to LNs to notify provider of any abnormal lab results in a timely manner. DON/Designee will conduct weekly audit on all new lab orders to verify provider was notified of any abnormal results in a timely manner. Audits will be completed weekly x 4 weeks, then monthly x 3. Findings will be reported to QAPI Committee x 3 months or until a lesser frequency is deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure a call light was accessible for 1 of 3 sampled residents (#3) reviewed for call lights. This placed residents at risk for incontinence. Findings include: Resident 3 was admitted to the facility in 2021 with diagnoses including a stroke. A 5/5/23 Quarterly MDS indicated Resident 3 was cognitively intact. A 5/15/23 Bowel and Bladder Screener assessment indicated Resident 3 was at times incontinent of bowel and bladder. A 6/2023 bowel record indicated the resident was incontinent on 6/26/23 night shift. On 6/28/23 Witness 3 (Complainant) stated Resident 3 reported on 6/26/23 at 3:00 AM she/he did not have a call light accessible, had to call out for help, staff did not come timely and was subsequently incontinent. On 11/15/2023 12:18 PM Staff 10 (CNA) stated Resident 3 was able to use the call light and if the resident did not have a call light was able to call out verbally for assistance. Staff 10 indicated on 6/26/23 she was not assigned to care for Resident 3. At some point during the night shift she heard a resident calling out for help, it took a few minutes to figure out who called for help and then identified Resident 3 called for help. Resident 3 did not have her/his call light. It was not within reach and staff did not know how it became out of the resident's reach. On 11/15/2023 12:35 PM Staff 11 (CNA) stated she recalled when Resident 3 did not have access to the call light and yelled out for help. Staff 11 stated it took approximately 10 minutes to locate who was yelling. Staff 3 stated the resident was incontinent, but this was not unusual for the resident on the night shift.

F919: Resident Call System Resident 3 no longer resides at the facility. DON/Designee baseline audit to be conducted to observe all current residents to verify call lights are in reach. DON/designee to educate staff to ensure residents call light is within reach before leaving a residents room. DON/Designee will conduct weekly observations of 10 residents to verify call light within reach. Audits will be completed weekly x 4 weeks, then monthly x 3. Findings will be reported to QAPI Committee x 3 months or until a lesser frequency is deemed appropriate.

*************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, Refer to F684 and F695 *************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F757 *************** OAR 411-086-0130 411 Nursing Services: Notification Refer to F773 *************** OAR 411-087-0440 Electrical Systems: Alarm and Nurse Call Systems Refer to F919 ***************

Based on observation, interview and record review it was determined the facility failed to provide a homelike dining experience for 1 of 3 dining rooms (main) reviewed for dining, and failed to speak to residents respectfully for 1 of 1 sampled resident (#15) reviewed for dignity. This placed residents at risk for an unhomelike environment and mental anguish. Findings include: 1. On 5/15/23 at 12:33 PM the main dining room center table had five residents at the table for lunch. One resident was served their meal, but then other tables in the dining room were served before the rest of the residents at the center table were served. The last resident at the center table was not served their meal until 12:53 PM, 20 minutes after the first resident was served. On 5/17/23 at 12:41 PM the main dining room center table had eight residents at the table for lunch, three residents were served their meals and were eating. The meal cart was moved to a hallway and the meal service in the dining room stopped until the next meal cart came out. The last resident at the center table was not served their meal until 12:50 PM, 19 minutes after the first residents were served. On 5/22/23 at 12:26 PM the main dining room center table had six residents sitting for lunch, three had their meals and were eating. The meal cart was moved to a hallway and meal service in the dining room stopped until the next meal cart came out. At 12:38 PM the remaining residents at the center table were served their meals, 12 minutes after the first residents were served. On 5/22/23 at 10:20 AM Staff 1 (Administrator) stated she expected the staff to deliver meals in the dining room to all residents at a table one table at a time. , 2. Resident 15 was admitted to the facility in 2022 with diagnoses including a stroke. An undated investigation summary revealed Resident 15 alleged abuse on 10/11/22. Resident 15 alleged Staff 32 (Former Agency CNA) was rough with care while providing a bed pan. The investigation indicated Staff 32 was mad at the resident and threw the bedpan. Resident 15's roommate called the front desk to report the concern. The investigation was completed and abuse was ruled out. On 05/16/23 at 10:19 AM Witness 2 (Family) stated Resident 42 was Resident 15's roommate at the time of the incident. An 10/26/22 Quarterly MDS indicated Resident 15 was cognitively intact. On 5/18/23 at 8:49 AM Resident 15 stated the Staff 32 was mad at her/him because she/he did not use the bed pan. Resident 15 stated the CNA spoke to her/him in an angry voice. Resident 15 also stated her/his roommate called the nurse's station. A 11/18/22 public complaint form revealed Resident 15 reported to Witness 1 (Complainant) Staff 32 "sternly" spoke to her/him when Staff 32 assisted the resident with the bed pan. The CNA was "angry." Witness 1 indicated the resident reported the incident to the facility staff. On 5/17/23 at 12:35 PM Witness 1 stated Resident 15 reported the incident with just the facts, she/he was not emotional about the events. On 5/17/23 at 11:24 AM Resident 42 stated she/he recalled an incident when Staff 32 entered her/his room to assist Resident 15 with a bed pan. A privacy curtain was pulled so she/he could not see the resident but could hear the interaction. Staff 32 yelled at the resident. Resident 42 stated she/he was concerned about the interaction and called the nurses station to report the concern. Resident 42 stated Resident 15 did not say anything to Staff 32. On 5/18/23 at 8:25 AM Staff 32 denied speaking to Resident 15 in an undignified manner. On 5/19/23 at 10:59 AM with Staff 1 (Administrator), Staff 2 (DNS) and Staff 28 (Regional Nurse Consultant) present, Staff 1 stated Staff 32 denied being rough with Resident 15 and abuse was ruled out. Staff 1 acknowledged Resident 15 and Resident 42 both reported Staff 32 did not speak to Resident 15 in a dignified manner while providing care.

The submission of this plan of correction does not constitute an admission by the facility of any fact or conclusion set forth in the statement of deficiencies. This plan of correction is being submitted because it is required by law. Resident #15 no longer resides at Green Valley. NHA/Designee will complete interviews with all current residents with a BIMS greater than 9 to verify staff are speaking to residents respectfully. NHA/Designee will complete a baseline audit on the 3 dining rooms to verify staff are delivering meals in the dining room to all residents at a table one at a time. NHA/Designee provided further education to staff on 6/12/23 related to communicating with residents with respect and dignity. NHA/Designee provided further education to staff on 6/12/23 related to promoting a homelike dining experience related to serving meals in the dining room to all residents at a table one table at a time. NHA/Designee will conduct interviews with 5 randomly selected residents with BIMS greater than 9 to verify staff are speaking to residents respectfully weekly for 4 weeks, then monthly for 2 months. NHA/Designee will conduct observations during meals of residents to verify a homelike dining experience weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to notify a resident of a medication change for 1 of 4 sampled residents (#17) reviewed for care planning. This placed residents at risk for lack of notification and participating in treatment decisions. Findings include: Resident 17 was admitted to the facility in 2021 with diagnoses including drowsiness. A 1/2023 MAR instructed staff to administer Modafinil (reduces extreme sleepiness) 200 mg daily which was discontinued on 1/4/23. On 1/4/23 staff were instructed to administer Modafinil 100 mg daily. No documentation was found in the clinical records Resident 17 was notified of the change of dosage of Modafinil. On 5/15/23 at 1:05 PM Resident 17 stated she/he was prescribed Modafinil, the dosage was reduced and she/he was not notified of the reason for the reduction. On 5/22/23 at 9:45 AM documentation was requested regarding if Resident 17 was notified of a dosage change for Modafinil from Staff 2 (DNS) and Staff 28 (Regional Nurse Consultant). At 10:53 AM Staff 28 stated there was no additional information to provide.

Resident #17s PCP discussed Modafinil dosage on 5/24/23. DON/Designee will complete a baseline audit to validate residents were notified of medication changes for the last 14 days. DON/Designee provided further education to nursing staff on 6/12/23 related to notifying residents/resident representatives of new orders. DON/Designee will complete audits to validate residents/representatives are notified of medication changes. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to provide call lights residents could activate and ensure residents had comfortable mattresses for 2 of 9 sampled residents (#s 5 and 451) reviewed for accommodation of needs and environment. This placed residents at risk for unmet needs. Findings Include: 1. Resident 451 was admitted to the facility in 5/2023 with diagnoses including central cord syndrome (an incomplete spinal cord injury) and heart failure. A Care Plan revised 5/15/23 revealed Resident 451 required extensive assistence to fully dependent for all care and staff were to ensure Resident 451's call light was within reach. On 5/16/23 at 1:58 PM Resident 451 was observed in bed, her/his call light was placed on her/his stomach approximately two inches from her/his hand. Resident 451 stated she/he could not move her/his hand to the call light, and when it was within reach it was hard to push. The call light was tapped three times and it did not activate. On 5/16/23 at 2:02 PM Staff 41 (LPN Unit Manager) stated Resident 451's call light needed to be on a hard surface to work. Staff 41 confirmed the call light was out of Resident 451's reach. Staff 41 was able to activate the call light after two unsuccessful taps. On 5/16/23 at 3:09 PM Staff 23 (Maintenance Director) stated when Resident 451 was first admitted to the facility she/he was provided with a touch pad call light and could use it at that time. Staff 23 stated he also provided a wedge call light to go under the pillow but at the time of admit it was not appropriate. On 5/16/23 at 3:20 PM Staff 41 stated it was hit or miss whether or not Resident 451 could use the call light, and her/his spouse, who was also Resident 451's roommate, was to call for assistance. Staff 41 stated the facility staff did frequent checks on Resident 451. On 5/17/23 at 3:15 PM Staff 2 (DNS) stated the facility tried to place Resident 451's call light at the end of the bed the previous night in an attempt to help her/him use it. Staff 2 stated Resident 453 (Resident 451's spouse) would continue to use the call light for both of them. Resident 451's call light was observed in her/his bedside table out of her/his reach. Staff 2 confirmed this and moved the call light so it was within reach. Resident 453 stated she/he had to use the call light for Resident 451 and had to wake up whenever Resident 451 coughed or called out. Resident 453 stated she/he would like it if Resident 451 could call for assistance her/himself. , 2. Resident 5 was admitted to the facility in 2022 with diagnoses including pain and an abnormal heart rhythm. A 3/29/23 revised care plan indicated to anticipate Resident 5's need for pain relief, to respond immediately to her/his complaint of pain, and the use of an air mattress was in place due to her/his potential for skin impairment. A 5/3/23 Work Order indicated Resident 5 stated her/his mattress was lumpy and uncomfortable. On 5/15/23 at 11:47 AM Resident 5 was observed upright in bed on top of an air mattress. Resident 5 stated her/his mattress needed to be changed because the bed caused her/him great discomfort. Resident 5 indicated she/he communicated this issue to CNAs and nurses for some time but the issues was not resolved. On 5/17/23 at 10:26 AM Staff 39 (CNA) stated Resident 5 complained about the bed, she/he was repositioned in the bed to ensure the air chambers were in the right place, but it did not resolve Resident 5's discomfort. On 5/17/23 at 10:30 AM Staff 51 (CNA) stated he was aware of Resident 5's issue with the mattress for over one month and spoke to Staff 23 (Maintenance Director) about it. On 5/18/23 at 9:45 PM Staff 23 stated he heard about Resident 5's mattress through a 5/3/23 work order, adjusted the mattress and did not hear about additional complaints. On 5/22/23 at 8:16 AM Staff 2 (DNS) stated she expected Resident's 5 discomfort related to her/his mattress should have been addressed earlier and not continue for four weeks.

Resident #5 the air mattress has been removed per resident request and the care plan was updated on 5/19/23. Resident #451 no longer resides at Green Valley. DON/Designee will audit all residents to ensure they are able to use their call system and if unable to use their call system, their care plan will be updated to include interventions to ensure residents care needs are met. DON/Designee will complete a baseline audit on all residents with air mattresses to validate comfort. DON/Designee provided further education to staff on 6/12/23 regarding resident rights to reasonable accommodation of needs related to call lights and air mattresses. DON/Designee will audit 5 residents weekly to validate residents are able to activate the call system and call lights are functional and within residents reach. DON/Designee will audit 5 residents with air mattresses weekly to validate they are comfortable on the air mattress. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to offer and periodically review advance directives for 2 of 4 sampled residents (#s 5 and 251) reviewed for advance directives. This placed residents at risk for unmet needs. Findings include: 1. Resident 5 was admitted to the facility in 2022 with diagnoses including hypertension. A 1/31/23 Quarterly MDS revealed Resident 5 had a BIMS score of 15 which indicated she/he was cognitively intact. A 7/28/22 Acknowledgement Form revealed Resident 5 received a blank copy of an advance directive. An 10/26/22 IDT Care Plan Conference/Welcome Meeting Form revealed Resident 5 did not have an advance directive on file but did not indicate if the resident wished to complete one. On 5/17/23 at 5:05 PM Staff 5 (Social Servics Director) stated advance directives were handled by admissions staff on admit to the facility and they were not reviewed periodically. On 5/17/23 at 12:00 PM Staff 1 (Administrator) stated advance directives were to be offered and reviewed on admission and quarterly. 2. Resident 251 was admitted to the facility in 2023 with diagnoses including an infection and was cognitively intact. A 5/1/23 care conference for Resident 251 did not include information about an advance directive. A review of the medical record on 5/16/23 did not reveal any information related to whether Resident 251 had an advance directive. On 5/17/23 at 3:12 PM Resident 251 was asked about an advance directive. The resident stated she/he but did not remember being asked about her/his desire to execute an advance directive or being offered a copy of an advance directive. On 5/17/23 at 5:05 PM Staff 5 (Social Services Director) was asked about the advance directive process in the facility and stated the admission person asked new admissions if they had an advance directive and obtained a copy if they had one. Staff 5 added the facility should review advance directives quarterly. Staff 5 stated the facility did not follow up with residents about their desire to execute an advance directive. ,

Resident #5 was offered an Advanced Directive on 6/6/23. Follow up on the Advance Directive will be completed by 6/14/23. Resident #251 no longer resides at Green Valley. SSD/Designee will complete a baseline audit to validate that all residents have been offered an advance directive, documentation of residents refusal for completing an advance directive is documented in the clinical record, follow up for those residents given blank advance directives has been completed and/or advanced directives are in the residents clinical record. NHA/Designee provided further education on 6/12/23 to Social Services and Nurse Managers on resident rights related to advance directives. SSD/Designee will audit all new admissions to validate advance directives have been offered, refusals are documented, advanced directives are in the residents clinical record and/or follow up has been completed with those residents who were given blank advanced directives. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. SSD/Designee will complete weekly audits on care conferences to validate advanced directives were discussed and documented. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of advanced beneficiary information for 1 of 3 sampled residents (#454) reviewed for required beneficiary notification. This placed residents at risk for not being informed of financial liabilities. Findings include: Resident 454 was admitted to the facility with Medicare Part A services in 2022. On 11/15/22 a Notice of Medicare Non-coverage was provided related to a pending discontinuation of Medicare Part A services on 11/17/22. According to the Skilled Nursing Beneficiary Protection Notification document provided by the facility, the resident remained in the facility after 11/17/22 paying privately. No evidence of written notification of financial responsibility was provided upon surveyor request. On 5/17/23 at 2:56 PM Staff 43 (Social Services Director) stated Resident 454 should have received an Advanced Beneficiary Notification form to inform her/him of her/his financial liability, but she/he did not.

Resident #454 no longer resides at Green Valley. NHA/Designee will complete a baseline audit on all current residents who admitted on Medicare and remained in the facility after their Medicare benefits ended to validate, they were issued an ABN (Advanced Beneficiary Notice) prior to their Medicare benefits ending. NHA/Designee provided further education on 6/7/23 to Social Services on Resident Rights related to ABNs. NHA/Designee will complete ongoing audits on all residents that remain in the facility after Medicare benefits have ended to validate ABNs were issued. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review, it was determined the facility failed to protect residents' right to be free from sexual abuse for 1 of 6 sampled residents (#18) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 18 was admitted to the facility in 2018 with diagnoses including dementia. Resident 62 admitted to the facility in 2021 with diagnoses including stroke and dementia with behavioral disturbance. A DSR (Documentation Survey Report) revealed in 1/2023 Resident 62 was sexually inappropriate on 1/8/23 on day shift, and the resident exhibited the behavior previously. Resident 62 was also sexually inappropriate on 1/19/23 on day shift. No notes were found in the clinical records what sexually inappropriate behaviors occurred on 1/8/23 and 1/19/23. A DSR revealed in 4/2023 Resident 62 was sexually inappropriate on 4/23/23 during evening shift, and on 4/27/23 during day shift. No notes were found in the clinical records what sexually inappropriate behaviors occurred on 4/23/23. A 4/27/23 Nursing Note indicated a CNA reported Resident 62 presented with sexual behaviors to a student NA and to continue to monitor noted behavior. A 5/2023 DSR revealed on 5/3/23 during day shift and evening shift Resident 62 was sexually inappropriate. A 5/3/23 Nursing Note indicated Resident 18 was in the dining room after dinner watching TV. Staff 36 (CNA) observed Resident 62 caressing Resident 18's right shoulder and right breast. Staff 36 moved Resident 62 away and asked if Resident 18 was okay. Resident 18 stated "yes". Staff 36 asked if Resident 62 touched her/him and she stated "yes." An Investigation Summary completed 5/10/23 revealed on 5/3/23 Staff 36 reported to Staff 20 (LPN) Resident 62 was found in the dining room touching Resident 18's right shoulder and caressing her/his right chest while they watched TV. The investigation ruled out abuse or neglect as it appeared Resident 62 was touching Resident 18's arm and shoulder and not the breast. A 5/10/23 revised care plan indicated Resident 62 was sexually inappropriate with female staff as well as seeking out female residents. Resident 62 made inappropriate sexual comments to female staff and grabbed female staff's breasts and vaginal area. Interventions included to always keep Resident 62 within line of sight when out of her/his room. On 5/16/23 at 9:39 AM, 5/17/23 at 9:31 AM, 11:33 AM and 12:21 AM Resident 62 was observed in the dining room with no staff observed within line of sight of Resident 62. On 5/18/23 at 12:17 PM Staff 36 stated she went to get Resident 62 about 8:30 PM to put her/him to bed and Resident 18 was watching TV. Staff 36 stated she saw Resident 62 have her/his "good" hand rubbing Resident 18's shoulder and breast. Staff 36 stated she pulled Resident 62 away from Resident 18 and put Resident 62 into bed. Staff 36 asked Resident 18 right after the incident if Resident 62 was touching her/his chest and she/he replied "yes." Staff 36 stated Resident 62 made inappropriate comments to staff. Staff 36 stated Resident 62 was care planned to be within line of sight of a staff member when she/he was out of her/his bed. On 5/18/23 at 10:48 AM Staff 20 stated she was the charge nurse on the evening of 5/3/23, Resident 18 and Resident 62 were in the dining room watching TV and Resident 62 was touching Resident 18's shoulder and breast. Staff 20 stated Resident 62 had a look like "you caught me." On 5/19/23 at 12:02 PM Resident 62 was observed in the dining room watching TV with three other same gender residents. A staff member was in the room and after approximatly one minute the staff member left the dining room and walked down the hall out of sight from Resident 62. On 5/22/23 at 8:36 AM Staff 2 (DNS) stated Resident 62 initially had one on one supervision but was since care planned to be within line of sight of a staff member .

Resident #18 has remained safe from Sexual Abuse. NHA/Designee will complete baseline interviews with all residents with BIMS greater than 9 to validate the residents feel safe in the facility. NHA/Designee provided further education to staff on 6/12/23 related to keeping residents safe from abuse, neglect, and exploitation. NHA/Designee will provide further education to staff related to reporting and documenting sexual behaviors, interventions and monitoring for increased/changed behaviors that may require a change in the plan of care. NHA/Designee will interview 5 residents weekly to ensure they feel safe in the facility. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. NHA/Designee will audit 5 residents weekly with sexual behaviors, interventions to decrease behavior and need for a change in the care plan due to behaviors. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to comprehensively assess 2 of 5 sampled residents (#s 19 and 46) reviewed for unnecessary medications. This placed residents at risk for unassessed needs. Findings include: 1. Resident 46 was admitted to the facility in 2021 with diagnoses including anxiety and contracture. An 8/2/22 Annual MDS revealed Resident 46's BIMS score was 15 which indicated she/he was cognitively intact. The section for Preferences for Routine and Activities was not assessed for Resident 46. On 5/22/23 at 8:28 AM Staff 2 (DNS) stated she would expect the MDS to be completed timely. 2. Resident 19 was admitted to the facility in 2021 with diagnoses including low back pain, depression and Bipolar disorder (mental illness characterized by extreme mood swings). An 7/21/22 Admission MDS revealed Resident 19's BIMS score was 15 which indicated she/he was cognitively intact. Resident 19 received scheduled pain medications and received PRN pain medications or was offered and declined PRN pain medications. Resident 19 should have a pain assessment interview completed. Resident 19 was not assessed if she/he had pain in the last five days. Resident 19's pain frequency, pain effect on function and pain intensity was not assessed. On 5/22/23 at 8:28 AM Staff 2 (DNS) stated she would expect the MDS to be completed timely.

Resident #19s Pain Evaluation was completed on 5/5/23. Resident #46s Preferences for Routine and Activities Evaluation was completed on 5/10/23. MDS Regional Consultant/Designee to complete a baseline audit on all residents last comprehensive assessment to validate all assessments were completed. The facility will complete an evaluation on all areas not assessed in the comprehensive MDS and the care plan will be updated as necessary. MDS Regional Consultant/Designee will provide further education completed 06/12/2023 to IDT staff responsible for completing the MDS on assessing all areas of the MDS per the RAI MDS Regional Consultant will audit 5 MDSs weekly to validate completion of all assessments areas as required per RAI. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to develop a baseline care plan to meet the immediate care needs for 1 of 5 sampled residents (#251) reviewed for medications. This placed residents at risk for unmet care needs. Findings include: Resident 251 was admitted to the facility in 2023 with diagnoses including infection and diabetes. A review of Resident 251's baseline care plan revealed interventions for diabetes, hypertension, ADL and mobility deficits, falls and depression. The baseline care plan did not address Resident 251's infection and antibiotic use, anticoagulant use, heart failure, anxiety disorder, chronic and acute pain related to gout, discitis (infection of the disc space) and bladder cancer for which she/he was being treated. On 5/18/23 at 10:17 AM Staff 46 (Assistant DNS) was asked about care plan development and stated the floor nurse started the care plan based on the initial assessment and then the Unit Manager reviewed and added other pertinent care needs. Staff 46 agreed there were additional problems that should have been included in the baseline care plan.

Resident #251 no longer resides at Green Valley. DON/Designee will complete a baseline audit on all new admission in the last 21 days to verify their baseline care plans are complete. DON/Designee provided further education to staff on 6/12/23 related to completing baseline care plans within 48 hours after a resident is admitted to the facility. DON/Designee will audit all new admissions to ensure the baseline care plan is completed within 48 hours of admission. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to develop a resident centered activity care plan for 1 of 1 sampled resident (#12) reviewed for activities. This placed residents at risk for lack meaningful activities. Findings include: Resident 12 was re-admitted to the facility in 2020 with diagnoses including cognitive deficit and legal blindness. A 5/6/22 Annual MDS indicated it was very important for the resident to listen to music, be around pets, keep up with the news and it was very important for the resident to do her/his favorite activities. A care plan last revised in 1/2023 indicated the resident liked to watch television, eat meals in her/his room and spend time with her/his family. The interventions did not indicate the type of television the resident preferred. The care plan also did not indicate the resident liked pets, music, and that the resident liked to keep current on the latest news. On 5/18/23 at 2:46 PM Staff 35 (Activity Director) stated she just started to work at the facility and was starting to familiarize herself with the residents. Staff 35 stated she wanted to ensure the residents with dementia had an activity program which was meaningful to each resident. Staff 35 acknowledged Resident 12's care plan did not include many interventions specific to the resident's preferences. Staff 35 also acknowledged the care plan did not indicate the type of music or television shows the resident preferred and did not indicate the resident liked pets. Staff 35 stated they had a volunteer who brought in animals and Resident 12 might benefit from a visit. Staff 35 also stated the residents with dementia could also benefit from more 1:1 activities from staff for social engagement. Refer to F679

Resident #12 will have a comprehensive activity assessment completed and the care plan will be updated with specific resident preferences. NHA/Designee will audit all residents to validate they have had a comprehensive activity assessment and their activity care plans are updated with specific resident preferences. Activity Director/Designee will complete comprehensive activity assessments and update the activity care plan with specific resident preferences for those residents without a comprehensive activity assessment. NHA/Designee provided further education on 6/12/23 to activity staff on completing comprehensive care plans and resident centered comprehensive care plans for all residents by their 21st day after admitting. NHA/Designee will audit all new admissions to validate the comprehensive activity assessment has been completed and the comprehensive activity care plan is resident centered with specific preferences. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to update and involve the resisidents in the care plan for 4 of 16 sampled residents (#s 9, 43, 73, and 102) reviewed for accidents, positioning and care planning. This placed residents at risk for unmet needs. Findings include: 1. Resident 43 was admitted to the facility in 10/2018 with diagnoses including Rheumatoid arthritis (RA). Review of an incident report dated 1/10/23 revealed Resident 43 was found on the floor in the resident's room after an unwitnessed fall. The incident report indicated the resident self transferred from bed to use the bathroom, fell and was bleeding from the forehead. The report also indicated the resident was at risk for falls due to decreased mobility related to RA, muscle wasting, abnormal gait and repeated falls. The resident was determined to have poor safety awareness. Review of a care plan for falls revised 1/17/23 revealed Resident 43 was at risk for falls due to reconditioning, gait and balance problems and a history of falls at home. Interventions included bed canes, anticipate resident needs, non-skid socks and call light within reach. The care plan did not include the resident's fall on 1/10/23 with injury and poor safety awareness. The care plan did not include the resident's current risks of the use of a walker to ambulate throughout the facility. In an interview on 5/19/23 at 8:57 AM Resident 43, who was alert and oriented, indicated on 1/10/23 she/he fell attempting to use the bathroom. Resident 43 said she/he did not use a wheelchair much for moving around the building and now she/he used a walker specially modified for her/him. In an interview on 5/19/23 at 11:38 AM Staff 1 (Administrator) acknowledged Resident 43's care plan was not updated regarding the recent fall, poor safety awareness and the use of a walker for ambulation. 2. Resident 102 was admitted to the facility in 12/2022 with diagnoses including dementia. Review of an incident report dated 1/6/23 revealed Resident 102 was found sitting on the floor in the resident's room after an unwitnessed fall. The report indicated the resident was at risk for falls due to confusion and disorientation due to dementia, encephalopathy, abnormal gait and mobility, muscle wasting, difficulty walking and a history of falls. The report also indicated the fall occurred due to the resident's self transfer and poor safety awareness. Review of an incident report dated 1/21/23 revealed Resident 102 was found on the floor in the resident's room after an unwitnessed fall. The report indicated the resident had attempted to dress herself/himself and lost balance. The report also indicated the resident was at risk for falls due to a history of falls, abnormal gait, confusion related to dementia and difficulty walking. Staff were to implement frequent checks and monitor for signs of latent injury. The resident was later diagnosed with a hip fracture which required surgery. Review of a fall care plan revised on 2/17/23 revealed the resident was at risk for falls due to confusion, gait problems, dementia and a history of falls. Interventions included anticipate resident needs and bed canes. The care pan did not include falls in the facility on 1/6/23 and 1/21/23, the resident's poor safety awareness due to dementia and interventions, such as frequent checks, to mitigate the risk of additional falls. In an interview on 5/17/23 at 9:18 AM Staff 2 (DON) acknowledged the resident's care plan was not updated to reflect the resident's recent falls, additional causative risks and interventions such a frequent checks. , 3. Resident 9 admitted to the facility in 2020 with diagnoses including Parkinson's disease. A Care Plan initiated 10/2020 indicated the resident was at risk for falls and staff were to ensure the wheelchair cushion with a lateral wedge which was provided by therapy was used to prevent the resident from leaning over in the wheelchair. An 10/11/22 Annual MDS assessment indicated Resident 9 had reduced mobility and ADL function related to Parkinson's disease (a progressive neurological disorder) and a decline was expected. Resident 9 was at risk for falls and worked with therapy for balance. The 12/2022 cognitive assessment indicated the resident had mild cognitive impairment. On 5/19/23 at 9:00 AM Resident 9 was observed in her/his wheelchair without a lateral wedge for positioning. On 5/19/23 at 10:10 AM and 10:47 AM Staff 7 (LPN Unit Manager) acknowledged the resident did not have a lateral cushion and leaned to both sides. Staff 7 indicated the care plan was not updated to reflect the resident's current wishes to not use the wedge. , 4. Resident 73 was admitted in 2022 with diagnoses including chronic pain and adjustment disorder with mixed anxiety and depressed mood. A 6/15/22 revised care plan indicated to involve Resident 73 in her/his care and decision making daily. An 10/4/22 IDT (Interdisciplinary Team) Care Conference/Welcome Meeting Form indicated Resident 73 was present and multiple care areas were reviewed. There was no evidence of ongoing IDT Care Conferences found. On 5/17/23 at approximately 2:00 PM Staff 5 (Social Services Director) stated care meetings with residents in general were lacking and reduced the opportunity for a resident's care team to directly hear and address the needs of residents like Resident 73. On 5/18/23 at 11:32 AM Resident 73 stated if she/he participated in her team care meetings she/he could ensure her/his care needs were coordinated. On 5/19/23 at 3:34 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed because of the lack of resident involvement in care meetings some communication that was needed for Resident 73's care was not updated.

Resident #9s care plan was updated on 5/19/23 to use the lateral wedge wheelchair cushion as the resident allows and prefers. Resident #43s fall care plan will be updated to include the 1/10/22 fall with injury, poor safety awareness and current risks related to using a walker throughout the facility. Resident #73 had a care conference on 6/6/23. Resident #102 no resides at Green Valley. DON/Designee will complete a baseline audit for the last 30 days to validate care plans revised after each MDS assessment, unusual occurrences, change of condition and change in goals or needs. DON/Designee provided further education on 6/12/23 to staff related to care plan reviews and revisions. DON/Designee will audit 5 residents weekly to validate care plans that have been reviewed and/or revised per schedule and as necessary. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to provide ADL care for 2 of 9 sampled residents (#s 102 and 400) reviewed for ADL care. This placed residents at risk for unmet care needs. Findings include: 1. Resident 102 was admitted to the facility in 12/2022 with diagnoses including dementia. Review of shower records dated 12/23/22 through 2/15/23 revealed: Resident 102 received one shower from 12/25/22 through 1/1/23. Resident 102 received one shower from 1/2/23 through 1/10/23. In an interview on 5/17/23 at 7:15 AM Witness 10 (Complainant) said Resident 102 did not receive showers or baths while at the facility. Witness 10 said the resident's family gave the resident at least one shower because the facility did not offer showers. Witness 10 said the resident's preference was to receive at least two showers a week. In an interview on 5/17/23 at 9:18 AM Staff 2 (DNS) acknowledged Resident 102 did not receive at least two showers a week per the resident's preference. , 2. Resident 400 was admitted to the facility in 2023 with diagnoses including palliative care and chronic obstructive pulmonary disease. A 5/15/23 updated care plan indicated Resident 400 required one person to assist her/him with personal hygiene which included oral care. The 5/4/23 through 5/16/23 ADL-Personal Hygiene task which included oral care indicated that six times Resident 400 was independent for her/his care. On 5/15/23 at 1:22 PM Resident 400 was observed sitting upright in bed and stated she/he had no teeth but wanted her/his mouth cleaned and oral care was not done since he/she admitted over a week ago. On 5/18/23 at 11:28 AM Resident 400 stated she/he still did not have her/his mouth cleaned and the staff who provided care were too quick to leave the room for her/him to ask for any additional assistance. On 5/18/23 at 12:51 PM Staff 39 (CNA) stated she did not yet provide Resident 400 with oral care on 5/18/23 and it should have been done earlier in the day. Staff 39 stated she assisted Resident 400 once before when she first started and oral care was not provided on that day either. On 5/18/23 at 2:53 PM Staff 10 (CNA) stated she provided no assistance during personal hygiene during the times she cared for Resident 400. Staff 10 stated she understood assistance was not required for Resident 400 based on communication with other CNAs and was surprised to learn Resident 400 needed one person to assist with her/his personal hygiene. Staff 10 stated she normally waited for an indication of interest in oral care from an independent resident before oral care was offered and now understood the issue because of Resident 400's need for assistance. On 5/18/23 at 3:10 PM Staff 7 (LPN Unit Manager) stated they were still trying to understand Resident 400's routine and expectations but staff should look at the care plan to know how to care for any resident.

Resident #102 no longer resides at Green Valley. Resident #400 is care planned for staff to provide limited assistance with oral care. DON/Designee will complete a baseline audit to validate residents are receiving showers and oral care as care planned. DON/Designee provided further education on 6/12/23 to nursing staff related to providing ADL care to dependent residents including showers and oral care as well as completing documentation when residents refuse ADL care. DON/Designee will audit 10 residents weekly to validate showers and oral care is completed as care planned. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to develop a meaningful activity program for 1 of 1 sampled resident (#12) reviewed for activities. This placed residents at risk for decreased quality of life. Findings include: Resident 12 was re-admitted to the facility in 2020 with diagnoses including cognitive deficit and legal blindness. A 5/6/22 Annual MDS indicated it was very important for the resident to listen to music, be around pets, keep current with the latest news and to do her/his favorite activities. A Care Plan revised in 1/2023 indicated the resident liked to watch television, eat meals in her/his room and spend time with her/his family. The interventions did not indicate the type of television the resident preferred. The care plan also did not indicate the resident liked pets, music, and she/he liked to keep current with the latest news. An Activity Provided task form revealed from 4/15/23 to 5/15/23 activities were not offered. On 5/16/23 at 2:18 PM Staff 33 (CNA) stated Resident 12's health declined, she/he did not participate in activities and the resident only got up for meals. On 5/17/23 at 11:46 AM Staff 34 (CNA) stated she never took residents to activities, including Resident 12. On 5/18/23 at 2:46 PM Staff 35 (Activity Director) stated she just started to work at the facility and was starting to familiarize herself with the residents. Staff 35 stated she wanted to ensure the residents with dementia had an activity program which was meaningful to each resident. Staff 35 acknowledged Resident 12's Care plan did not include many interventions specific to the resident's preferences. Staff 35 acknowledged the care plan did not indicate the type of music or television shows the resident preferred and did not indicate the resident liked pets. Staff 35 stated they had a volunteer who brought in animals and Resident 12 might benefit from a visit. Staff 35 also stated residents with dementia could also benefit from more 1:1 activities from staff for social engagement. Staff 35 also acknowledged the resident's record did not have documentation to show the resident was offered any type of activities .

Resident #12 will have a comprehensive activity assessment completed and the care plan will be updated with specific resident preferences. NHA/Designee will complete a baseline audit to validate all residents have a resident centered activity program. Activity Director/Designee will update the activity care plan with specific resident preferences for those residents without a resident centered activity program. NHA/Designee provided further education on 6/12/23 to the activity department related to providing ongoing resident centered activities program that supports residents in their choice of activities. NHA/Designee will audit 5 residents weekly to validate they are being offered resident centered activities. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to follow physician orders and care plans for 1 of 4 sampled residents (# 73) reviewed for care planning. This placed residents at risk for unmet needs. Findings include: Resident 73 was admitted in 2022 with diagnoses including chronic pain and adjustment disorder with mixed anxiety and depressed mood. An 8/16/22 revised care plan indicated to involve Resident 73 in her/his care and decision making daily and Resident 73's ventral hernia (a protrusion of intestine or abdominal tissue through a weak spot in the stomach muscle) added to her/his chronic pain. An 10/13/22 physician note revealed Resident 73 needed to lose weight in order to be a surgical candidate. A 12/20/22 physician note indicated Resident 73's ventral hernia was worsening and to refer to general surgery for evaluation. A 1/13/23 Provider Order Sheet identified a referral for bariatric surgery that needed to occur before hernia surgery. On 5/15/23 at 2:17 PM Resident 73 stated she/he had an appointment with a surgeon on 1/13/23 who made a referral in order to get her/his hernia surgery and the faciltiy had not yet scheduled the surgery. On 5/17/23 at approximately 2:00 PM Staff 5 (Social Services Director) stated she was not aware appointments that were lacking for Resident 73, but recognized deficiencies in communication related to residents' needs. On 5/18/23 at 3:10 PM Staff 7 (LPN Unit Manager) stated a charge nurse handled referrals and she was not aware of any referrals not addressed for Resident 73. Staff 7 referred to the 1/13/23 referral in Resident 73's medical record and stated she had conversations with Resident 73 routinely about her/his care needs but conversations with Resident 73 were not documented. On 5/19/23 at 3:34 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected the ward clerk to enter the referrals into the schedule system and the Unit Manager to follow up to ensure the referral was done.

Resident #73, facility has been in contact with getting bariatric surgeon appointment and follow-up. DON/Designee will complete a baseline audit on all residents to validate ordered referrals are completed. DON/Designee provided further education on 6/12/23 to staff related to following physician orders related to referrals. DON/Designee will audit all new referrals to validate referrals are made as ordered. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further

Based on interview and record review it was determined the facility failed to ensure residents were provided routine eye appointments for 1 of 2 sampled residents (#42) reviewed for communication and sensory needs. This placed residents at risk for worsening vision. Findings include: Resident 42 was admitted to the facility in 2023 with diagnoses including cataracts (clouding of the eye lens impairing clear sight). A 7/9/22 Admission MDS indicated Resident 42 had visual impairment and was not able to see distance due to cataracts. The resident was at risk for continued vision loss. Review of resident 42's record revealed there was no scheduled vision appointments to ensure the resident's cataracts were monitored. An 4/11/23 Quarterly MDS indicated Resident 42 was cognitively intact. On 5/15/23 at 11:01 AM Resident 42 stated she/he was diagnosed with cataracts before admission to the facility. The facility was aware of the cataracts and did not yet set up an appointment. On 5/7/23 at 3:35 PM Staff 5 (Social Services Director) stated she was not aware Resident 42 had cataracts. If she was aware she would follow-up with the resident and make an appointment. Staff 5 stated the nursing staff did not request assistance to set up an appointment. On 5/17/23 at 3:49 PM and 5/18/23 at 11:30 AM Staff 3 (LPN Unit Manager) stated if a resident had cataracts it was important for follow-up with the resident's provider to see how often the resident was to be examined. Staff 3 stated Resident 42 did not have an eye appointment since she/he was admitted to the facility. Staff 3 also indicated follow-up was important to ensure vision did not deteriorate.

Resident #42 has an ophthalmologist appointment on 6/12/23. SSD/Designee will interview all residents to validate vision needs are met. NHA/Designee provided further education on 6/12/23 to staff related to meeting residents vision needs. SSD/Designee will interview all new admissions for vision needs. Vision referrals will be completed as indicated by the interview. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. SSD/Designee will audit all vision referrals to validate appointments were made and follow up after the appointments were completed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to provide ROM for 1 of 5 sampled residents (#60) reviewed for mobility. This placed residents at risk for decreased ROM. Findings include: Resident 60 was admitted to the facility in 2023 with diagnoses including a stroke. A 1/12/23 Admission MDS indicated Resident 60 required the assistance of two staff for most ADLs. The resident participated in therapy and was at risk for continued decline, contractures and muscle weakness. The goal was to minimize risks. A Care Plan initiated 1/29/23 indicated the resident had limited mobility and staff were to provide daily gentle ROM as tolerated. The resident's record from 4/15/23 to 5/16/23 did not have documentation to indicate ROM was provided. An 4/18/23 Quarterly MDS indicated the resident did not have functional limitation in ROM to the arms or legs. On 5/17/23 at 2:24 PM Staff 18 (Therapy Director) stated he did not work with Resident 60. Staff 18 stated the therapy notes indicated the resident was able to move her/his arms and legs but refused to feed her/himself. On 5/17/23 at 2:41 PM Staff 37 (CNA) stated Resident 60 was able to move all her/his arms and legs. If the resident required ROM it was on the care plan. Staff 37 stated he never provided ROM for Resident 60. On 5/17/23 at 2:45 PM Staff 38 (LPN Unit Manager) acknowledged the resident's care plan indicated the resident was to have gentle ROM but the task was not set up for staff to document. A request was made to Staff 38 to provide documentation to show Resident 60 was provided or offered ROM. No additional information was provided.

Resident #60 is longer at the facility. DON/Designee will complete a baseline audit ICF resident with limited ROM and physical limitations for need of ROM. Restorative nursing will be initiated as necessary. DON/Designee will complete a baseline audit for residents currently care planned for ROM to determine need for ROM and completion of ROM as indicated on care plan. DON/Designee provided further education on 6/12/23 to CNAs related to completing ROM as indicated on the care plan. DON/Designee will audit documentation of ROM on 5 residents weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to investigate falls and supervise meals per care plan for 2 of 11 sampled residents (#s 84 and 99) reviewed for accidents and nutrition. This placed residents at risk for injury and choking. Findings include: 1. Resident 84 was admitted to the facility in 2023 with diagnoses including dysphagia (difficulty swallowing) and dementia. The 3/28/23 care plan indicated the resident had an ADL self-care performance deficit and was to be supervised while eating. The care plan further indicated resident 84 had a swallowing problem related to not having upper dentures with a goal the resident would have no choking episodes. Staff were to monitor, document and report as needed signs or symptoms of dysphagia including: -pocketing -choking -coughing -drooling -holding food in her/his mouth -several attempts at swallowing -refusing to eat -appearing concerned during meals Meal observations on 5/16/23 through 5/22/23 during breakfast and lunch revealed Resident 84 in her/his bed with the door and curtain closed eating her/his meals. No staff were observed in the resident's room supervising. On 5/22/23 at 8:52 AM Staff 7 (LPN Unit Manager) stated the resident did not have swallowing problems. On 5/22/23 at 8:57 AM Staff 38 (CNA) stated she was not aware the resident had swallowing problems or if she/he was to be supervised while eating. On 5/22/23 at 9:00 AM Staff 22 (CNA) stated she was not aware the resident had swallowing problems or if she/he was to be supervised while eating. On 5/22/23 at 10:55 AM Resident 84 stated she/he choked on a hamburger awhile back but had not choked since. Resident 84 stated she/he did not have upper teeth and some food was hard to chew and swallow. On 5/22/23 at 11:09 AM Staff 7 and Staff 42 (LPN Unit Manager) stated they were not aware Resident 84 had swallowing problems and needed to be supervised with meals. Staff 7 and Staff 42 agreed the resident should have been supervised while eating. 2. Resident 99 admitted to the facility in 2022 with diagnoses including hip fracture. A 12/2/22 Progress Note created at 10:34 AM indicated Resident 99's daughter reported the resident hit her/his leg with the wheelchair or the door during a transfer. A 12/2/22 Progress Note created at 1:18 PM indicated Resident 99's daughter-in-law called the facility and stated the resident's leg was hit by the wheelchair or door as she/he was being transferred back to the facility. A 12/2/22 Progress Note created at 2:50 PM indicated Resident 99's daughter-in-law stated during transport Resident 99's leg was hit with the wheelchair. A review of the 12/2/22 Incident Report contained mixed information from all the incidents which was not accurate. On 5/19/23 at 3:30 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 28 (Regional Nurse Consultant) confirmed the investigation was not complete or accurate.

Resident #84 is no longer needing supervision for meals. Resident #99 no longer resides at Green Valley. DON/Designee will complete a baseline audit on all residents who need supervision with meals to validate this is being completed. DON/Designee provided further education on 6/12/23 to staff related to supervised eating per care plan. DON/Designee will complete a baseline audit on all investigations for the last 30 days to verify the investigation is complete and accurate. DON/Designee will observe meals to validate supervision is provided as indicated on care plan. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. DON/Designee will audit investigations to validate they are complete and accurate. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to provide incontinent care for 1 of 9 sampled residents (#46) reviewed for ADLs. This placed residents at risk for lack of incontinent care. Findings include: Resident 46 was admitted to the facility in 2021 with diagnoses including anxiety and contracture (shortening of tendons and ligaments). A 6/28/22 Resident Council Minutes revealed peri care was not completed well enough and when asked for more care the resident was met with a "bad attitude". An 8/2/22 Annual MDS revealed Resident 46's BIMS score was 15 which indicated she/he was cognitively intact. Resident 46 required extensive one-person physical assist with toilet use. An 8/2022 Documentation Survey Report revealed Staff 12 (CNA) worked with Resident 46 eight-night shifts from 8/1/22 through 8/10/22. Staff 14 (CNA) worked four-day shifts after Staff 12 worked a night shift from 8/1/22 through 8/10/22. On 5/15/23 at 11:47 AM Resident 46 stated call light wait times were long over the last year. Resident 46 stated she/he had incontinent episodes because of waiting, and staff left her/his urinal on the trash can and she/he could not reach it. Resident 46 stated call light wait times were worse on day and evening shifts. Resident 46's urinal was observed to be hanging on her/his trash can approximately six feet away and out of Resident 46's reach. On 5/18/23 at 12:06 PM Witness 1 (Complainant) stated in 2022 the following occurred. -Week of 5/16/22 there were two occasions when Resident 46 was incontinent of bowel, used the call light for assistance, and staff took a long time to to respond. On both occasions staff told Resident 46 to finish eating and then they would assist her/him with peri-care. Resident 46 did not want to sit in a soiled brief while eating. -8/2022 Resident 46 reported to Witness 1 that Staff 12 worked the night shift and two times refused to change Resident 46's brief. -2/20/23 Witness 1 met with Resident 46, and she/he was soiled and required a brief change. Resident 46 stated staff left to obtain another staff person to assist with her/his incontinent care but did not come back. The call light was activated, and the wait time was 40 minutes. On 5/19/23 at 11:34 Staff 14 stated in 8/2022 she remembered coming on to day shift and Resident 46 had dried bowel movement on her/him two to three different instances. On 5/22/23 at 8:23 AM Staff 2 (DNS) stated it was expected for staff to check residents every two hours for peri care. Refer to F725

Resident #46 will be provided incontinence care as care planned, when incontinent and as requested. DON/Designee will complete a baseline audit on residents who are incontinent to validate they are being provided incontinent care as care planned, when incontinent and as requested by the resident. DON/Designee provide further education on 6/12/23 to CNAs related to providing incontinence care to residents as care planned, when incontinent and as requested by the resident. DON/Designee will complete weekly audits on 5 residents who are incontinent to validate they are being provided incontinent care as care planned, when incontinent and as requested by the resident. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to monitor weights for 1 of 4 sampled residents (# 451) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 451 was admitted to the facility in 5/2023 with diagnoses including heart failure. A review of Resident 451's 5/2023 TAR revealed: - A 5/7/23 order for daily weights for one week. Weights were not completed on 5/7/23, 5/8/23, 5/11/23 and 5/13/23. - A 5/17/23 order for once weekly weights. The 5/17/23 weight was not completed. The 5/2023 Documentation Survey Report revealed no documentation Resident 451 refused care. On 5/18/23 at 10:48 AM Witness 4 (Family Member) stated she was concerned Resident 451 lost weight since admission. On 5/18/23 at 10:49 AM Resident 451 stated she/he did not refuse to be weighed in the facility. On 5/18/23 at 1:11 PM Staff 41 (LPN Unit Manager) stated Resident 451 had orders for daily weights related to her/his heart failure diagnosis and stated the weights were not completed as ordered due to Resident 451 refusing but it was not documented.

Resident #451 no longer resides at Green Valley. DON/Designee will complete a baseline audit to validate weights are being completed as ordered and documentation is being completed when a resident refuses a weight. DON/Designee provided further education on 6/12/23 to nursing staff related to obtaining weights as ordered and documenting when a resident refuses to be weighed. DON/Designee will complete weekly audits on 5 residents to validate weights are being completed as ordered and refusals are being documented. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI X 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure risk and benefits for the use of bed canes were discussed with residents' responsible parties for 1 of 7 sampled residents (#12) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 12 was admitted to the facility in 2016 with diagnoses including dementia and legal blindness. A 9/27/22 cognitive assessment form indicated the resident had a score indicating severe memory issues. A Fall investigation dated 4/29/23 indicated the resident was found on the floor with her/his left hand hanging onto the bed cane. The resident did not sustain an injury. A 5/8/23 Restraint versus Enable Screen form indicated the resident requested the bilateral bed canes for mobility. The resident was assessed to be oriented to person, had impaired cognition, and had poor safety awareness and attempted to get out of bed on her/his own. The resident had recent falls. The assessment indicated the bed canes did not limit the resident's movement and helped assist her/him with repositioning and holding while turning to the side. The form indicated the risk and benefits of the bed canes were reviewed with Resident 12. On 5/16/23 at 9:11 AM Resident 12's bed was observed with bilateral bed canes. There were open areas in the bed canes which a resident's hand/arm could become entrapped. On 5/18/23 at 2:25 PM Staff 7 (LPN Unit Manager) stated Resident 12 recognized staff and could respond to some questions. Staff 7 stated Resident 12's spouse was involved with her/his care. Staff 7 indicated Resident 12 used the bed canes for mobility. Staff acknowledged the consent for use of bed canes with potential risk versus benefits was reviewed with a cognitively impaired resident and not her/his responsible party. On 5/22/23 at 9:19 AM Staff 49 (SLP) stated she worked with Resident 12 and indicated the resident could not process complex information such as risk and benefits. With a low cognitive assessment score it was best to review information with the resident's responsible party.

Resident #12s wife has given verbal consent for the use of bed canes. DON/Designee will complete a baseline audit for all residents with BIMS of 9 or less and with bed canes/rails to validate risks were reviewed and consent for use was given by the resident representative. DON/Designee provided further education on 6/12/23 to nurses related to reviewing risks and obtaining consent from resident representatives for residents with a BIMS of 9 or less. DON/Designee will audit new admissions and residents with new placement of bed canes/rails to validate resident representatives for residents with BIMS of 9 or less have been informed of risks related to bed canes/rails and have given consent for use. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 16 sampled residents (#s 15, 19 and 46) and 2 of 4 halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident Council Minutes reviewed for 8/30/22, 10/18/22, 11/22/22 and 4/19/23 indicated a concern with long call light wait times on all shifts. In observations on 5/17/23 the following was revealed on (ICF) Intermediate Care Facility Halls A and B: -7:28 AM the call light monitoring system at the nurses' station Room 10-1 indicated 75 minutes. -7:46 AM Staff 29 (CMA) entered room 10-1 with medications and when she exited the call light was still on. Staff 29 stated she thought 10-1 would like a cup of coffee. -7:53 AM a staff member entered room 10-1 with coffee and the light was turned off (one hour and 40 minutes). -8:28 AM through 8:37 AM the call light monitoring system at the nurses' station revealed Room 38-1 was on 48 minutes and Room 42-2 was on 29 minutes. -8:41 AM Staff 51 (CNA) entered room 38-1 and the call light was turned off (one hour one minute). Staff 51 stated he did not have a difficult time answering call lights timely. -9:26 AM the call light monitoring system at the nurses' station revealed Room 41-1 was on 20 minutes. On 5/18/23 at 10:48 AM Staff 20 (LPN) stated there were some complaints from residents regarding agency CNAs not answering call lights timely. Staff 20 stated some CNAs would not answer a resident's call light if they were not assigned to them and she informed them that all the residents "are theirs." On 5/18/23 at 11:02 AM Staff 27 (CNA) stated residents complained of long call light wait times. On 5/22/23 at 8:43 AM Staff 2 (DNS) stated she expected call light wait times to be around 10 to 15 minutes. 2. Resident 19 was admitted to the facility in 2021 with diagnoses including low back pain, depression and Bipolar disorder (mental illness characterized by extreme mood swings). The 4/19/23 Resident Council minutes indicated call light wait times took up to 30 minutes or longer. CNAs came in and turned off the call light stating they would come back but did not. CNAs looked at the call lights and walked away. On 5/15/23 observations and interviews revealed the following: -10:31 AM Staff 22 (CNA) and Staff 31 (CNA) entered Resident 22's room to answer the call light (26 minutes). -10:36 AM Resident 19 stated long call light wait times happened daily and evening took the most time. Resident 19 stated staff do not work well together. On 5/22/23 at 8:43 AM Staff 2 (DNS) stated she expected call light wait times to be around 10 to 15 minutes. 3. Resident 46 was admitted to the facility in 2021 with diagnoses including anxiety and contracture (shortening of tendons and ligaments). An 8/2/22 Annual MDS revealed Resident 46's BIMS score was 15 which indicated she/he was cognitively intact. Resident 46 required extensive one-person physical assist with toilet use. Resident Council Minutes reviewed for 8/30/22, 10/18/22, 11/22/22 and 4/19/23 indicated a concern with long call light wait times on all shifts. On 5/15/23 at 11:47 AM Resident 46 stated call light wait times were long over the last year. Resident 46 stated she/he had incontinent episodes because of long call light wait times. As staff left her/his urinal on the trash can and she/he could not reach it. Resident 46 stated the worst times of the day were day and evening shifts. Resident 46's urinal was observed to be hanging on her/his trash can approximately six feet away and out of Resident 46's reach. On 5/18/23 at 12:06 PM Witness 1 (Complainant) stated the following occurred from 5/2022 through 3/2023: -Week of 5/16/22 two occasions when Resident 46 was incontinent of bowel and used the call light for assistance and it took a long time for staff to respond. -The week of 6/2022 on two occasions Resident 46 waited for two hours for staff to respond to her/his call light. Resident 46 required assistance with getting dressed after using her/his urinal. -On 10/10/22 Witness 1 visited with Resident 46 and her/his call light was on when he arrived. Witness 1 stated the call light was not answered for an hour. -11/21/22 Witness 1 stated he met with Resident 46 for approximately an hour and her/his call light was on, but staff did not respond to the call light. Resident 46 required assistance with cutting up her/his food. -2/20/23 Witness 1 met with Resident 46 and she/he was soiled and required a brief change. Resident 46 stated staff left to obtain another staff person to assist with incontinent care but did not come back. The call light was activated and the wait time was 40 minutes. On 5/18/23 at 11:02 AM Staff 27 (CNA) stated residents complained of long call light wait times and stated Resident 46 complained she/he got "ignored" on other shifts and sat for 30 minutes or more waiting for her/his call light to be answered. A review of the DCSDRs (Direct Care Staff Daily Reports) from 5/20/22 through 5/23/22, 6/11/22 through 6/20/22, 10/1/22 through 10/11/22 and 2/15/23 through 2/25/23 revealed the facility did not have sufficient CNA staff to meet the state required minimum CNA to resident staffing ratios for 15 of 79 shifts. On 5/22/23 at 8:43 AM Staff 2 (DNS) stated she expected call light wait times to be around 10 to 15 minutes. , 4. Resident 15 was admitted to the facility in 2022 with diagnoses including a stroke. A 7/26/22 Quarterly MDS indicated Resident 15 was cognitively intact. An 8/23/22 public complaint indicated it took staff up to 60 minutes to answer Resident 15's call light. The 8/30/22 Resident Council Minutes revealed long call light wait times on all shifts and improvement was still needed. On 5/18/23 at 8:49 AM Resident 15 stated it could take up to one to one and a half hours for staff to answer the call light. Resident 15 indicated she/he told staff about her/his concern. The 8/16/22 through 8/23/22 Direct Care Staff Daily Reports revealed the facility did not meet the state required minimum CNA to resident staffing ratio on 8/16/22 evening shift, all shifts on 8/20/22, day and evening shifts on 8/21/22, evening shift on 8/22/22 and all shifts on 8/23/22. On 5/19/23 at 9:27 AM Staff 50 (CNA) stated when the facility did not have sufficient staff it took longer to answer call lights. Staff 50 did not indicate how long it took to answer call lights. On 5/18/23 at 8:25 AM Staff 32 (Former Agency CNA) stated CNA staff did not cover for each other when they went on lunch. Call light wait times were over 30 minutes while she was at lunch and no one covered for her. On 5/18/23 at 10:51 AM Staff 52 (LPN) stated at times the CNAs did not cover for each other and staff tried to answer the call lights within 20 minutes. On 5/22/23 at 10:22 AM Staff 1 (Administrator) confirmed insufficient staff on at least one shift on 8/16/22, 8/20/22, 8/21/22, 8/22/22 and 8/23/23.

The facility will ensure sufficient staffing to meet the needs of residents and to meet the state required minimum CNA to resident staffing ratios. DON/Designee will interview residents with BIMS greater than 9 to ensure care needs are being met timely. DON/Designee will complete a baseline call light audit on all shifts. DON/Designee provided further education on 6/12/23 to staff related to answering call lights timely and meeting residents care needs timely. DON/Designee will interview 5 randomly selected residents with a BIMS greater than 9 weekly to validate care needs are being met timely. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. DON/Designee provided further education on 6/12/23 to staff coordinators and managers on requirements related to CNA and RN staffing. DON/Designee will complete weekly audits to validate CNA ratios are in compliance and an RN is scheduled each day for 8 hours consistently between the start of day shift and the end of evening shift. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports (DCSDR) were accurate and posted in a prominent location for 5 of 5 days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information. Findings include: 1. The DCSDRs were compared against the nursing schedule for the first five days of the survey. The review indicated discrepancies. On 5/15/23 at 3:48 PM the nurse on the Intermediate Care hall was observed talking with another staff member who asked about additional staffing due to call ins. The nurse stated no additional staff were coming into work and they were down two staff for the shift. A review of the 5/15/23 DCSDR revealed only an adjustment to the census number and no adjustment to the number of staff as a result of the call ins for that day. Additionally, the DCSDR forms for 5/16/23 to 5/19/23 revealed adjustments to the census numbers only. On 5/19/23 at 10:24 AM Staff 2 (DNS) was asked about the process related to staffing. Staff 2 stated the staffing person filled out the form and then the nurse was expected to confirm the staff numbers for each shift making adjustments as needed. The forms were then reconciled by the staffing person with the assignment sheets to confirm accuracy. The facility provided copies of the DCSDR forms and the assignment sheets for 5/15/23 through 5/19/23. The DCSDRs revealed many changes to each form related to staffing numbers. There was no indication who made the adjustments to the staffing numbers. On 5/19/23 at 12:41 PM the DCSDRs were reviewed with Staff 46 (Assistant DNS) and Staff 28 (Regional Nurse Consultant) for accuracy and they agreed the nurses did not make the adjustments to the staffing numbers and the numbers did not appear accurate. On 5/19/23 at 1:15 PM Staff 28 provided updated DCSDRs and stated the staffing person counted the Unit Managers in the licensed nurse category which was not accurate. 2. The Direct Care Staff Daily Reports (DCSDR) were observed posted on the Intermediate Care side of the facility behind closed double doors. There were no other locations throughout the facility which indicated the number of staff present on shift. On 5/22/23 at 9:55 AM the location of the DCSDR posting was discussed with Staff 1 (Administrator) and Staff 2 (DNS) who stated the forms were posted in that location for years and would be moved to the entrance of the facility in a prominent location .

The Daily Nurse Staff Posting placement has been moved to a more prominent place nearer to the facility entrance. The Daily Nurse Staff Posting will be completed and updated to ensure accuracy. DON/Designee provided further education on 6/12/23 to staff related to completing the Daily Nursing Staff Posting and updating the posting as necessary to ensure accuracy. DON/Designee will audit the Daily Nurse Staffing Posting weekly for completion and update as necessary to validate accuracy. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure appointments were made to replace dentures in a timely manner for 1 of 4 sampled residents (#15) reviewed for dental. This placed residents at risk for weight loss. Findings include: Resident 15 was admitted to the facility in 1/2022 with diagnoses including a stroke. A 1/21/22 Admission Inventory of Personal Items form revealed Resident 15 had upper and lower dentures. An 8/23/22 public complaint indicated in approximately 6/2022 Resident 15's dentures were in a paper towel on a food tray. The tray was removed and the dentures were thrown away. The staff were aware of the lost dentures but did not help set up an appointment or assist with reimbursement for the dentures. A 12/20/22 hospital Speech Therapy note indicated Resident 15 admitted to the hospital on 12/17/22. During the speech therapy assessment Resident 15 reported her/his upper denture was missing. A 12/23/22 Nutritional Evaluation form indicated the resident gained weight in the last month and did not have chewing or swallowing issues. The form revealed "NA [Not Applicable]" for dentures. A 12/31/22 Social Service Note indicated Staff 5 (Social Services Director) spoke to Resident 15's family. The family member reported "many months ago" an upper denture was lost. Arrangements were made to send the resident to the denturist but the resident went to the hospital and the appointment was canceled. A 12/31/22 revised care plan indicated staff were to arrange an appointment to remake the resident's upper plate which was lost or thrown away. On 5/16/23 at 10:19 AM Witness 2 (Family) indicated the resident's dentures were lost for approximately one year and the facility did not assist with the appointments for replacement. On 5/18/23 at 8:49 AM Resident 15 stated her/his dentures were missing since approximately 5/2022. On 5/18/23 at 11:38 AM Staff 5 stated she started to work in the facility in 11/2022 and was not sure when the resident's dentures were lost. There was no missing item form related to the dentures. Staff 5 indicated once she was aware of the missing denture she ensured an appointment was made. On 5/19/23 at 3:50 PM Staff 20 (LPN) stated Resident 15 lost her/his dentures in 2022 but she was not sure of the exact month. On 5/18/23 at 12:10 PM Staff 2 (DNS) stated she was not sure if or when the resident lost her/his dentures. Staff 2 acknowledged the resident had appointments set for denture replacements. A request was made for information on when the dentures were lost. No additional information was provided.

Resident #15 no longer resides at Green Valley. SSD/Designee will interview all residents with dentures/partials to validate they are not missing or damaged. Residents with missing or damaged dentures/partials will have appointments made for replacement within 3 days. The facility will provide interventions to ensure residents can still eat and drink adequately to residents with missing or damaged dentures/partials who cannot be seen in 3 days. NHA/Designee provided further education on 6/12/23 to staff regarding reporting missing or damaged dentures/partials to Social Services and implementing interventions to ensure residents can still eat and drink until their dentures/partials are replaced or fixed. NHA/Designee provided further education on 6/12/23 to SSD on making appointments within 3 days of a resident reporting missing or damaged dentures. NHA/Designee will audit 5 residents weekly to ensure dentures/partials are not missing or damaged, appointments have been made for residents with missing or damaged dentures/partials have been made and interventions are in place to for residents with missing or damaged dentures/partials to ensure they are able to eat and drink adequately. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure proper flavor and food palatability was maintained for 1 of 1 facility kitchen reviewed for food service and 5 of 8 sampled residents (#s 19, 40, 43, 46 and 399) reviewed for food. This placed residents at risk for food that was not palatable or appetizing. Findings include: 1. Resident 399 was admitted to the facility in 2021 with diagnoses including paralysis on the right dominant side and cognitive communication deficit. A 1/18/23 Meal/Temperature Audit revealed resident food comments included that the "meat was a little difficult to chew." The 2/22/23 and 4/20/23 Meal/Temperature Audits revealed resident food comments included that the food was "bland." A 3/27/23 Dining Committee Meeting Minutes revealed resident food comments included that the meat was tough. On 5/17/23 at 12:55 PM Staff 9 (Dietary Manager) was observed during lunch meal service to scrape the sides of a pan of grits to serve the few remaining meals. On 5/17/23 at 1:22 PM a food test tray was sampled. The cheesy grits were bland without the taste or appearance of cheese as indicated on the menu and served in a portion cup. The portion cup contained approximately two ounces instead of four ounces of grits. The pork was bland and tough to chew. The green beans were overcooked and mushy and the roll on the plate touched the liquid from the green beans. On 5/17/23 at 2:51 PM Staff 11 (Regional Dietary Manager) stated Staff 9 was new to his position and should have asked for assistance when he realized that the grits served were running low and the final servings did not meet quality standards. On 5/17/23 at 5:32 PM Witness 5 (Complainant) stated the facility often served tough meat and Resident 399 complained about the palatability of her/his food. On 5/19/23 at 9:06 AM Staff 11 and Staff 4 (Dietary Manager) stated in 1/2023 tough meats were addressed through staff education, the administration was notified and resident food concerns were addressed and continued to be addressed in the moment. , 2. Resident 46 was admitted to the facility in 2021 with diagnoses including anxiety and contracture (shortening of the tendons and ligaments). A 1/18/23 Meal/Temperature Audit revealed resident food comments included that the "meat was a little difficult to chew." A 3/27/23 Dining Committee Meeting Minutes indicated concerns regarding tough meat. On 5/15/23 at 11:50 AM Resident 46 stated the pork tasted low quality and was "extremely tough." On 5/17/23 at 1:22 PM a test tray was provided to the survey team with pureed and regular texture food. The two trays consisted of pork, green beans, cheesy grits, roll and fruit. The pork was bland, overcooked and tough. On 5/19/23 at 9:06 AM Staff 11 and Staff 4 (Dietary Manager) stated in 1/2023 tough meats were addressed through staff education. The administration was notified and resident food concerns were addressed. 3. Resident 19 was admitted to the facility in 2021 with diagnoses including anxiety. A 7/21/22 Admission MDS revealed Resident 19's BIMS score was 15 which indicated she/he was cognitively intact. The 2/22/23 and 4/20/23 Meal/Temperature Audits revealed resident food comments included that the food was "bland." On 5/15/23 at 10:42 AM Resident 19 stated the food did not taste good, there were too many carbohydrates all in one meal and there was very little variety in the menu. On 5/17/23 at 1:22 PM a test tray was provided to the survey team with pureed and regular texture food. The two trays consisted of pork, green beans, cheesy grits, roll and fruit. The regular textured green beans were flavorless and overcooked. The cheesy grits for the regular texture had a small amount of cheese and were flavorless. The cheesy grits for the pureed tray did not have cheese and were flavorless. The kitchen served garlic bread but ran out and served rolls. The pork was bland, overcooked and tough. On 5/17/23 at 2:51 PM Staff 11 (Regional Dietary Manager) stated Staff 9 was new to his position and should have asked for assistance when he realized the grits served were running low and the final servings did not meet quality standards. On 5/19/23 at 9:06 AM Staff 11 and Staff 4 (Dietary Manager) stated in 1/2023 tough meats were addressed through staff education. The administration was notified and resident food concerns were addressed. , 4. Resident 40 was admitted to the facility in 2022 with diagnoses including heart disease. The 9/27/21 Admission MDS indicated the resident was at risk for nutritional deficits related to a BMI (body mass index) of 25.79, and due to constipation noted on admission and during the assessment look-back period. The 2/14/23 care plan indicated Resident 40 had the potential for nutritional problems related to the need for therapeutic diet, history of heart disease and GERD (gastrointestinal reflux disease). A 1/18/23 Meal Temperature Audit revealed resident food comments included the "meat was a little difficult to chew." The 2/22/23 and 4/20/23 Meal Temperature Audits revealed resident food comments included the food was "bland". The 3/27/23 Dining Committee Meeting Minutes revealed residents indicated the meat was tough. On 5/16/23 at 8:35 AM Resident 40 was in her/his room eating breakfast which consisted of a fried egg, toast, and sausage. Resident 40 stated the food had no flavor, was cold, the toast was soggy, and the egg was rubbery. The food did not appear appetizing. On 5/19/23 at 12:35 PM Resident 40 was observed in her/his room eating lunch which consisted of a chicken breast, garlic cauliflower, broccoli and a roll. Resident 40 stated the chicken was dry and she/he was not able to cut the chicken with a fork and the cauliflower and broccoli were cold with no flavor. Resident 40 had to call staff to cut her/his chicken and add gravy. The food did not appear appetizing. On 5/19/23 at 12:40 PM Staff 38 (CNA) and Staff 39 (CNA) observed Resident 40's lunch tray and stated the meal appeared unappetizing. On 5/17/23 at 1:22 PM a food test tray was sampled. The cheesy grits were bland without the taste or appearance of cheese as indicated on the menu. The pork was bland, appeared overcooked and tough. On 5/19/23 at 9:06 AM Staff 4 (Dietary Manager) stated in 1/2023 tough meats were addressed through staff education, the administration was notified and resident food concerns were addressed and continue to be addressed. 5. Resident 43 was admitted to the facility in 2022 with diagnoses including malnutrition. The 12/10/22 Admission MDS nutritional status CAA triggered due to a diagnosis of malnutrition. The resident's admitting weight was 93.4 lbs. The 3/3/23 revised care plan indicated Resident 43 had nutritional problem due to a low BMI, rheumatoid arthritis, the need for an altered texture diet, and increased metabolic demand for participation in therapies. The care plan further indicated goals to maintain adequate nutritional status as evidenced by maintaining weight and no signs or symptoms of malnutrition. A 1/18/23 Meal Temperature Audit revealed resident food comments included the "meat was a little difficult to chew." The 2/22/23 and 4/20/23 Meal Temperature Audits revealed resident food comments included the food was "bland." The 3/27/23 Dining Committee Meeting Minutes revealed residents indicated the meat was tough. On 5/15/23 at 1:03 PM Resident 43 was observed in her/his room having lunch. Resident 43 stated the food was awful, it was cold and had no flavor. Resident 43 had crumbled up meat with gravy, noodles and bread. Resident 43 stated she/he would not eat the food due to the food being cold and bland. The food did not appear appetizing. On 5/16/23 at 8:11 PM Resident 43 was observed in her/his room having breakfast. Resident 43 had scrambled eggs and toast. Resident 43 stated the food had no flavor, the bread was soggy and eggs were cold. Resident 43 stated most of the time she/he did not eat the food because it tasted bad and was cold. Resident 43 stated she/he did not ask for an alternative because all of the food tasted bad. On 5/16/23 at 8:22 PM Staff 22 (CNA) observed Resident 43's breakfast and stated the meal appeared unappetizing. On 5/17/23 at 1:22 PM a food test tray was sampled. The cheesy grits were bland without the taste or appearance of cheese as indicated on the menu. The pork was bland, appeared overcooked and tough. On 5/19/23 at 9:06 AM Staff 4 (Dietary Manager) stated in 1/2023 tough meats were addressed through staff education, the administration was notified and resident food concerns were addressed and continue to be addressed.

The dietary department will serve flavorful and palatable food to residents. RDM/Designee provided education on 06/12/2023 to the dietary department on serving flavorful and palatable food. RDM/Designee will complete weekly random meal tasting to validate the food is flavorful and palatable. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure food preferences were honored for 2 of 8 sampled residents (#s 46 and 400) reviewed for food. This placed residents at risk for lack of food choices. Findings include: 1. Resident 400 was admitted to the facility in 2023 with diagnoses including palliative care and chronic obstructive pulmonary disease. A 5/10/23 Dietary Profile indicated Resident 400 received a puree diet texture and liked bananas, muffins, beef, chicken and turkey but did not like sausage. A 5/11/23 BIMS evaluation revealed Resident 400 was cognitively intact. On 5/15/23 at 1:18 PM Resident 400 stated food came to her/him automatically and she/he received no choices for meals. Resident 400 stated preferences were asked during a recent interview but her/his preferences were not included in the food provided. On 5/17/23 at 9:31 AM Staff 9 (Dietary Manager) stated based on current food production sheets there were no alternative choices available for residents on a puree texture diet. On 5/18/23 at 12:01 PM with Staff 11 (Regional Dietary Manager) the kitchen computerized menu system was observed with the surveyor including specific food preferences for Resident 400. Staff 11 stated any resident with pureed texture or diabetic menus had meal choices but Staff 11 did not believe those options were communicated to all those residents. Staff 11 stated special diets were prepared as a "default" menu unless a resident was interviewed and a "select" menu was chosen. Staff 11 confirmed the food preferences for Resident 400 were not in the computer menu system as Staff 11 expected. Staff 11 stated because of the error Resident 400's food preferences were not honored. , 2. Resident 46 was readmitted to the facility in on 5/2023 with diagnoses including anxiety and contracture (shortening of tendons and ligaments). A 5/2023 Documentation Survey Report revealed on 5/14/23 no documentation Resident 46 received her/his breakfast or lunch. On 5/17/23 at 8:34 AM Resident 46 stated she/he requested cream of wheat, but the kitchen had none. Resident 46 was eating cold cereal. Staff 19 brought in another bowl of cold cereal. On 5/17/23 at 12:50 PM Staff 19 (CNA) stated during breakfast on 5/17/23 she went into the kitchen to get cream of wheat cereal for Resident 46 as she/he requested. Staff 19 stated the kitchen was out of cream of wheat cereal before the meal service was over and they offered to send oatmeal for Resident 46 instead. Staff 11 (Regional Dietary Manager) confirmed Resident 46 did not get what she/he ordered and had to settle for cold cereal. A 5/18/23 Dietary Profile indicated Resident 46 liked cream of wheat.

Resident #46 will be served food from her food preferences. Resident #400s food preferences will be inputted in the computer menu system. RDM/Designee will complete a baseline audit to validate all residents have their food preferences inputted in the computer menu system. RDM/Designee will provide further education on 06/12/2023 to the dietary department related to serving food based on residents food preferences and inputting food preferences in the computer menu system RDM/Designee will complete weekly audits on 10 randomly selected residents to validate they are receiving foods per their preference. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. RDM/Designee will complete weekly audits on new admissions to validate their food preferences are inputted in the computer menu system. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determine the facility failed to ensure processes were followed to provide a clean and sanitary kitchen for 1 of 1 kitchen. This placed residents at risk for food borne illnesses. 1. On 5/17/23 at 9:12 AM the Dish Machine Log for 5/2023 was reviewed and no temperatures or chemicals were yet recorded for 5/17/23. Staff 11 (Dietary Manager) was observed using the dish machine to wash dishes and was asked to test the chemical level of the low temperature dish machine. Results revealed the sanitizer level was at ten instead of 100 parts per million as required. Staff 4 (Dietary Manager) was called. On 5/17/23 at approximately 9:15 AM Staff 4 stated the kitchen typically used the dish machine to clean dishes left from the previous meal before breakfast was served and chemical levels and temperatures were not usually checked until after breakfast. Staff 4 stated all dishes would be rewashed because standards were not met. On 5/17/23 at 3:16 PM Staff 4 stated a new chemical system for the dish machine was installed in 3/2023 and not all staff were trained how to properly prime the machine pump when new chemicals were added. 2. On 5/17/23 at 12:01 PM the Service Line Checklist was reviewed for 5/17/23 and no start of meal food temperatures for breakfast or lunch were found. Staff 4 (Dietary Manager) stated food temperatures were to be checked prior to each meal service to ensure each food reached the minimum cooking temperature for food safety. Staff 4 confirmed the temperatures for breakfast and lunch on 5/17/23 did not occur as expected. On 5/17/23 at 12:15 PM the half wall between the kitchen food service area and preparation area was observed. A pipe connected from the top of the wall to the ceiling was covered with grease and dust, the hood and shelf above the stove was covered with a film of grease and splatters of brown debris and grease were on the wall behind the stove and on the side of the oven. Staff 4 stated the areas were to be cleaned daily and confirmed the amount of grease and debris in the area appeared to be more than a week's worth of accumulation. An unlabeled and undated cleaning log for the previous week was reviewed and Staff 4 stated it was not yet completed. On 5/17/23 at 11:52 AM Staff 8 (Dietary Aide) stated that resident and snack refrigerators were checked twice daily for outdated food. On 5/17/23 from 12:27 PM to approximately 12:40 PM the snack and resident refrigerators in the facility were observed with Staff 11 (Regional Dietary Manager). A variety of foods that belonged to residents and containers of boxed juices provided by the facility were identified as not appropriately dated to identify the expiration date of the food. A whole chicken with a date of 5/12/23, an opened container of banana almond milk with a date of 4/18/23 and unidentifed sandwiches with the date of 5/1/23 were also observed. Staff 11 confirmed all observed refrigerators contained some undated or outdated food and did not meet food safety standards. On 5/17/23 at 3:48 PM Staff 11 stated the weekly cleaning log were last completed on 4/2/23 and weekly cleaning of the kitchen was not done as expected.

The dietary staff is following processes to ensure the kitchen is clean and sanitary. RDM/Designee will complete a base line audit to validate the Dish Machine Log is completed per policy, food temperatures are being completed per policy and the cleaning log is being completed per policy. RDM/Designee provided further education on 06/12/2023 completing logs, use of the dish machine, cleaning tasks and taking food temperatures. RDM/Designee will complete random weekly audits to validate the Dish Machine Log and Cleaning log is completed routinely, temperature is taken on foods per policy and cleaning is being completed per policy. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to use PPE appropriately for 1 of 4 halls (subacute B) and 1 of 3 dining rooms (main dining room) reviewed for infection control. This placed residents at risk for exposure to infections. Findings include: On 5/15/23 at 12:33 PM Staff 44 (CNA) served meals in the main dining room. Staff 44 wore gloves, delivered and set up a meal for a resident, returned to the meal cart with the same gloves without completing hand hygiene and began to get another meal tray out for another resident. Staff 44 stated she wore the gloves because at times the residents required their meals to be cut up. Staff 44 stated she did not sanitize her hands in between serving residents because she wore gloves and did not change her gloves between residents. On 5/17/23 at 8:23 AM Staff 45 (NA) exited room 128 with gloves on, removed them as she went through the hall, balled the dirty gloves into her hand and went into room 125. Staff 45 then exited room 125 with a bag of garbage and the same balled up gloves in her hand, walked down the hall and disposed of both in the dirty utility room. Staff 45 confirmed she exited room 128 with gloves and brought them into room 125. Staff 45 stated this was not good practice but did it because she was in a rush. On 5/19/23 at 10:08 AM Staff 40 (LPN) was in the hallway with gloves on both hands and a handful of unbagged dirty linen in one hand. Staff 40 stopped in the hallway to speak with a staff, removed her face mask with a gloved hand and then placed the mask back on her face. Staff 40 then spoke to another staff, removed her face mask with the same gloved hand and then replaced the face mask. Staff 40 confirmed wearing the gloves in the hallway and touching her face mask with the glove was not acceptable practice but she was busy. On 5/19/23 at 10:17 AM Staff 42 (Infection Preventionist) reviewed the identified infection control issues and stated they were not acceptable.

IP/Designee provided further education on 6/12/23 to staff on appropriate hand hygiene and appropriate disposal of PPE. IP/Designee will audit 20 hand hygiene opportunities and 20 PPE use opportunities weekly. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure a RN was scheduled for 8 consecutive hours between day shift and evening shift 7 days per week for 5 of 15 days reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: The Direct Care Staff Daily Report forms were reviewed from 4/14/23 through 5/15/23. The review revealed from 5/1/23 through 5/15/23 there were 5 out of 15 days when the facility failed to have a RN scheduled on day or evening shift and a waiver was not in affect. On 5/19/23 at 1:15 PM Staff 28 (Regional Nurse Consultant) confirmed the lack of RN staffing after the end of waiver related to RN coverage.

The facility will use all available means to schedule an RN charge nurse consecutively for 8 hours between the start of day shift and the end of evening shift. The facility will utilize the existing RN waiver when unable to schedule an RN charge nurse for 8 hours consecutively between the start of day shift and the end of evening shift. The facility has hired 2 full time RNs and 1 part time RN and will continue to advertise and hire competent RNs. DON/Designee provided further education on 6/12/23 to scheduling staff related to scheduling an RN charge nurse between the start of day shift and the end of evening shift. DON/Designee will complete a weekly audit to validate an RN charge nurse was scheduled daily between the start of day shift and the end of evening shift. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing requirements were met for 15 out 79 shifts. This placed residents at risk of not receiving care in a timely manner. Findings include: A review of the DCSDRs (Direct Care Staff Daily Reports) from 5/20/22 through 5/23/22, 6/11/22 through 6/20/22, 10/1/22 through 10/11/22 and 2/15/23 through 2/25/23 revealed the facility did not have sufficient CNA staff to meet the minimum state required CNA to resident staffing ratio for 15 of 79 shifts. On 5/22/23 at 8:43 AM Staff 2 (DNS) stated she was aware the facility did not meet CNA staffing requirements and the facility was working on a solution.

The facility will use all available means to ensure minimum CNA staffing ratios are met each shift. The facility will continue to advertise and hire competent CNAs. DON/Designee provided further education on 6/12/23 to staff coordinators and managers on requirements related to minimum CNA staffing ratios. DON/Designee will complete weekly audits to validate minimum CNA staffing ratios are met each shift. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

******************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F550 and F552 ******************************** OAR 411-085-0360 Abuse Refer to F600 ******************************** OAR 411-086-0360 Resident Furnishings, Equipment Refer to F558 ******************************** OAR 411-086-0040 Admission of Residents Refer to F578 and F655 ******************************** OAR 411-085-0320 Residents ' Rights: Charges and Rates Refer to F582 ******************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F636, F656 and F657 ******************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684 and F685 ******************************** OAR 411-086-0230 Activity Services Refer to F679 ******************************** OAR 411-086-0150 Nursing Services: Restorative Care Refer to F688 ******************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689, F690 and F700 ******************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725, F732 ******************************** OAR 411-086-0210 Dental Services Refer to F791 ******************************** OAR 411-086-0250 Dietary Services Refer to F804, F806 and F812 ******************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ********************************

Based on interview and record review it was determined the facility failed to conduct thorough investigations to rule out abuse and neglect for 2 of 2 sampled residents (#s 12 and 188) reviewed for injuries of unknown origin. This placed residents at risk for abuse and neglect. Findings include: 1. Resident 12 was admitted to the facility in 2020 with diagnoses including heart failure and Alzheimer's Disease. An Incident Report dated 7/6/21 indicated a CNA reported Resident 12 had a new skin issue. The resident was assessed and found to have two shin wounds. The report indicated the wounds may have occurred when the resident was transferred using a sit-to-stand lift (mobility aide to assist residents to rise from a seated position and sit from a standing position). The resident was unable to give a description of what happened. There was no statement from the CNA who reported the incident or from the CNA who transferred the resident. The nurse who assessed the resident was not identified in the report. There was no documentation from the nurse who wrote the report to indicate why it was felt the wounds were a shearing injury related to the transfer using the sit-to-stand lift. No other substantial information was provided in the Incident Report. A Progress Note dated 7/9/21 included an investigation summary of the incident reported on 7/6/21 and indicated staff noted reddened areas on both the resident's shins. The resident did not know what happened but suggested it happened while she/he was being toileted and using the sit-to-stand lift since the shin wounds were located where the padding on the lift rested on her/his shins. The resident, who had an Alzheimer's diagnoses, was the only one to report the lift as the possible cause of the shin wounds. No documentation was found to indicate an investigation of the use of the lift was conducted or identification of the staff member who had transferred the resident. The summary indicated abuse and neglect were ruled out but not enough information was included in the summary to indicate how abuse and neglect were ruled out. No witness statements were included in the summary and no indication training would be provided to staff who transferred residents with mobility aides to prevent further injuries. On 4/22/22 at 10:07 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) indicated there were no additional investigation materials available and they understood the investigation was not thorough. 2. Resident 188 was admitted to the facility in 2021 with diagnoses including dementia and a history of falls. An Incident Report dated 4/30/21 indicated a CNA noted Resident 188's left foot was bleeding through her/his non-skid sock. A nurse removed the sock and the left great toe nail came off with the sock. Neither the CNA or the resident knew what occurred. No written witness or staff statements were included with the report. There was no information as to where the resident was, or what the resident was doing, when the injury occurred and no identification of any staff involved. A Progress Note dated 5/4/21 included an investigation summary for injury to the left great toe sustained on 4/30/21. The resident was assisted to the toilet by a CNA via the sit-to-stand lift (mobility aide to assist residents to rise from a seated position and sit from a standing position). When the CNA returned, bleeding was seen from the resident's left foot. When the sock was removed the toe nail came away with the sock. The summary included it was "likely the resident hit her/his toe against a part of the stand-aide during the transfer causing the injury to the toe." No information was included related to the sit-to-stand lift and how it may have been involved in the injury or if the resident was left alone in the lift. The CNA involved was not identified and no statement from the aide was provided. There was no information provided to indicate staff would receive additional training on use of the sit-to-stand lifts. The summary indicated abuse and neglect were ruled out but not enough information was included in the summary to indicate how abuse and neglect were ruled out. On 4/22/22 at 10:07 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) indicated there were no additional investigation materials available and they understood the investigation was not thorough.

Resident #12--thorough investigation will be completed of skin integrity compromise 7/6/21. Resident #188 is no longer a resident at the facility. Residents residing in the facility who experience an injury of unknown origin are at risk. DON/Designee completed baseline audit of the last 14 days of current residents who experienced an injury of unknown origin to verify that investigations are thorough. Identified inconsistencies addressed. Regional staff provided re-education to Administrator and DON related to conducting thorough investigations to include root cause analysis and including witness statements 5/17/22. DON/Designee initiated further education to Licensed Nurses 5/20/22 and ongoing on completing thorough investigations to include obtaining witness statements to assist in determining root cause. DON/Designee will conduct audit of incidents involving residents with injuries of unknown origin to verify a thorough investigation was completed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure psychotropic medications were appropriately managed for 2 of 7 sampled residents (#s 74 and 78) reviewed for medications. This placed residents at risk for unnecessary psychotropic medications. Findings include: 1. Resident 78 was admitted to the facility in 3/2022 with diagnoses including Alzheimer's Disease, depression and anxiety disorder. A review of the 3/2022 MAR indicated Resident 78 received: -Seroquel (antipsychotic) 50 mg at noon and 100 mg at bedtime for generalized anxiety. -Cymbalta (antidepressant) 60 mg twice a day for depression. -Namenda (used to treat confusion in dementia) 10 mg twice a day for dementia without behavioral disturbance. -Risperdal (antipsychotic) 0.5 mg twice a day for dementia/bipolar from 3/22/22 to 3/26/22. - Ativan (antianxiety) 1 mg every 4 hrs PRN for nausea, agitation or anxiety started 3/31/22. Resident 78 was admitted to hospice services on 3/31/22 related to dementia. A Psychiatric-Mental Health Nurse Practitioner (PMHNP) evaluation dated 3/31/22 recommended starting haloperidol (antipsychotic) 2.5 mg twice a day, Ativan 0.5 mg twice a day and consider decrease of Cymbalta as a dose greater than 60 mg was rarely effective with further plans to discontinue Cymbalta. There was no evidence in the record to indicate the recommendations were considered or implemented. A review of the 4/2022 MAR indicated: -Cymbalta dose did not change and was not discontinued per the recommendation of the PMHNP. -haloperidol 5 mg twice a day was started on 4/19/22, which was twice the recommended dosage. -Seroquel 200 mg twice a day reduced to 100 mg twice a day on 4/19/22. -Ativan 1 mg every 4 hrs PRN continued and was administered a total of 38 times. It was twice the recommended dose and not scheduled per the recommendation of the PMHNP. A Pharmacy Review dated 4/5/22 recommended an AIMS ([Abnormal Involuntary Movement Scale] used to determine the presence of abnormal movements caused by antipsychotic medications) be conducted for Resident 78. A Psychotropic Medication Review conducted on 4/13/22 with committee recommendations revealed the following: -continue Cymbalta -attempted use of Risperdal and subsequent discontinuation by hospice. -discontinue Seroquel 200 mg twice a day due to high dose and ineffectiveness -transition to haloperidol 5 mg twice a day to manage behaviors and review next month -continue use of Ativan. There was no documented risk/benefit or consent in the record for the use of Ativan or haloperidol, no rationale for the use of two antipsychotic medications or the high dose of Cymbalta and there was no evidence the recommendations provided by the PMHNP were reviewed or considered. Observations of Resident 78 on 4/27/22 and 4/28/22 found her/him to be up in a wheelchair looking out a window or watching TV, calm with occasional foot movements, fidgeting and talking to someone not seen. On 4/28/22 at 10:09 AM Staff 6 (Unit manager) was asked about the use of two antipsychotic medications, medication consents, the high dose of Cymbalta and when AIMS tests should be completed. Staff 6 stated when Resident 78 moved to LTC she was confused. Resident 78's Seroquel was 200 mg twice a day. The facility planned to decrease the resident's Seroquel dose and eventually discontinue the medication due to the high dose and ineffectiveness and use the haloperidol. Staff 6 stated the taper was usually for two weeks but it was not completed. She did not know why there were no consents for Ativan and haloperidol, why the dose of Cymbalta was double the usual dose or why the PMHNP recommendations were not implemented. She stated the AIMS test was usually done at admission and the pharmacist would inform the facility if one was needed. There was no evidence in the record to indicate further reduction of Seroquel or a change in the recommendations. On 4/28/22 at 11:39 AM Staff 2 (DNS) was asked about medication review and stated the facility obtained consents, conducted an AIMS test upon admission and residents were placed on monitoring. Staff 2 stated she was aware Resident 78 used Seroquel and Cymbalta prior to entering the facility and the facility made adjustments to the Seroquel to manage Resident 78's behaviors. Staff 2 did not provide any additional information related to the dose of Cymbalta. Staff 2 acknowledged the diagnosis for Seroquel was incorrect, a consent for Ativan was added to the record on 4/28/22 and there was no consent for the use of haloperidol. , 2. Resident 74 was admitted to the facility in 2019 with diagnoses including bipolar II disorder (patterns of manic and depressive episodes) and anxiety disorder. Resident 74's medical record revealed she/he received psychotropic medications since admission to the facility. The 9/14/21 Psychotropic Medication Review revealed the following information regarding the resident's medications: -Abilify (antipsychotic) 2 mg every morning, decreased from 5 mg based on a 5/6/21 GDR, -Buspar (antianxiety) 10 mg BID, -Ambien (hypnotic) 5 mg at bedtime, increased from 2.5 mg on 6/23/21 due to a failed GDR attempted on 4/7/21 and -Wellbutrin (antidepressant) 150 mg every morning started 10/1/19. A 2/15/22 physician order indicated Resident 74's Ambien was increased from 5 mg to 7.5 mg at bedtime. The 3/7/22 Psychotropic Medication Review noted the increase in the dose of the resident's Ambien to 7.5 mg at bedtime. There was no additional information regarding the increased dose of the medication. A physician order dated 3/23/22 decreased the dose of Ambien to 5 mg at bedtime. The medical record revealed no additional information related to the decreased dose of Ambien. Psychotropic Medication Reviews from 3/1/21 through 3/23/22 lacked information related to GDRs for the Buspar and Wellbutrin. The 4/2022 MAR indicated Resident 74 currently received the following psychotropic medications and the dosages: -Abilify 2 mg every morning, -Buspar 10 mg BID, -Ambien 5 mg at bedtime and -Wellbutrin 150 mg daily. During an interview on 4/28/22 at 9:38 AM Staff 6 (Unit Manager) stated the resident wanted to be in charge of her/his psychiatric medications but she/he did not go to scheduled appointments or follow up as required. Staff 6 said the resident recently went to a different doctor for Ambien and got the dose increased after the dose was decreased. Staff 6 indicated other staff were aware of the resident's attempts to be secretive and manipulative with her/his medications. Staff 6 indicated GDR information should be documented in the resident's record. The surveyor requested copies of the GDR history for the resident's current psychotropic medications: Abilify, Ambien, Buspar and Wellbutrin. No additional information was provided.

Resident # 74 Lowest Effective Dose for Wellbutrin, Buspar, Ambien and Abilify were reviewed and documented in psychotropic meeting 5/11/22 with the provider present and involved. Resident #78 recommendations by PMHNP 3/31/22 were reviewed by current hospice provider. Consent for Haldol obtained 4/29/22. Residents with orders for psychotropic medications are at risk. NHA/Designee completed baseline audit of current residents with an order for a psychotropic medication to verify that resident has consented to medication, that GDR tracking is being monitored, orders are aligned with recommendations, and AIMS is conducted for residents who take antipsychotics. Identified inconsistencies addressed. NHA/Designee initiated further education to Unit Managers, MDS and Social Services on 5/20/22 and ongoing related to Unnecessary medications with specific focus on psychotropic medications to include the required tracking on GDRs, obtaining consents for use, completion of AIMs for those that take an antipsychotic, and process for follow up on recommendations from PMHNP. NHA/Designee will conduct audit of newly prescribed psychotropics to verify that resident has consented to medication, GDR tracking is being monitored, recommendations are followed up, and AIMS is completed on resident who is taking antipsychotic. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

****************************** 411-085-0360 Abuse Refer to F610 ****************************** 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F758 ******************************