Life Care Center of Coos Bay

Resident 6 was admitted to the facility in 11/2025 with diagnoses including Alzheimer's disease. -á A 11/25/25 Admission MDS indicated Resident 6 was severely impaired and rarely made decisions, had disorganized thinking, and altered level of consciousness. -á The facility's 12/8/25 investigation documented that Resident 6 had been found in bed with blankets tucked in on both sides of her/his body, restricting movement. The investigation concluded that abuse and neglect had not been substantiated, but the rolled blankets had limited the resident's movement, and staff had significantly deviated from resident-rights standards and facility policy. -á The investigation included the following written staff statements: -Staff 3 (CNA) reported Staff 3 and Staff 4 found Resident 6 in a praying position, lying sideways on the bed. Staff 3 and 4 assisted Resident 6 back into the center of the bed. Two subsequent times, staff found Resident 6 in a ""weird"" position, though not on the floor. Staff 3 and Staff 4 folded blankets and placed them on both sides of Resident 6 to keep the resident in a ""safe"" position in bed. -Staff 4 (CNA) documented during resident rounds she had seen Resident 6 lying sideways in a ""weird"" position. Staff 3 asked about using pillows, and Staff 11 (RN) stated it was okay. No pillows were available, so blankets were rolled up and placed under the resident on each side, with a sheet tucked in at the foot of the bed. -á -Staff 11 (RN) reported Resident 6 was hard of hearing and ""very wiggly."" Staff had found the resident in ""weird"" positions at night, with her/his head on one side of the bed and feet off the other side, but not on the floor. -áStaff 3 had suggested using pillows, but none were available, so staff had tucked blankets under the mattress at the foot of the bed. -á -á On 4/15/26 at 9:13 AM, Staff 4 confirmed her written statement was accurate. Staff 4 stated she would never place blankets under a resident on that way again because it was considered a restraint, and Resident 6 could not exit the bed if she/he wanted to. -á On 4/16/26 at 7:55 AM, Staff 3 confirmed her written witness statement was accurate. Staff 3 stated she and Staff 4 were unable to find pillows, so they used blankets rolled up. Staff 3 stated she was educated and now knows it was not permitted to roll blankets as it was a restraint for Resident 6. -á On 4/16/25 at 8:41 AM, Staff 5 (CNA) stated when she entered Resident 6's room on 12/8/25, the resident grasped her arm and had a concerned expression. Usually, Resident 6 smiled when Staff 5 entered the room. Staff 5 stated she observed blankets ""waded"" at both sides of Resident 6 and a sheet wrapped over the top of her/him and tucked under the blankets in a manner which restricted the residentGÇÖs movement. -á On 4/16/26 at 12:38 PM, Staff 2 (DNS) confirmed Staff 3 and Staff 4 should not have placed blankets under Resident 6 restricting her/his movement. -á

F 604  Right  to be Free from Physical Restraints How the nursing home will correct the deficiency as it relates to the resident .    Resident 6 no longer  resides  in facility ? How? the ?nursing home? will act ?to protect residents in similar? situations. ?No residents were? identified , but all residents could be affected.? ? ? Measures the nursing home will take or systems it will alter to ensure that the problem does not recur .   C NA’s  were in - service d on Residents Rights. ? How? the ?nursing home? plans ?to? monitor ?its performance to make sure that solutions are? sustained. ?? Random audits of residents  will be? conducted  monthly?x3  to verify that Residents are free from any physical restraints  and until?substantial?compliance is achieved.?Results of audits will be reported to QAPI ? ? Dates when corrective action will be completed: ?? May 5 th  2026 ?   ? ? ? The title of the person responsible to ensure correction: ??DON or designee ?

Resident 5 was admitted to the facility in 3/2026 with diagnoses including multiple sclerosis (MS) (an autoimmune disease that affects the central nervous system, leading to damage of the nerve fibers, resulting in a range of physical and cognitive symptoms). -á A 3/18/26 MDS indicated Resident 5 was cognitively intact. -á A 3/17/26 Event Note indicated Staff 20 (Assistant DNS) was notified Resident 5 had marijuana in her/his room. Resident 5 stated her/his friend brought it in. Staff 20 educated Resident 5 on the importance and side effects with medication. Resident 5 informed Staff 20 she/he would have her/his friend pick up and remove the marijuana from the facility. Staff 20 documented ResidentGÇ»5GÇÖs friend removed the marijuana from the facility. -á Psychosocial Notes dated 3/18/26 indicated Staff 19 (Social Services Director) stated Resident 5 told StaffGÇ»20 she/he had marijuana and a pipe in her/his room on 3/18/26 and used the marijuana. Staff 19 documented GÇ£staff membersGÇ¥ smelled the marijuana in her/his room. StaffGÇ»19 went into Resident 5GÇÖs room with Staff 21 (Medical Records Director) and informed ResidentGÇ»5 the facility could no longer continue care and would discharge her/him home on 3/18/26 because she/he had used marijuana, which violated facility policy. ResidentGÇ»5 became upset, yelled, and kicked a table. Staff 22 (LPN Unit Care Coordinator) entered the room and informed Resident 5 the facility was federally funded and could no longer keep her/him. Staff 22 explained that smoking combined with aggressive behavior meant she/he was not in the right facility. ResidentGÇ»5 yelled and cursed, stating she/he would not leave. Staff 20, Staff 7 (LPN), and Staff 33 (LPN) also entered the room. -á A 3/18/26 Care Management Note indicated Staff 22 heard Resident 5 yelling, GÇ£beratingGÇ¥ staff, throwing items, and kicking the bedside table. Resident 5 had smoked marijuana in the facility. Staff discussed the policy forbidding indoor smoking. Marijuana was not allowed and was confiscated by Staff 20 on 3/17/26. Reports of continued use were received on 3/18/26. Discharge was warranted, and physician orders were obtained. StaffGÇ»attempted to discuss discharge options; Resident 5 continued to scream, curse, and verbally insult Staff 22. ResidentGÇ»5 refused to leave. Staff 22 stated safeGÇædischarge education was needed; Resident 5 responded, GÇ£IGÇÖm not going anywhere.GÇ¥ Local law enforcement was contacted to assist. -á Review of Resident 5's clinical round found a Notice of Involuntary Transfer dated 3/18/26 and was issued due to resident's behaviors created a serious and immediate threat. -á A 3/18/26 Discharge Summary indicated Resident 5 discharged to home or community reason for discharge was non-compliance with facility policy. Resident required one person with stand pivot transfers, dressing and bed mobility. Home health services was not checked. -á On 4/13/26 at 8:18 AM andGÇ»4/15/26GÇ»at 8:45 AM, Resident 5 stated staff searched her/his room without consent. StaffGÇ»20 entered with a bag and stated she/he could not have it. ResidentGÇ»5 stated she/he did not know the contents. Resident 5 explained that a friend brought it and he/she was unaware. With multiple sclerosis, ResidentGÇ»5 stated she/he had difficulty with emotions from GÇ£ragingGÇ¥ to crying to laughing. Resident 5 stated five staff members were in her/his room, and it felt GÇ£overwhelming.GÇ¥ Resident 5 felt GÇ£attackedGÇ¥ upon learning of the discharge. With no alternatives, she/he GÇ£blew a fuse.GÇ¥ ResidentGÇ»5 stated she/he never smoked the marijuana and did not touch the marijuana. -á On 4/16/26GÇ»atGÇ»9:53 AM, StaffGÇ»19 stated in a 3/18/26 staff meeting she had been informed the facility would discharge ResidentGÇ»5 for using marijuana and that Staff 20 stated ResidentGÇ»5 had smoked the marijuana. -á On 4/16/26 atGÇ»10:17 AM, StaffGÇ»22 stated ResidentGÇ»5 smoked over the weekend of 3/14/26 which was reported through the 24GÇæhour report. She explained they could not safely provide care due to threats to staff. -á On 4/16/26 at 10:25 AM, Staff 20 stated he had found Resident 5's marijuana in her/his room. Staff 20 stated Resident 5's friend came and got the marijuana. Staff stated that Resident 5 told him they had not used any of the marijuana and was upset about being discharged. Staff 20 did not hear from other staff Resident 5 had smoked in the facility. -á On 4/16/26 at 10:31 AM, Staff 21 stated during staff meeting on 3/18/26 he was informed Resident 5 had been caught smoking marijuana, and it was confiscated and was caught a second time. Staff 20 confiscated the marijuana and Resident 5 was caught a second time.-á -á On 4/16/26 at 12:27 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated on 3/17/26 Resident 5 had marijuana in her/his room and it was removed. The next morning Resident 5 was smoking in her/his room. Staff 1 thought Staff 20 had seen her/him smoking. Staff 1 stated Resident 5 had made the decision to leave. Staff 1 put in a form for involuntary transfer and thought she had completed one for a 30-day and one for an immediate transfer. -á -á

F 627  Inappropriate  Discharge How the nursing home will correct the deficiency as it relates to the resident .    Resident 5 no longer  resides  in facility ? How? the ?nursing home? will act ?to protect residents in similar? situations. ?All residents who have  discharged  from the  building  the last  30 days  at the buildings request will have their charts reviewed for  appropriate notice  of discharge. ? Measures the nursing home will take or systems it will alter to ensure that the problem does not recur .   The IDT  team  will be in - serviced on  the facility  Notice of  Transfers or Discharges Policy. ? How? the ?nursing home? plans ?to? monitor ?its performance to make sure that solutions are? sustained. ?? The facility will audit  all residents discharging  from  the facilit y weekly x 4 and then monthly x2  to verify the  appropriate Notice  of Transfer w as issued. ?Results of audits will be reported to  facility  QAPI  team. ? ? Dates when corrective action will be completed: ??May 5 th  2026 ?   ?

Review of the facility's bariatric records for 3/2026 and 4/2026 indicated the facility had four bariatric residents. -á Review of the facility's Direct Care Staff Daily Reports for 3/2026 and 4/2026 indicated the following understaffed bariatric staffing ratios: -á -3/27/26: Day shift understaffed two CNAs, evening shift understaffed one CNA, and night shift understaffed one CNA. -3/28/26: Evening shift understaffed two CNAs and night shift understaffed one CNA. -3/29/26: Day shift understaffed two CNAs evening shift understaffed two CNAs. -3/30/26: Day shift understaffed one CNA and evening shift understaffed one CNA. -3/31/26: Day shift understaffed one CNA. -4/1/26: Evening shift understaffed one CNA. -4/2/26: Night shift understaffed one CNA. -4/3/26: Evening shift understaffed one CNA. -4/4/26: Day shift understaffed two CNAs, evening shift understaffed two CNAs, and night shift understaffed two CNAs. -á On 4/16/26 at 12:43 PM, Staff 1 (Administrator) confirmed the facility was understaffed for bariatric residents. Staff 1 stated Staff 17 (Staffing Coordinator) was out on leave and Staff 1 was out of the facility during the days understaffing occurred.

M0185  Bariatric Criteria and Services How the nursing home will correct the deficiency as it relates to the resident. ? ? Staffing coordinator? monitors ?daily requirements for bariatric standards. ? How? the ?nursing home? will act ?to protect residents in similar? situations. ? ? No bariatric residents were? identified ?however bariatric residents?have the potential to be affected by this alleged deficient practice. ? Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. ? ? A recruitment ad for NAC’s will be placed online  and on the facility website  to help recruit new  NAC’s  to the community.  ? How? the ?nursing home? plans ?to? monitor ?its performance to make sure that solutions are? sustained. ?? ? Staffing will be audited weekly x4  and  then monthly  x 2 ? or  until substantial compliance is achieved.?Results will be reported to  the facility  QAPI  team.  ? Dates when corrective action will be completed: ??? ? May 5, 2026 ? ? The title of the person responsible to ensure correction: ?? ? ED or designee ?

Resident 5 was admitted to the facility in 3/2026 with diagnoses including multiple sclerosis (an autoimmune disease that affects the central nervous system, leading to damage of the nerve fibers, resulting in a range of physical and cognitive symptoms). Resident 5 was discharged on 3/18/26. -á A 3/18/26 MDS indicated Resident 5 was cognitively intact. -á Review of Resident 5's clinical round found a Notice of Involuntary Transfer dated 3/18/26 and indicated it was due to the resident's behaviors created a serious and immediate threat. There was no evidence Resident 5 was provided adequate written transfer notice prior to the resident's discharge. -á On 4/16/26 at 12:27 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated on 3/17/26 Resident 5 had marijuana in her/his room and it was removed. The next morning Resident 5 was smoking in her/his room. Staff 1 thought Staff 20 had saw her/him smoking. Staff 1 stated Resident 5 had made the decision to leave. Staff 1 put in a form for involuntary transfer and thought she had completed one for a 30-day transfer and another one for an immediate transfer.-á

M 0402  Transfer  Notice  Less than 30 Days How the nursing home will correct the deficiency as it relates to the resident .    Resident 5 no longer  resides  in facility ? How? the ?nursing home? will act ?to protect residents in similar? situations. ?All residents who have  discharged  from the  building  the last  30 days  at the buildings request will have their charts reviewed for  appropriate notice  of discharge. ? Measures the nursing home will take or systems it will alter to ensure that the problem does not recur .   The IDT team will be in-serviced on the facility Notice of Transfers or Discharges Policy. ? How? the ?nursing home? plans ?to? monitor ?its performance to make sure that solutions are? sustained. ?? The facility will audit all residents discharging from the facility weekly x 4 and then monthly x2 to verify the  appropriate Notice  of Transfer was issued.?Results of audits will be reported to facility QAPI team. ? ? Dates when corrective action will be completed : ??May  5 th  2026 ?   ? ? ? The title of the person responsible to ensure correction: ??ED or designee ?

2. Resident 24 admitted to the facility in 9/2024 with diagnoses including anxiety and diabetes. -á A 6/5/25 physician order included sertraline 50 MG (used to treat anxiety) one time daily and a 9/16/25 physician order included trazodone 25 MG (used to treat anxiety and insomnia) at bedtime. Resident 24GÇÖs 6/2025 through 12/2025 MARs revealed the resident received sertraline 50 MG daily since 6/6/25. Resident 24GÇÖs 9/2025 through 12/2025 MARs revealed the resident received trazodone 25 MG nightly since 9/16/25. A review of Resident 24GÇÖs medical record revealed no documentation that Resident 24 was informed of the risks and benefits for use of sertraline and trazodone prior to administration. On 12/19/25 at 8:36 AM Staff 2 (DNS) confirmed Resident 24 was not provided with the risk and benefits for use of sertraline and trazodone. , 1. Resident 5 was admitted to the facility in 3/2025 with a diagnosis of fibromyalgia (widespread chronic pain). Resident 5's 9/16/25 Quarterly MDS indicated the resident was cognitively intact with a BIMS score of 13.-á Resident 5GÇÖs 10/2025 physician orders included amitriptyline (antidepressant) 50 mg once daily at bedtime, started on 10/21/25. There was no evidence in Resident 5GÇÖs health record to indicate the resident was informed of the risks, benefits, and side effects of amitriptyline prior to administration. On 12/17/25 at 9:12 AM, Resident 5 was unable to recall details of her/his medications.-á On 12/18/25 at 3:02 PM, Staff 4 (LPN Resident Care Manager) reviewed Resident 5's health record and confirmed there was no evidence Resident 5 was provided the risks and benefits for the amitriptyline. -á

F0552: Right to be Informed/Make Treatment Decisions Individual Residents: Resident #5 has been informed of the risks, benefits, and side effects of amitriptyline. Resident #24 has been informed of the risks, benefits, and side effects of sertraline and trazodone. Residents in Similar Situations: DON or Designee will conduct an audit of all current residents using a psychotropic medication, to ensure that all have been informed of the risks, benefits, and side effects of using a psychotropic medication. Measures to Prevent Reoccurrence: DON or Designee will re-educate all licensed nurses on the policy of “Informed Consent” Any newly hired Licenses nurses will receive the same education Ongoing Monitoring: DON or Designee will audit residents on psychotropic medication to ensure they have been informed of the risks, benefits, and side effects, weekly x4 weeks, then monthly x2 to ensure documentation is present for all psychotropic medication.  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

The facilityGÇÖs 1/7/25 Grievance Program policy detailed expectations for a prompt effort to resolve grievances and maintain a recordkeeping system with grievance receipt date, grievance summary statement, investigation steps, pertinent findings or conclusions, whether grievance was confirmed or not confirmed, and decision date. -á A review of facility grievances from 7/2025, 8/2025, 9/2025, 10/2025, and 11/2025 revealed six grievance forms with incomplete documentation to indicate the grievances were resolved. -á -á On 12/18/2025 at 1:39 PM Staff 1 (Administrator) said the process for addressing grievances was to fill out a Concern and Comment card, submit the card to the Social Services Director, complete an investigation, then once all steps toward resolution were finished the Administrator signed off on the card. Staff 1 said once her signature was on the card the investigation was considered closed. Staff 1 reviewed the six incomplete grievances and confirmed documentation toward resolution was incomplete.

Individual Residents Grievances identified during survey as not completed have been completed. Residents in Similar Situations: LNHA or designee will audit open grievances to ensure that documentation showing resolution is complete. Measures to Prevent Reoccurrence: On or before 2/2/26 ED or Designee will re-educate IDT on the policy of Grievance Program. Ongoing Monitoring: LNHA or designee will audit grievances to ensure that documentation showing resolution is complete, weekly x4 weeks, then monthly x2 to ensure documentation is present for all grievances.  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

Resident 52 admitted to the facility in 11/2024 with diagnoses including anxiety and adult failure to thrive. An 11/4/25 Annual MDS revealed a BIMS score of 14 which indicated the resident had no cognitive impairment. Resident 52 passed away in the facility on 11/25/25. On 12/18/25 at 9:51 AM and at 1:49 PM Staff 16 (CNA) stated she witnessed Staff 17 (CNA) showing pictures of Resident 52GÇÖs genitals to Staff 18 (CNA) on Staff 17GÇÖs personal cell phone. Staff 16 stated the incident occurred in 11/2025, and she reported it to Staff 1 (Administrator) the following Monday. No evidence was found to indicate the incident was reported to the State Agency. On 12/18/25 at 11:27 AM Staff 1 and Staff 2 (DNS) stated they were unaware of any allegations of abuse related to Resident 52. Staff 1 stated she spoke with Staff 16 recently regarding a separate incident but was not told about an incident regarding Resident 52. On 12/18/25 at 2:15 PM Staff 1 and Staff 2 stated they just learned Staff 19 (Staffing Coordinator) was aware of the allegation of abuse involving Resident 52 in 11/2025 and it was not reported to the State Agency. On 12/18/25 at 2:28 PM Staff 19 stated on 12/8/25 in the morning before 8:30 AM, Staff 16 told her about an incident that occurred over the weekend that was already reported to Staff 1 and proceeded to tell Staff 19 about a different incident that involved Staff 17, Staff 18, and Resident 52 that occurred in 11/2025. Staff 19 stated she told Staff 16 to go report that incident to Staff 1 immediately. Staff 19 stated she did not follow up with Staff 1 to confirm the allegation of abuse was reported. On 12/18/25 at 5:33 PM Staff 2 stated she expected all staff to report any allegations of abuse immediately to their supervisor so the State Agency could be notified timely.

Individual Residents Resident 52 no longer resides at the facility Residents in Similar Situations: Alert residents on the unit, along with additional staff members, to identify any additional concerns related to reporting abuse. Measures to Prevent Reoccurrence: ED or Designee will re-educate staff on Reporting Abuse and Neglect. Ongoing Monitoring: Random staff quizzes will be completed related to reporting abuse weekly x4 weeks, then monthly x2 .  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

-á 2. Resident 66 admitted to the facility in 9/5/25 with a diagnosis of pneumonia. A 10/9/25 Progress Note revealed Resident 66 experienced a change of condition and was sent to the hospital. A review of the medical record revealed no indication a written Notice of Transfer was issues to Resident 66 or her/his resident representative.-á On 12/18/25 at 4:53 PM Staff 24 (LPN) stated she did not issue a written Notice of Transfer to Resident 66 when she sent her/him to the hospital and was not aware it was required.-á , 1. Resident 8 admitted to the facility in 5/2024 with diagnoses including bipolar disorder and diabetes. A review of Resident 8GÇÖs medical record revealed she/he was transferred to the hospital on 10/10/25 due to confusion and unrelieved pain. Resident 8 re-admitted to the facility from the hospital on 10/28/25 with a diagnosis of septic arthritis in the right hip. -á A review of Resident 8GÇÖs medical record revealed no indication the resident was notified in writing of the reason she/he was transferred to the hospital. On 12/18/25 at 4:34 PM Staff 2 (DNS) stated Resident 8 was not notified in writing of the reason she/he went to the hospital.

Individual Residents Resident 8 notice of transfer has been reported to OMBUDSMAN in monthly report Resident 66 is no longer at the facility Residents in Similar Situations: DON or Designee will audit all transfers to ensure proper notifications are reported. Measures to Prevent Reoccurrence: DON or Designee will re-educate licensed Nurses on Notice before transfer. Ongoing Monitoring: DON or Designee will audit transfers to ensure that residents re weekly x4 weeks, then monthly x2.  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

Resident 1 was admitted to the facility in 9/2025 with diagnoses including right leg fracture and sepsis (life-threatening medical emergency caused by the bodyGÇÖs overwhelming response to an infection). A 9/23/25 Admission MDS revealed a BIMS score of 15 which indicated the resident had no cognitive impairment. On 12/15/25 at 12:47 PM Resident 1 stated she/he was supposed to receive restorative services after skilled therapy ended, but staff had not walked or done any exercises with her/him in several weeks.-á On 12/16/25 at 1:20 PM Staff 21 (CNA) stated the facility had two RAs (Restorative Aides) and they completed all the restorative therapies for the residents. Staff 21 stated she did not do any exercises or ambulation with Resident 1. On 12/17/25 at 9:28 AM Staff 22 (CNA) stated there were RAs who completed all the restorative programs for the residents. On 12/17/25 at 1:43 PM Staff 4 (LPN, Unit Care Coordinator) stated Resident 1GÇÖs restorative program was completed by the CNAs and there were no RAs in the facility. On 12/18/25 at 12:44 PM Staff 2 (DNS) Staff 2 stated she expected CNAs to read the care plan before each shift and follow the care plan related to the restorative program.-á -á

Individual Residents Resident 1 is receiving restorative services Residents in Similar Situations: DON or designee will audit care plans and POC tasks of current residents to ensure if restorative services are indicated, and that these services are being provided Measures to Prevent Reoccurrence: DON or Designee will re-educate CNA’s on how to utilize the restorative assignment in POC to complete documentation, and how they can view the restorative information on the Kardex. Ongoing Monitoring: DON or Designee will audit residents with a restorative program and ensure they are receiving services weekly x4 weeks, then monthly x2.  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

-á 2. Resident 45 admitted to the facility in 7/2024 with a diagnosis of diabetes. A 12/3/25 physician order revealed Resident 45 was to receive wound care on her/his right shin every three days.-á The 12/2025 MAR revealed Resident 45 was documented to have received wound care on her/his right shin on 12/12/25 by Staff 21 (LPN) and on 12/15/25 by Staff 25 (LPN). On 12/15/25 at 4:24 PM Resident 45's right shin was observed with a dressing in place with ""12/8"" written on it.-á-á On 12/16/25 at 10:27 AM Resident 45's right shin was observed with a dressing in place with ""12/8"" written on it. Resident 45 stated her/his wound was last changed on whatever date was written on the dressing.-á On 12/16/25 at 10:31 AM Staff 25 confirmed Resident 45's wound care was scheduled to be completed every three days and the current dressing on her/his right shin was dated ""12/8"". Staff 25 stated Resident 45's wound care needed to be completed.-á On 12/18/25 at 12:55 PM Staff 21 stated she did not recall if she changed Resident 45's right shin dressing as scheduled on 12/12/25, but if she did, she would have signed and dated the dressing.-á On 12/18/25 at 3:00 PM Staff 2 (DNS) stated Resident 45's dressing was expected to be changed as scheduled and when the nurse changed dressings they were to sign and date the dressing.-á On 12/18/25 at 4:13 PM Staff 25 stated she saw Resident 45's 12/15/25 wound care was not completed and stated she if she signed the wound care as complete, she would have intended to complete the task but did not get to it. Staff 25 stated she did not recall if she asked another nurse to do Resident 45's 12/15/25 wound care.-á -á , Resident 24 admitted to the facility in 9/2024 with diagnoses including chronic pulmonary embolism (when blood clots in the lung arteries donGÇÖt dissolve leading to blocked blood flow) and diabetes. -á A review of the 12/2025 MAR revealed a 6/5/25 physician order for Eliquis (an anticoagulant) 5 MG one tablet by mouth two times a day for chronic pulmonary embolism. The 12/11/25, 12/12/25, and 12/13/25 MAR indicated the 8 AM dose was not given to Resident 24 and coded as, GÇ£Other/See Progress NoteGÇ¥ by Staff 21 (LPN). A review of Resident 24GÇÖs progress notes for 12/11/25, 12/12/25, and 12/13/25 revealed Eliquis 5 MG tablet was GÇ£on order.GÇ¥ No further information was documented. On 12/17/25 at 1:30 PM and on 12/18/25 at 4:49 PM Staff 21 stated if a resident was out of a medication the pharmacy and physician was notified, and she checked the Omnicell machine (an automated medication management system to securely store, track, dispense, and manage pharmaceuticals) to see if the medication was on hand. Staff 21 stated if she notified the physician and pharmacy, she would have made a progress note in the residentGÇÖs chart. Staff 21 stated she did not recall if she checked the Omnicell on 12/11/25, 12/12/25, and 12/13/25 for Resident 24GÇÖs Eliquis medication. On 12/18/25 at 5:28 PM Staff 2 (DNS) stated if a resident was out of a medication the nurse was to verify it was re-ordered and check if the medication was available in the Omnicell. If the medication was not available, the nurse was to call the pharmacy to satellite the order, notify the physician of a missed dose of medication and the nurse on-call was to be notified. Staff 2 stated Eliquis 5 MG tablet was a medication available in the Omnicell and stated she was the nurse on-call during the weekday. Staff 2 stated she was not notified by Staff 21 that Resident 24 missed a dose of Eliquis on 12/11/25, 12/12/25, and 12/13/25. On 12/19/25 at 8:36 AM Staff 2 provided an Omnicell Transaction by Item, Eliquis 5 MG tablet 1 each, report for a date range of 12/7/25 through 12/13/25. This report revealed the following two transactions: -12/12/25 at 7:43 PM one Eliquis 5 MG tablet was dispensed from the Omnicell for Resident 24 and there was a total of eight Eliquis 5 MG tablets on hand in the Omnicell. -12/13/25 at 7:30 PM one Eliquis 5 MG tablet was dispensed from the Omnicell for Resident 24 and there was a total of seven Eliquis 5 MG tablets on hand in the Omnicell. On 12/19/25 at 11:25 AM Staff 2 confirmed Eliquis 5 MG tablet was available in the Omnicell and should have been given to Resident 24 on 12/11/25, 12/12/25, and 12/13/25 per the physician order.

Resident 24 is receiving Eliquis as ordered Resident 45 dressing is being changed as ordered Residents in Similar Situations: DON or designee will conduct an audit of current physician orders for wounds to ensure orders are being followed.  DON or designee will audit administration records to ensure medications orders are being followed. Measures to Prevent Reoccurrence: DON or Designee will re-educate Licensed Nurses on 5 rights of medication and the importance of completing provider orders accurately, and the process of documenting and notifying the provider of a missed or refused medication or treatment. Ongoing Monitoring: DON or Designee will audit residents x4 weeks, then monthly x2 .  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

The facilityGÇÖs 7/22/25 Antibiotic Stewardship Policy indicated the facility should follow the McGeer Criteria for assessment of residents suspected of having an infection prior to initiation of antibiotics. According to Revised McGeer Criteria for Infection Surveillance, UTI without indwelling catheter must fulfill at least one sign or symptom on a checklist. The symptoms include discomfort, fever, leukocytosis, hematuria, and/or increase in incontinence, urgency, or frequency. Resident 5 was admitted to the facility in 3/2025 with diagnoses including fibromyalgia (widespread chronic pain). -á Resident 5GÇÖs 11/15/25-12/1/25 progress notes revealed no urinary complaints including discomfort, fever, leukocytosis, hematuria, or increased urgency/frequency/incontinence. Resident 5GÇÖs health record demonstrated a UA collection occurred on 12/1/25. Resident 5GÇÖs health record revealed no corresponding physician order for the UA. A 12/1/25 UA Final Result report reflected positive results for leukocytes, nitrites, protein, blood, and two or more types of bacteria. There was no evidence in the resident record to support a sensitivity was completed to identify an appropriate antibiotic to treat the UTI. A 12/4/25 Physician Order included Nitrofurantoin (antibiotic) 100 mg, one capsule by mouth twice daily for 10 days for UTI. On 12/18/25 at 4:45 PM, Staff 15 (Medical Director) reviewed the 12/1/25 UA report and confirmed it reflected positive results which supported the need for a culture and sensitivity test. Staff 15 indicated the importance of starting residents on an accurate antibiotic to eliminate bacteria causing a UTI. On 12/19/25 at 10:46 AM, Staff 2 (DNS) confirmed Resident 5GÇÖs health record lacked documentation of any urinary complaints leading up to the 12/1/25 UA and acknowledged the lack of a physician order for the UA test. -á Staff 2 stated Resident 5GÇÖs 12/1/25 UA results were indicative a culture and sensitivity should have been carried out to ensure the appropriate antibiotic was administered. -á

All residents currently on antibiotics  meet McGeer criteria and were prescribed appropriately. DON or designee will provide LN education on McGeer criteria and antibiotic stewardship. DON or Designee will audit residents receiving antibiotics to ensure they were prescribed appropriately x4 weeks, then monthly x2 .  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

Resident 24 admitted to the facility in 9/2024 with diagnoses including diabetes and anxiety. A 12/4/25 pharmacy recommendation revealed Resident 24 received a thyroid replacement medication but a TSH (Thyroid-Stimulating Hormone) laboratory test within the last year was not located in the residentGÇÖs medical record. A 12/10/25 physician order revealed an order for a fasting lipid panel, TSH and serum magnesium concentration laboratory test scheduled for 12/10/25. A review of the 12/2025 TAR revealed the task to draw labs for a fasting lipid panel, TSH and serum magnesium concentration was completed on 12/10/25 at 5:34 AM. A review of the 12/11/25 lab results revealed results to the lipid panel and magnesium tests, but no indication of results for the TSH lab test. A review of Resident 24GÇÖs record revealed no indication of the TSH lab results. On 12/18/25 at 4:15 PM Staff 4 (LPN Unit Care Coordinator) confirmed the TSH lab was not drawn for Resident 24 and should have been drawn on 12/10/25 with the lipid panel and magnesium. Staff 4 stated she expected staff to ensure lab services were provided when ordered.

Individual Resident :  Resident 24 has had TSH lab done. Residents in Similar Situations: DON or designee will audit current residents with current lab orders to ensure completion. Measures to Prevent Reoccurrence: DON or Designee will re-educate License Nursing on Completing labs as ordered Ongoing Monitoring: DON or Designee will audit residents who are receiving an antibiotic weekly x4 weeks, then monthly x2 .  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

The 10/28/25 Hand Hygiene Policy and Procedure indicates the facility must establish and maintain an infection prevention and control program designed to maintain to provide as a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Procedure: 2. Associates perform hand hygiene (even if gloves are used) in the following situations: a. Before and after contact with the resident; b. After contact with blood, body fluids or visibly contaminated surfaces; c. After contact with objects and surfaces in the residentGÇÖs environment; On 12/18/25 at 12:11 PM Staff 20 (CNA) was observed in the dining room delivering a lunch tray to a resident. Staff 20 removed lids from the bowls and cut up items on the plate for the resident. Staff 20 touched the residentGÇÖs shoulder and asked if she/he needed anything else. Staff 20 touched her face, twirled her hair and adjusted her clothing while waiting for another lunch tray to be prepared by the dietary staff. Staff 20 retrieved another lunch tray and delivered the tray to a resident. On 12/18/25 at 12:20 PM Staff 20 stated she was uncertain when she was supposed to complete hand hygiene. Staff 20 acknowledged she did not sanitize her hands between delivery of the lunch trays and touching of other surfaces. On 12/18/25 at 12:40 PM Staff 2 (DNS) stated she expected staff to complete hand hygiene before they entered and left a room, in the dining room, in between handing out trays and when staff were in contact with the residents or their environment.

Residents in Similar Situations: Staff member identified has been reeducated on proper hand hygiene. Measures to Prevent Reoccurrence: DON or designee will reeducate CNA's on proper hand hygiene Ongoing Monitoring: DON or Designee will audit staff to ensure that proper hand hygiene is being done  re weekly x4 weeks, then monthly x2 .  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

1. On 12/17/25 at 10:45 AM a review of three randomly selected newly hired employees was conducted with Staff 26 (Accounting Clerk). Staff 27 (RN) began working in the facility on 9/24/25. Staff 26 stated Staff 27 did not authorize her criminal background check to begin until 10/21/25. A review of Staff 27's timesheets revealed she worked in the facility between 9/24/25 and 10/21/25. Staff 26 confirmed Staff 27 worked in the facility before the criminal background check was started. On 12/18/25 at 11:44 AM Staff 1 (Administrator) acknowledged the facility did not criminal background checks timely.-á 2. On 12/17/25 at 10:45 a review of three randomly selected staff due for a criminal background recheck was completed with Staff 26 (Accounting Clerk). Staff 28 (Cook) was hired on 7/28/22 and a new criminal history check was required by 10/3/25. Staff 26 confirmed Staff 28's criminal background check did not begin until 12/15/25. A review of Staff 28's timesheets revealed he worked in the facility between 10/3/25 and 12/15/25. Staff 26 confirmed Staff 28 worked in the facility after 10/3/25.-á On 12/18/25 at 11:44 AM Staff 1 (Administrator) acknowledged the facility did not complete criminal background checks timely.-á -á

All employees working in the building have current background checks. ED or Designee will audit all new employees as well any who require a background recheck, weekly x4 weeks, then monthly x2 .  Audit results will be monitored through QAPI for 3 months or until compliance has been achieved.

On 1/31/25 a concern was reported indicating the facility used NAs as more that the 25 percent of the aides on duty.-á Review of the Direct Care staff Daily Report for 1/2025 indicated the following dates the facility used NAs as more than 25 percent of the total aides on duty:-á 1/1/25,-á1/2/25, 1/3/25,-á1/4/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/11/25, 1/12/25, 1/13/25, 1/16/25, 1/18/25, 1/19/25, 1/20/25, 1/25/25, 1/26/25, 1/27/25, 1/29/25 and 1/30/25.-á On 12/16/25 at 12:45 PM Staff 1 (Administrator) acknowledged NA to CNA ratios exceeded 25 precent for the identified dates.-á

Staffing coordinator monitors daily requirement to be staffed with less than 25% NAs. How the nursing home will act to protect residents in similar situations. No residents were identified however residents have the potential to be affected by this alleged deficient practice. ED or designee will audit staffing weekly x4 then monthly until substantial compliance is achieved. Results will be reported to QAPI,

On 1/31/25 and 8/25/25 a concern was received by the State Agency which alleged the facility was short staffed CNAs resulting in longer call light times.-á Review of the facility's Direct Care Staff Daily Report indicated the following dates the facility did not meet the required bariatric CNA ratio for one or more shifts: 1/9/25, 1/10/25, 1/11/25, 1/13/25, 1/18/25, 1/19/25,-á1/21/25, 1/22/25, 1/25/25, 1/26/25, 1/31/25, 9/20/25 and 9/23/25.-á On 12/16/25 at 12:45 PM Staff 1 (Administrator) acknowledged the facility did not meet the required CNA staffing ratios for the bariatric rate for the identified dates.-á

Staffing coordinator monitors daily requirements for bariatric standards. How the nursing home will act to protect residents in similar situations. No bariatric residents were identified however bariatric residents have the potential to be affected by this alleged deficient practice. ED or designee will audit staffing weekly x4 then monthly until substantial compliance is achieved. Results will be reported to QAPI,

Based on interview and record review it was determined the facility failed to ensure residents were included in care planning for 1 of 2 sampled residents (#31) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include: Resident 31 was admitted to the facility in 7/2022 with diagnosis including autism. A review of Resident 31's profile sheet revealed Witness 2 (Family Member) was Resident 31's responsible party and guardian. A review of Psychosocial Notes from 7/31/23 through 7/17/24 revealed the following: -10/26/23 Quarterly care conference held with Witness 2 via phone. -5/6/23 note did not indicate the meeting was a care conference and attendance did not include Witness 2. No documentation Witness 2 was invited to a care conference meeting. -7/17/24 late entry for 7/11/14 note did not indicate the meeting was a care conference meeting and did not include documentation Witness 2 was in attendance or was invited. No additional documentation was found in Resident 31's clinical record which indicated Witness 2 was invited or attended a care conference since 10/26/23. On 9/24/24 at 7:51 AM Witness 2 stated he was not invited or attended to a care conference for quite some time. Witness 2 stated it was before Staff 4 (Social Services Director) started working at the facility. A review of the facility's staff list revealed Staff 4 was hired on 4/23/24. On 9/26/24 at 12:56 PM Staff 2 (DNS) Staff 3 (Regional Vice President) and Staff 29 (Regional Nurse) stated they would look for additional information for care plan conferences. No additional documentation which indicated Witness 2 was invited or attended a care conference meeting since 10/26/23 was provided.

F553 – Right to Participate in Planning Care Conference How the nursing home will correct the deficiency as it relates to the resident. Resident 31 has had an updated care conference to include power of attorney. How the nursing home will act to protect residents in similar situations. Audit done to ensure current residents have had a quarterly care conference. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Social worker, RCM, BOM, DON, have been educated on policy for person centered care planning. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Facility will audit required care conferences Weekly X4 and monthly until substantial compliance is obtained. Results will be reported to QAPI The title of the person responsible to ensure correction: Executive Director or Designee will ensure compliance.

Based on interview and record review it was determined the facility failed to ensure residents' current advance directive information was reflected in clinical records for 3 of 5 sampled residents (#s 3, 45 and 51) reviewed for advance directives. This placed residents at risk for end of life choices not being honored. Findings include: 1. Resident 3 admitted to the facility in 7/2024 with a diagnosis of rib fractures. A 7/9/24 admission MDS revealed Resident 3 was cognitively intact. A care plan initiated 7/16/24 indicated Resident 3 had an advance directive and staff were to honor her/his wishes. Resident 3's clinical record did not include a copy of her/his advance directive. On 9/25/24 at 10:00 AM Resident 3 stated she/he had an advance directive and her/his medical provider had a copy of the form. On 9/25/24 at 10:10 AM Staff 4 (Social Service Director) stated upon admission a resident was provided information related to advance directives. If a resident stated she/he had an advance directive staff were to follow-up and obtain a copy for the clinical record. Staff 4 acknowledged Resident 3's care plan indicated she/he had an advance directive and her/his clinical record did not include a copy. Staff 3 also stated the hospital clinical record indicated Resident 3 had an advance directive but the hospital also did not have a copy. Staff 3 stated he did not follow-up with Resident 3 to ensure her/his clinical record included a copy of her/his advance directive. On 9/25/24 at 11:16 AM Staff 2 (DNS) stated if a resident's care plan indicated she/he had an advance directive staff were to follow-up and obtain a copy or revise the care plan as needed if the care plan was not accurate. , 2. Resident 45 admitted to the facility in 2024 with diagnoses including diabetes and left-sided weakness. Review of Resident 45's medical record revealed no advanced directive. Review of progress notes revealed no information indicating she/he was offered an advanced directive. On 9/26/24 at 12:47 PM Staff 4 (Social Services Director) stated all residents were offered an advanced directive and it was discussed at care conferences. He acknowledged Resident 45 had no advanced directive and no documentation of one being offered or refused. 3. Resident 51 admitted to the facility in 2024 with diagnoses including chronic obstructive pulmonary disease and surgical amputation of her/his left leg above the knee. Review of Resident 51's medical chart revealed no advanced directive. An undated facility Conference/DC Planning form revealed Resident 51 was provided information regarding an advanced directive. Review of progress notes revealed no follow up information for the advanced directive. On 9/26/24 at 12:47 PM Staff 4 (Social Services Director) stated all residents were offered an advanced directive and it was discussed at care conferences. He acknowledged Resident 51 had no advanced directive and there was no follow up documentation for the advanced directive previously offered.

F578 – Request/Refuse/Discontinue Treatment; Formulate Adv Directives How the nursing home will correct the deficiency as it relates to the resident. Resident 51 no longer resides in the facility. Residents 45 and 3 have had their advanced directives reviewed and updated. How the nursing home will act to protect residents in similar situations. Audit to ensure advanced directives have been offered to current Residents. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Social workers, RCM, BOM, DON, have been educated on policy for advanced directives and advanced care planning. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Facility will audit required Advanced directives Weekly X4 and monthly until substantial compliance is obtained. Results will be reported to QAPI

Based on interview and record review it was determined the facility failed to ensure a resident representative was notified of hospitalizations for 1 of 2 sampled residents (#33) reviewed for notification. This placed resident representatives at risk for lack of care decisions. Findings include: Resident 33 admitted to the facility in 4/2023 with a diagnosis of dementia. Resident 33's clinical record indicated Witness 6 (Family Member) was Resident 33's first emergency contact. On 9/23/24 at 3:52 PM Witness 6 stated in the recent past she/he was not notified when Resident 33 was admitted to the hospital. Progress Notes revealed on 8/17/24 Resident 33 had a change of condition and was transported to the hospital for evaluation and treatment. There was no indication Witness 6 was notified. On 9/25/24 at 1:58 PM a request was made to Staff 24 (LPN IP) to provide documentation Witness 6 was notified of Resident 33's hospitalization. No additional information was received .

F580 Notify of Changes How the nursing home will correct the deficiency as it relates to the resident. Resident # 33 family was notified of change of condition. How the nursing home will act to protect residents in similar situations. The IDT reviewed and audited residents’ medical records to validate notification and proper documentation of resident sent to hospital. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. The facility will re-educate the licensed nurses on notification of change of conditions. How the nursing home plans to monitor its performance to make sure that solutions are sustained. The Resident Care Managers (RCM’s) and/or designee, with the oversight from the Director of Nursing Services, will conduct audits, to ensure proper notification occurred, weekly x4 and then monthly until substantial compliance is achieved. Results will be reported to QAPI. The title of the person responsible to ensure correction: The Resident Care Manager with oversight of the Director of Nursing Services and/or designee are accountable for compliance.

Based on interview and record review it was determined the facility failed to provide written notification regarding a change in coverage for 1 of 3 sampled residents (#9) reviewed for Medicare notification of non-coverage. This placed residents and their representatives at risk for unknown financial liabilities. Findings include: Resident 25 was admitted to the facility in 7/2024 with diagnosis including fracture of the left leg. A review of the 7/16/24 Admission MDS indicated Resident 9's BIMS was 9 which indicated moderate cognitive impact. A NOMNC (Notice of Medicare Non-Coverage) form was signed by Resident 9 on 7/22/24. It was not documented if her/his responsible party was contacted or made aware of the form and the effective date Medicare would no longer pay for skilled nursing services, which was 7/25/24, or how to appeal the decision if they disagreed. On 9/26/24 at 10:39 AM Witness 1 (Family Member) stated she was Resident 9's responsible party and she/he was able to understand the NOMNC form. Witness 1 stated the facility did not contact her regarding the NOMNC form, and she wondered why as the facility knew she was Resident 9's responsible party. On 9/26/24 at 10:59 AM and 11:58 AM Staff 21 (Social Services Director) and Staff 27 (Business Office) stated the protocol for the NOMNC form for a cognitively impaired resident was to notify and have the family representative present during the signing of the form. Staff 21 stated he would review a resident's BIMS score and if the resident was their own responsible party. Staff 27 stated she had Resident 9 sign the NOMNC form and she did not review Resident 9's clinical record for a responsible party. In an interview on 9/26/24 at 12:52 PM Staff 2 (DNS), Staff 3 (Regional Vice President) and Staff 29 (Regional Nurse) stated the expectation of staff was residents who were cognitively intact signed the NOMNC and/or a resident's representative.

F582 Medicaid/Medicare Coverage/Liability Notice How the nursing home will correct the deficiency as it relates to the resident. Resident #9 has been corrected with proper ABN notification How the nursing home will act to protect residents in similar situations. Residents in the facility who have had a change in coverage for the last 30 days have been audited to ensure they have received proper notification of charges. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. IDT team to include Business office, social worker and Rehab director received training on ABN and NOMNC notification How the nursing home plans to monitor its performance to make sure that solutions are sustained. Facility will audit required ABN notification Weekly X4 and monthly until substantial compliance is obtained. Results of audit will be submitted to QAPI. The title of the person responsible to ensure correction: Executive Director or Designee

Based on observation and interview it was determined the facility failed to provide a building in good repair 2 of 3 sampled residents (#s 11 and 20) reviewed for environment. This placed residents at risk for unsafe and unhomelike environment. Findings include: Resident 11 admitted to the facility in 12/2023 with diagnoses of vertigo (sense of spinning when someone is still) and unsteadiness on feet. Resident 20 was admitted to the facility in 3/2024 with diagnoses including muscle weakness and unsteadiness on feet. A review of the 8/30/24 MDS indicated revealed Resident 11's BIMs score was 13 which indicated Resident 11 was moderately cognitively impaired. A review of the 9/5/24 MDS indicated revealed Resident 20's BIMs score was 15 which indicated Resident 20 was cognitively intact. On 7/5/24 a public complaint was received which indicated the floor of Resident 11's room was so uneven that her/his bedside table would roll across the room. On 9/24/24 at 10:11 AM Resident 11 stated her/his room was going downhill, and staff had to engage the brakes on everything in her/his room or the items would roll downhill. A visible slope was observed in the room with appearance of the room sloping up from the window of the room to the doorway. On 9/26/24 at 6:54 AM and 6:59 AM Staff 20 (Maintenance Director) stated the facility was going to have someone come and find out what the slope of the rooms were and what was happening. Staff 20 stated when outside the building it appeared to have a "U" shape. Staff 20 stated Resident 20 requested blocks under one side of her/his bed to make the bed more level in her/his room. On 9/26/24 at 7:19 AM Staff 8 (CNA) stated when she went into the rooms numbered in 40's range it was like "oh my goodness." Staff 8 stated she had to be cautious when she walked and watch her footing as she felt like she could lose her balance. On 9/26/24 at 7:58 AM Resident 20 stated there was one block under her/his bed but the one at the head of the bed came out and staff were to come and fix it. Resident 20 stated she/he felt like she/he was going downhill in her/his room. Resident 20 was observed to have a wood block approximately 1/2 to 1 inch thick under one side of the leg of the at the foot of the bed. In an interview on 9/26/24 at 1:08 PM Staff 2 (DNS), Staff 3 (Regional Vice President) and Staff 29 (Regional Nurse) stated the rooms were inspected and another company was coming to inspect the rooms. Staff 3 stated there was no structural damage to the building and they would be moving the residents who were affected to other rooms.

How the nursing home will correct the deficiency as it relates to the resident. Resident #11 and # 20 have been moved. How the nursing home will act to protect residents in similar situations. Affected rooms have been closed to resident use. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. The facility will close the affected rooms until repaired by an appropriate contractor. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Rooms will be inspected to ensure beds are not on blocks weekly x4 and monthly until substantial compliance is obtained and will be reported to QAPI The title of the person responsible to ensure correction: Executive Director or Designee

Based on interview and record review the facility failed to protect residents' rights to be free from verbal and physical abuse by Staff for 1 of 2 sampled residents (#56) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 56 admitted to the facility in 7/2024 with diagnoses including kidney disease and diabetes. A review of Resident 56's MDS and cognitive loss dementia CAA dated 6/5/24 revealed Resident 56's BIMS was 10 which indicated moderate cognitive impairment. The CAA revealed contributing factors to Resident 56's cognitive loss included dementia, change in mental status, and short and long-term memory loss. A review of Resident 56's care plan dated 6/12/24 revealed Resident 56 had impaired cognitive ability with a score of 10 on her/his BIMS assessment. Interventions included allow extra time for the resident to respond to questions and instructions, ask yes and no questions to determine the resident's needs, identify yourself at each interaction, face Resident 56 when speaking and make eye contact, reduce any distractions. The care plan also indicated Resident 56 understandood consistent, simple, and direct sentences, to provide the resident with necessary cues and stop and return if Resident 56 became agitated, and to try and provide a consistent routine and caregivers as much as possible to decrease confusion. On 7/5/24 the State Survey Agency received a public complaint which indicated on 6/15/24, during the night shift, Staff 15 (Agency LPN) came out into the hallway from Resident 56's room and "bragged" about his interaction with Resident 56. Staff 15 stated Resident 56 pushed her/his bedside table into Staff 15 , which upset Staff 15, and he grabbed Resident 56's bed covers into a ball, pushed down on Resident 56's chest and told her/him to "never do that again." On 6/16/24 Resident 56 made a comment about the incident, and it was reported. Resident 56 reported she/he was scared to even mention it. Resident 56's family was notified. Staff 15 was removed from the schedule and did not return to the facility. On 9/24/24 at 10:40 AM Witness 4 (Family Member) and Resident 56 stated the nurses at the facility reported to Witness 4 Staff 15 put his hands on Resident 56. Witness 4 stated Staff 15 woke Resident 56 up at 4:00 AM in the morning and it startled Resident 56. Witness 4 stated if Resident 56 was woken up in the wrong way she/he had a negative reaction. Resident 56 stated she/he did not remember pushing her/his bedside table against a staff member and she/he did not remember a staff member touching her/him. On 9/25/24 at 11:07 AM Staff 12 (CNA) stated on the night shift of 6/15/24 Staff 15 reported Resident 56 pushing her/his bedside table into Staff 15 and grabbing Resident 56 and telling her/him to not do that again. Staff 12 stated Staff 15 reported this information to all the staff who were working the night shift. On 9/27/24 at 8:28 AM Staff 15 stated he went into Resident 56's room on 6/15/24 and Resident 56 started yelling and shoved the bedside table into Staff 15's groin. Staff 15 stated he was loud, stern and pointed at Resident 56 and told her/him to "not do that." Staff 15 stated it made him mad and he wanted to hit Resident 56 but did not lay hands on him. Staff 15 stated he documented the incident in nurse's notes, but notes and incident reports come up "missing" at the facility. On 9/27/24 at 10:02 AM Staff 13 (RN) stated Staff 15 came in to work on 6/15/24 upset about the schedule and "ranting and raving." Staff 15 was swearing, and Staff 13 told him to relax. Staff 13 stated Staff 15 reported Resident 56 pushed the bedside table into Staff 15 and Staff 15 grabbed Resident 56's shirt and pulled him toward Staff 15 and told Resident 56 to "knock it off." Staff 15 reported to Staff 13 that he was "fucking out of here" and left the facility. Staff 13 stated Staff 15 cussed a lot while at work. On 9/27/24 at 10:13 AM Staff 3 (Regional Vice President) stated he did not feel it was abuse. While Resident 56 was in the facility staff reported she/he was cognitively intact, and Resident 56 reported she/he was not abused. Staff 3 stated Staff 1 (Administrator) came into the facility and spoke with staff and the resident regarding the incident. No investigation regarding abuse on 6/15/24 was provided.

F600 Free from Abuse and Neglect How the nursing home will correct the deficiency as it relates to the resident. Resident 56 no longer resides at the facility. How the nursing home will act to protect residents in similar situations. Alert residents on the unit were interviewed along with additional staff members to identify any additional concerns related to abuse. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Staff will be in-serviced on reporting and identifying Abuse and Neglect. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Random staff quizzes will be completed related to identifying and/or reporting abuse weekly x 4 and then monthly x 2. The results of the quizzes will be shared with the QAPI team to identify opportunities for improvement. The title of the person responsible to ensure correction: Executive Director

Based on interview and record review it was determined the facility failed to report to the State Survey Agency an allegation of abuse for 1 of 2 sampled residents (#56) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 56 admitted to the facility in 7/2024 with diagnoses including kidney disease and diabetes. A review of Resident 56's MDS and cognitive loss dementia CAA dated 6/5/24 revealed Resident 56's BIMS was 10 which indicated moderate cognitive impairment. The CAA revealed contributing factors to Resident 56's cognitive loss included dementia, change in mental status, and short and long-term memory loss. On 7/5/24 the State Survey Agency received a public complaint which indicated on 6/15/24, during the night shift, Staff 15 (Agency LPN) came out into the hallway from Resident 56's room and "bragged" about his interaction with Resident 56. Staff 15 stated Resident 56 pushed her/his bedside table into Staff 15 , which upset Staff 15, and he grabbed Resident 56's bed covers into a ball, pushed down on Resident 56's chest and told her/him to "never do that again." On 6/16/24 Resident 56 made a comment about the incident, and it was reported. Resident 56 reported she/he was scared to even mention it. Resident 56's family was notified. Staff 15 was removed from the schedule and did not return to the facility. No documentation was found indicating the facility reported the alleged abuse from Staff 15 to Resident 56 on 6/15/24 to the State Survey Agency. On 9/24/24 at 10:40 AM Witness 4 (Family Member) and Resident 56 stated the nurses at the facility reported to Witness 4 staff put his hands on Resident 56. Witness 4 stated Staff 15 woke Resident 56 up at 4:00 AM in the morning and he startled Resident 56. Witness 4 stated if Resident 56 was woken up in the wrong way she/he had a negative reaction. On 9/25/24 at 11:07 AM Staff 12 (CNA) stated on the night shift of 6/15/24 Staff 15 reported Resident 56 pushing her/his bedside table into Staff 15 and grabbing Resident 56 and telling her/him to not do that again. On 9/27/24 at 8:28 AM Staff 15 stated he went into Resident 56's room on 6/15/24 and Resident 56 started yelling and shoved the bedside table into Staff 15's groin. Staff 15 stated he was loud, stern and pointed at Resident 56 and told her/him to "not do that." Staff 15 stated it made him mad and he wanted to hit Resident 56 but did not lay hands on him. On 9/27/24 at 10:02 AM Staff 13 (RN) stated Staff 15 reported Resident 56 pushed the bedside table into Staff 15 and he grabbed Resident 56's shirt, pulled the resident toward him and told Resident 56 to "knock it off." In an interview on 9/26/24 at 1:02 PM Staff 2 (DNS), Staff 3 (Regional Vice President) and Staff 29 (Regional Nurse) stated they expected staff to report allegations of abuse to the State Survey Agency and to law enforcement. Refer to F600

F609 Reporting of Alleged Violations How the nursing home will correct the deficiency as it relates to the resident. Resident 56 no longer resides at the facility. How the nursing home will act to protect residents in similar situations. Alert residents on the unit were interviewed along with additional staff members to identify any additional concerns related to reporting abuse. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Staff have been in-serviced on reporting Abuse and Neglect. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Random staff quizzes will be completed related to identifying and/or reporting abuse weekly x 4 and then monthly x 2. The results will be reported to QAPI. The title of the person responsible to ensure correction: Executive Director or Designee

Based on interview and record review it was determined the facility failed to investigate an allegation of abuse for 1 of 2 sampled residents (#56) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 56 admitted to the facility in 7/2024 with diagnoses including kidney disease and diabetes. A review of Resident 56's MDS and cognitive loss dementia CAA dated 6/5/24 revealed Resident 56's BIMS was 10 which indicated moderate cognitive impairment. The CAA revealed contributing factors to Resident 56's cognitive loss included dementia, change in mental status, and short and long-term memory loss. On 7/5/24 the State Survey Agency received a public complaint which indicated on 6/15/24 during the night shift Staff 15 (Agency LPN) came out into the hallway from Resident 56's room and "bragged" about his interaction with Resident 56. Staff 15 stated Resident 56 pushed her/his bedside table into Staff 15, which made Staff 15 mad, and he grabbed Resident 56's bed covers into a ball and pushed down on Resident 56's chest and told her/him to "never do that again." On 6/16/24 Resident 56 made a comment about the incident, and it was reported. Resident 56 reported she/he was scared to even mention it. Resident 56's family was notified. Staff 15 was removed from the schedule and did not return to the facility. No documentation was found the facility completed an investigation for the alleged allegation of abuse on 6/15/24 from Staff 15 to Resident 56. On 9/24/24 at 10:40 AM Witness 4 (Family Member) and Resident 56 stated the nurses at the facility reported to Witness 4 staff put his hands on Resident 56. Witness 4 stated Staff 15 woke Resident 56 up at 4:00 AM in the morning and it startled Resident 56. Witness 4 stated if Resident 56 was awoken in the wrong way she/he had a negative reaction. On 9/25/24 at 11:07 AM Staff 12 (CNA) stated on the night shift of 6/15/24 Staff 15 reported Resident 56 pushing her/his bedside table into Staff 15 and grabbing Resident 56 and telling her/him to not do that again. On 9/27/24 at 8:28 AM Staff 15 stated he went into Resident 56's room on 6/15/24 and Resident 56 started yelling and shoved the bedside table into Staff 15's groin. Staff 15 stated he was loud, stern and pointed at Resident 56 and told her/him to "not do that." Staff 15 stated it made him mad and he wanted to hit Resident 56 but did not lay hands on him. On 9/27/24 at 10:02 AM Staff 13 (RN) stated Staff 15 reported Resident 56 pushed the bedside table into him, and Staff 15 grabbed Resident 56's shirt and pulled the resident toward him and told Resident 56 to "knock it off." In an interview on 9/26/24 at 1:02 PM and 9/27/24 at 10:13 AM Staff 2 (DNS), Staff 3 (Regional Vice President) and Staff 29 (Regional Nurse) stated they expected staff to report allegations of abuse to the State Survey Agency and to law enforcement. Staff 3 stated Staff 1 (Administrator) came into the facility and spoke with staff and the resident. No investigation regarding the incident was provided. Refer to F600

F610 Investigate/Prevent/Correct Alleged Violation How the nursing home will correct the deficiency as it relates to the resident. Resident 56 no longer resides at the facility. How the nursing home will act to protect residents in similar situations. Alert residents on the unit were interviewed along with additional staff members to identify any additional concerns related to abuse. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Staff have been in-service to the facility’s Abuse and Neglect policy. How the nursing home plans to monitor its performance to make sure that solutions are sustained. The IDT team will audit all incident reports weekly x 4 and then monthly x 2 to ensure all incidents were investigated. The results will be shared with QAPI. The title of the person responsible to ensure correction: Executive Director or Designee

Based on observation, interview and record review it was determined the facility failed to update the care plan for 3 of 7 sampled residents (#s 3, 9, and 43) reviewed for positioning and pressure ulcers. This placed residents at risk for unmet care needs. Findings include: 1. Resident 3 admitted to the facility in 7/2024 with a diagnosis of fractured ribs. Resident 3's admission MDS revealed she/he was cognitively intact. On 9/23/24 at 12:02 PM Resident 3 was observed with a wound dressing on her/his right shin. Resident 3 stated there was an open area on her/his shin for at least one month. Resident 3's care plan initiated on 7/16/24 was not revised to address her/his shin wound. On 9/25/24 at 11:12 AM Staff 2 (DNS) acknowledged Resident 3's care plan was not revised to address her/his skin issue. 2. Resident 43 admitted to the facility in 2/2024 with a diagnosis of kidney disease. A 2/9/24 admission MDS revealed Resident 43 was cognitively impaired and had a left hand contracture. An Occupational Therapy Discharge Summary dated 3/18/24 revealed Resident 43 had a left hand contracture and she/he was dependent on staff to place a soft hand roll. On 9/24/24 at 2:51 PM Resident 43 was observed with a soft hand roll in her/his left hand. A care plan initiated 2/22/24 was not revised to include staff were to assist Resident 43 with the soft hand roll. On 9/25/24 at 11:12 AM Staff 2 (DNS) acknowledged Resident 43's care plan was not revised to include staff were to assist her/him with the soft hand roll. , 3. Resident 9 admitted to the facility in 2024 with diagnoses including sepsis (severe infection) and diabetes. An Admission MDS dated 7/16/24 indicated Resident 9 was cognitively impaired. The MDS revealed Resident 9 was at risk for pressure injuries. A 9/1/24 provider order revealed staff were to cleanse the left ankle wound and place a foam dressing every three days and as needed. A 9/4/24 provider order revealed staff were to place sheepskin (a type of padding) between the leg brace and left inner ankle to decrease pressure. Review of the resident's care plan, revised 9/23/24, revealed no goals or interventions for the left ankle wound. On 9/24/24 at 2:36 PM Resident 9 was observed to a thigh to ankle leg brace with sheepskin tucked between the left ankle and the brace. A small foam wound dressing was observed on the inner left ankle under the sheepskin. On 9/27/24 at 11:36 AM Staff 2 (DNS) acknowledged Resident 9's care plan did not contain goals or interventions for the left ankle wound. She also acknowledged the care plan was not updated properly.

F657 Care Plan Timing and Revision How the nursing home will correct the deficiency as it relates to the resident. Care Plans for Residents #s 3,9 and 43 were updated to reflect current interventions. How the nursing home will act to protect residents in similar situations. The Clinical IDT audited and reviewed current residents' care plans to date to validate that care plans reflect appropriate interventions. Identified concerns will be addressed. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. The facility will educate the clinical IDT updating the resident care plans. In addition, the IDT will discuss changes in resident conditions with direct care staff during nursing rounds to validate accuracy. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Current residents with adaptive equipment and skin concerns will have their care plans audited to ensure appropriate interventions are in place weekly X 4 weeks, monthly for 2 months. Results will be reported to QAPI. The title of the person responsible to ensure correction: Director of Nursing Services and/or designee.

Based on observation, interview and record review it was determined the facility failed to provide shaving for 1 of 3 sampled residents (#43) reviewed for ADLs. This placed residents at risk for lack of self esteem. Findings include: Resident 43 admitted to the facility in 2/2024 with a diagnosis of a stroke. On 9/23/24 at 12:45 PM and 9/24/24 at 2:51 PM Resident 43 was observed to have long facial hair . A 2/9/24 admission MDS revealed Resident 43 was cognitively impaired, was able to make needs known, and required assistance for most ADLs. On 9/23/24 at 3:30 PM Witness 7 (Family Member) stated Resident 43 preferred to have no facial hair. On 9/24/24 at 3:06 PM Staff 31 (CNA) stated residents were shaved on shower days. Resident 43 had a shower on the day shift, she was not sure the reason Resident 43 was not shaved, and acknowledged her/his facial hair was likely not shaved for several days. On 9/24/24 at 3:45 PM Resident 43 stated she/he usually liked to not have facial hair. Resident 43 also stated her/his facial hair was so long she/he required a "weed whacker" to shave.

F677 ADL Care Provided for Dependent Residents How the nursing home will correct the deficiency as it relates to the resident. Resident #43 beard has been trimmed. How the nursing home will act to protect residents in similar situations. Current residents with facial hair will be interviewed for preference. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. The facility will educate the direct care staff on the requirement to ensure preferences for facial hair are maintained How the nursing home plans to monitor its performance to make sure that solutions are sustained. Residents with facial hair will be audited weekly for 4 weeks and then monthly for 2 months to validate preferences are maintained. Results will be reported to QAPI The title of the person responsible to ensure correction: Director of Nursing and/or designee.

Based on observation, interview and record review it was determined the facility failed to provide care to a non-pressure skin injury and failed to provide preparation for a medical procedure for 2 of 2 sampled residents (#s 3 and 21) reviewed for non-pressure skin conditions and medical procedures. This placed residents at risk for delayed care needs and treatment. Findings include: 1. Resident 3 was admitted to the facility with a diagnosis of heart disease. On 9/23/24 at 12:02 PM Resident 3 was observed to have a wound dressing on her/his right shin. Resident 3 stated there was an open area on her/his shin for at least one month. Weekly Skin Integrity Data Collection forms reveled on 8/14/24 and 9/16/24 Resident 3 was assessed to have scabs to the right shin. Resident 3's clinical record did not indicate the shin wound was measured, assessed to determine cause, or treatment orders were obtained, and her/his care plan initiated on 7/16/24 was not revised to address her/his shin wound. A 9/25/24 Skin Related Injury investigation revealed Resident 3 reported to the a State surveyor she/he had an open area to the right shin. It was determined Resident 23's walker caused friction to the leg when she/he walked. Staff adjusted the walker to prevent continued injury. On 9/25/24 at 9:59 AM Staff 32 (CNA) stated for approximately one week Resident 3's shin bled and a nurse applied a dressing. On 9/25/24 at 11:12 AM Staff 2 (DNS) acknowledged Resident 3's care plan was not revised to address her/his skin issue and there was no orders or assessments to indicate when the skin issue developed. 2. Resident 21 admitted to the facility in 7/2018 with a diagnosis of a stroke. Per medlineplud.gov (web based resource) a sigmoidoscopy was a procedure used to see inside the colon and rectum. To preprepare for this procedure a patient must empty their bowels by using enema (medicine inserted rectally resulting in bowel movements.) and must not eat before the procedure. 7/3/24 hospital discharge orders revealed Resident 21 was to follow up with a general surgeon on 7/25/24. A facility calendar revealed Resident 21 went to the general surgeon on 7/22/24. A Progress Notes dated 9/3/24 revealed Resident 21 returned from an appointment and she/he "was transported for sigmoidoscopy (bowel scope) procedure, without prep. Will arrange for re-scheduling/repeat clinic visit..." On 9/26/24 at 3:25 PM Witness 10 (Medical Assistant) stated Resident 21 was seen on 7/22/24. She/he was to return to do a follow up procedure on 9/3/24 to diagnose the reason Resident 21 was bleeding. Witness 20 stated Resident 21 was not prepped and her/his diagnostic tests were delayed. On 9/25/24 at 4:24 PM Staff 2 (DNS) stated Resident 21 had multiple emergency room visits for her/his bleeding. Staff 2 acknowledged Resident 21 was not prepped for a diagnostic procedure on 9/3/24. No additional information related to this concern was provided.

F684 Quality of Care How the nursing home will correct the deficiency as it relates to the resident. 1) Resident #3 wound measured, assessed to determine cause, treatment order and care plan updated. 2) Resident #21 no longer resides at the facility. How the nursing home will act to protect residents in similar situations. 1) Current residents with skin issues were reviewed. 2) Current residents with outpatient surgical procedures reviewed. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. 1) Licensed Nursing educated on skin assessments. 2) Licensed Nursing educated on entering orders. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Residents with skin issues and outpatient surgical procedures will be audited weekly x4, then monthly until substantial compliance is achieved. Results will be reported to QAPI. The title of the person responsible to ensure correction: Director of Nursing or designee

Based on observation, interview and record review it was determined the facility failed to ensure treatment was provided for a resident's decreased ROM for 1 of 4 sampled residents (#36) reviewed for positioning. This placed residents at risk for pain. Findings include: Resident 36 admitted to the facility in 4/2023 with a diagnosis of Parkinson's disease. An 4/19/24 annual MDS and associated CAAs indicated Resident 36 was confused at times, required staff assistance for ADLs, and was able to make needs known. The CAAs also indicated Witness 8 (Family Member) was very involved in Resident 36's care. On 9/23/24 at 4:19 PM Witness 8 stated Resident 36 had a "contracture" to her/his hands and was not aware if staff provided ROM. On 9/26/24 at 9:55 AM Resident 36 was observed to not be able to straighten her/his third and fourth fingers on both hands. Resident 36 stated her/his hands hurt to straighten. Review of Resident 36's clinical record revealed no treatments or care plan related to her/his decreased finger ROM. On 9/26/24 at 9:55 AM Staff 26 (PT) stated at that time therapy was not working with Resident 36 for decreased ROM. On 9/26/24 at 4:30 PM Staff 2 (DNS) stated she was not aware of a concern related to Resident 36's fingers.

F688 Increase/Prevent Decrease in ROM/Mobility How the nursing home will correct the deficiency as it relates to the resident. Resident #36 is being seen by PT to work on ROM. How the nursing home will act to protect residents in similar situations. A review of current residents with contractures was completed to ensure ROM is being done as necessary Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. DOR was educated on identifying contractures. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Audits will be done weekly x4 to ensure residents with contractors are being seen as necessary. Results will be reported to QAPI The title of the person responsible to ensure correction: DON or Designee

Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from accidents and update care plans after accidents for 3 of 4 sampled residents (#s 21, 36 and 48) reviewed for accidents and non-pressure wounds. Resident 21 fell from a mechanical lift resulting in a left arm fracture and hospitalization. Findings include: 1. Resident 21 admitted to the facility in 2018 with diagnoses including left side paralysis and depression. A FRI and associated investigation dated 6/8/24 revealed Staff 43 (CNA) and Staff 44 (CNA) transferred Resident 21 using a mechanical lift that did not have required safety clips attached. As a result the left leg strap of the lift sling came off the arm of the mechanical lift and Resident 21 fell and landed on her/his left arm. Resident 21 was transferred to a local hospital and was identified to have a fractured arm. A 9/6/24 quarterly MDS indicated Resident 21 had moderate cognitive impairment. On 9/23/24 at 2:46 PM Resident 21 was interviewed and confirmed she/he fell out of the mechanical lift and went to the hospital. Resident 21 was not able to recall the specific details of her/his fall or injury, however the resident remembered the fall and stated, "I fell out of the [mechanical lift] and broke my arm." On 9/25/24 at 10:19 AM Staff 10 (CNA) stated mechanical lift training was provided in CNA school, but no updated training was provided at the facility. She recalled when Resident 21 fell on 6/8/24 and broke her/his arm because of CNAs' failure to properly and safely operate the mechanical lift. On 9/25/24 at 2:17 PM Staff 2 (DNS) confirmed Resident 21's accident on 6/8/24 occurred because of CNAs' error in using the mechanical lift. From 9/23/24 through 9/27/24 Staff 43 and Staff 44 did not respond to multiple attempts to interview. , 2. Resident 36 was admitted to the facility in 4/2023 with a diagnosis of Parkinson's disease. An 4/19/24 annual MDS revealed Resident 36 had impaired mobility and was at risk for falls. A care plan initiated 4/20/23 revealed Resident 36 was at risk for falls. Interventions to prevent falls included staff were to keep her/his wheel chair within reach and to ensure brakes were locked. Staff were also to provide toileting after meals and before bed. Staff were to encourage the resident to use her/his call light and to ensure frequently used items were within reach. a. On 9/26/24 at 8:28 AM Resident 36 was in bed, her/his wheelchair was not within reach, and the wheelchair brakes were not locked. Resident 36 was observed to have a wrist call light. On 9/26/24 at 8:29 AM Staff 36 (CNA) verified Resident 36's wheelchair was not locked and not within reach. On 9/26/24 at 10:29 AM Staff 2 (DNS) stated Resident 36's wheel chair was to be locked and within reach. b. Un-witnessed Fall investigations dated 7/22/24, 7/30/24, 8/1/24, 8/2/24, 8/10/24, 8/18/24, 8/31/24, 9/24/24 and 9/26/24 revealed the following: -7/22/24 at 3:53 PM Resident 36 was found on the floor in front of the bathroom. The investigation did not include when Resident 36 was last visualized, when she/he was toileted, and where her/his wheelchair was located at the time of the fall. New interventions included staff were to ensure frequently used items were within reach (this was not a new intervention). - 7/30/24 at 5:45 AM Resident 36 was found on the floor near her/his window. Resident 36 requested to use the bathroom when staff found the resident. The investigation did not indicate when the resident was last visualized or toileted. New interventions included the resident was to use a wrist call light. The care plan was not updated to include a wrist call light. -8/1/24 at 8:00 PM Resident 36 was found at the side of her/his bed. Resident 36 reported she/he had to use the bathroom. New intervention to be implemented included for staff to remind Resident 36 to use her/his call light (this was not a new intervention). -8/2/24 at 8:00 PM Resident 36 was found on the floor near her/his bed and wheelchair. The investigation indicated Resident 36 was last "checked on" 10 minutes prior to the fall but did not specify if the resident was assisted with toileting. New interventions included staff were to ensure frequently used items were to be within reach (this was not a new intervention). -8/10/24 at 9:21 PM Resident was found on the floor. The resident was last observed and incontinent check done at 8:55 PM. New interventions to be implemented included keeping frequently used items within reach (this was not a new intervention). -8/18/24 at 7:10 AM Resident 36 was observed on the floor with her/his unlocked wheelchair in front of her/him. New interventions to prevent falls included to have frequently used items within reach (this was not a new intervention). -8/31/24 at 5:56 AM Resident 36 was observed between her/his bed and window. The investigation did not include when Resident 36 was last assisted. New interventions to prevent falls included to have frequently used items within reach (this was not a new intervention). -9/24/24 at 8:50 PM Resident 36 was observed on the floor near her/his bathroom. The investigation did not indicate when Resident 36 was last assisted. On 9/26/24 at 10:32 AM Staff 2 (DNS) acknowledged Resident 36's investigations did not always include information to ensure care plan interventions were followed and new interventions identified to prevent falls were already in place. c. Resident 36's post fall Neurological Check List forms (assessment for head injury: assessments were to be done every 15 minutes for one hour, every 30 minutes for two hours, every two hours for eight hours, every eight hours for 32 hours) revealed the following neurological checks: - For a 7/22/24 fall: on 7/22/24 at 3:50 PM, 4:05 PM, 4:35 PM, 5:05 PM and 6:00 PM, on 7/23/24 at 4:45 PM and 8:45 PM, and on 7/24/24 at 4:45 AM and 7:25 AM. -For a 8/18/24 fall: on 8/18/24 at 3:30 AM and 5:30 AM, on 8/19/24 at 9:30 AM and 1:30 PM, and on 8/20/24 at 1:30 PM. -For a 8/31/24 fall: on 8/31/24 at 11:30 PM, on 9/1/24 at 1:30 AM and 11:30 PM, and on 9/2/24 at 1:30 AM and 5:30 AM. -For a 9/11/24 fall: on 9/12/24 at 4:00 AM and 8:15 PM, and on 9/13/24 at 8:15 PM. -For a 9/24/24 fall: on 9/2/24 at 1:45 AM, and on 9/25/24 at 5:45 AM. On 9/27/24 at 5:08 PM Staff 2 (DNS) stated she would provide neurological assessments for the above missing dates and times. No additional information was provided. , 3. Resident 48 admitted to the facility in 2024 with diagnoses including chemical imbalance affecting the brain and repeated falls. An Admission MDS dated 7/9/2024 indicated Resident 48 was cognitively intact. The MDS also revealed Resident 48 had a history of falls. Review of progress notes revealed Resident 48 had a falls on 7/12/24 and 8/10/24, and two falls on 9/21/24. Review of fall investigations and progress notes revealed staff were to place fall mats on both sides of Resident 48's bed, keep the bed in the lowest position, and keep all frequently used items within the resident's reach. A 9/23/24 review of the resident's care plan revealed the risk for falls area was not updated with the most recent falls, and no new interventions were created after any of her/his falls. On 9/27/24 at 11:36 AM Staff 2 (DNS) acknowledged Resident 48's care plan did not contain the interventions mentioned in the fall investigations and progress notes.

F689 Free of Accident Hazards/Supervision/Devices How the nursing home will correct the deficiency as it relates to the resident. Resident #21 no longer resides at the facility. Resident # 36 and Resident #48 have had their fall care plans updated How the nursing home will act to protect residents in similar situations. Falls in the last 30 days for current residents have been reviewed to ensure interventions are in place and effective. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Licensed Nurses and CNAs were re-inserviced on transferring a resident with a Mechanical Lift. Nurses were inserviced on the policy for Fall Management . Any newly hired nurses and CNAs will receive the same education. How the nursing home plans to monitor its performance to make sure that solutions are sustained. DON or designee will randomly audit mechanical lift transfers for proper technique, fall interventions, and fall care plans weekly x4 and monthly x2 or until compliance has been achieved. Investigations of falls will be audited to ensure they are completed appropriately and that neuros are completed as necessary weekly x4 and monthly x2 or until compliance has been achieved. Results will be reported to QAPI The title of the person responsible to ensure correction: Director of Nursing or designee

Based on observation, interview and record review it was determined the facility failed to provide adequate urinary catheter care and incontinent care for 1 of 5 sampled residents (#43) reviewed for pain and incontinence. This placed residents at risk for unmet urinary catheter needs and UTI. Findings include: , Resident 43 admitted to the facility in 4/2024 with diagnoses including retention of urine and acute kidney failure. A 2/7/24 care plan revealed Resident 43 had an indwelling catheter with interventions including catheter care every shift, change catheter every month and change bag PRN. Every shift was to observe and report to the physician any signs and symptoms of a UTI, pain, burning, blood tinged urine, cloudy urine, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, and change in patterns. A 5/10/24 Quarterly MDS indicated Resident 43's BIMS was 12 which indicated moderately impaired cognition. Resident 43 had an indwelling catheter. A review of Resident 43's MAR from 7/1/24 through 7/4/24 revealed instruction to staff to provide the following: -Change catheter and bag as needed for infection, obstruction or when the closed system was compromised. There was no documentation Resident 43 had a PRN catheter change. On 7/1/24 and 7/3/24 the MAR referred the reader to Administration notes. On 7/2/24 the MAR was documented with a check mark. A 7/1/24 Administration Note indicated to change the catheter and bag one time a day starting on the first and ending on the third every month. The note indicated the catheter was replaced on 6/28/24. A 7/3/24 Administration Note indicated to change the catheter and bag one time a day starting on the first and ending on the third every month. The note indicated "was already done." A review of the 7/2024 Documentation Survey Report indicated on 7/3/24 evening shift there was no documentation for Resident 43's urine output. A 7/4/24 Alert Note indicated Resident 43 was yelling at the start of night shift. Resident 43 did not have any urine output. Resident 43's catheter was changed at the start of the shift with good results: over 1000 ccs of urine flowed freely. A public complaint was received on 7/5/24 which indicated Resident 43 yelled out in pain for eight hours and complained of bladder pain. Staff 30 (LPN Unit Nurse) was notified and administered pain medications and instructed the resident to complete deep breathing exercises. Staff 30 was informed by Staff 12 (CNA) the last time Resident 43 complained of bladder pain her/his catheter was clogged. Staff 30 was also informed by Staff 12 Resident 43 did not have any urine output. It was unknown if the physician was notified. When Staff 13 (RN Unit Nurse) arrived for night shift Resident 43's catheter was changed and her/his pain was relieved. On 9/25/24 at 11:04 AM Staff 12 (CNA) stated she arrived to evening shift and was informed Resident 43 was yelling out in pain on day shift. Staff 12 stated Resident 43 informed her she/he had bladder pain. Staff 12 told Staff 30 about Resident 43's bladder pain and was told it was bladder spasms. Resident 43 yelled out in pain the entire evening shift. At midnight Staff 12 continued working on night shift. Staff 12 stated she was in the room when Staff 13 completed a catheter change on Resident 43 and over 600 ccs of urine came out of her/his bladder. Staff 12 stated she did not document anything for output for Resident 43 as she/he did not have any output on evening shift. On 9/25/24 at 1:43 PM Resident 43 stated she/he remembered a couple of months ago her/his bladder hurt and she/he could not urinate. On 9/25/24 at 2:32 PM Staff 14 (CMA) stated Resident 43 was in pain often and she/he complained of her/his catheter not draining. On 9/26/24 at 9:48 AM Staff 10 (CNA) stated on 7/3/24 on day shift Resident 43 was yelling out in pain stating her/his left leg was hurting. When Staff 12 arrived to the facility Staff 10 reported to Staff 12 Resident 43 was in pain during day shift. The following interviews occurred on 9/26/24: -1:00 PM Staff 2 (DNS) and Staff 29 (Regional Nurse) stated they would like to review Resident 43 and her/his catheter care for 7/3/24. -2:45 PM Staff 2 and Staff 29 stated Staff 30 who worked the evening shift of 7/3/24 was available to come in and discuss what occurred. -2:47 PM with Staff 2, Staff 29 and Staff 30 in the room Staff 30 stated in the beginning of 7/2024 Resident 43 had sediment in her/his urine and they started flushing her/his catheter. Resident 43 was in constant pain for a long time. The facility attempted to provide pain medications to help with her/his pain. Staff 30 stated her normal procedure when a CNA reported bladder pain was to make sure the catheter was flowing, and medications were in place. Staff 30 indicated she was assigned two halls, and many CNAs requested her to assess residents. She placed the residents' names on a list so she would not forget. Staff 30 stated she did not remember completing a bladder scan on Resident 43 on 7/3/24 evening shift. No documentation was found in clinical records Staff 30 completed an assessment on Resident 43 on 7/3/24 for concerns of bladder pain and no urine flow from her/his catheter. On 9/27/24 at 10:06 AM Staff 13 stated she started working on the 7/3/24 night shift. After Staff 30 left the facility Resident 43 started yelling out in pain. Staff 30 completed an assessment of Resident 43. Resident 43's bladder was distended and firm and she/he stated she/he could not urinate.

F690 Bowel/Bladder Incontinence, Catheter, UTI How the nursing home will correct the deficiency as it relates to the resident. Resident 43 has had adequate output and no complaints of bladder pain. How the nursing home will act to protect residents in similar situations. An audit of current residents with indwelling catheters will be carried out to ensure adequate output is documented. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Licensed nurses will be trained on catheter output by the Staff development coordinator How the nursing home plans to monitor its performance to make sure that solutions are sustained. Ongoing audits will be done for residents with indwelling catheters for adequate output weekly x4 and monthly until compliance is achieved. Results will be reported to QAPI. The title of the person responsible to ensure correction: DON or designee

Based on interview and record review it was determined the facility failed to follow the nutritional care plan for 1 of 5 sampled residents (#36) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 36 admitted to the facility admit in 4/2023 with a diagnosis of Parkinson's disease. An 4/16/24 Nutrition: Assessment/Nutritional Data Collection form indicated Resident 36 was at nutritional risk due to her/his Parkinson's disease and mental health disorders. Resident 36 was also assessed to have difficulty swallowing. The RD assessment indicated Resident 36 had a gradual weight loss but was stable. The current plan of care was to be continued which included snacks BID. A care plan revised on 6/23/24 revealed Resident 36 was to be provided snacks BID. There was no documentation in Resident 36's record to indicate she/he was provided snacks BID On 9/26/24 at 1:08 PM Staff 2 (DNS) stated staff did not enter the task for Resident 36's snacks correctly and the CNA task only included meal intake. On 9/27/24 9:12 AM Staff 33 (CNA) stated if a resident was to be provided scheduled snacks it was on the CNA task list. Staff were to document if a snack was provided.

F692 Nutrition/Hydration Status Maintenance How the nursing home will correct the deficiency as it relates to the resident. Res 36 is being offered snacks as ordered How the nursing home will act to protect residents in similar situations. An audit will be done to ensure snacks are offered and documented. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Training will be provided to Licensed Nurses to ensure snacks are offered and documented as ordered. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Audits will be conducted weekly x4 and monthly until substantial compliance is achieved. Results will be reported to QAPI. The title of the person responsible to ensure correction: DON or designee

Based on observation, interview and record review it was determined the facility failed to ensure residents received appropriate pain management for 2 of 2 sampled residents (#s 41 and 52) reviewed for pain. Resident 41 was not administered pain medication for five days resulting in unresolved severe pain which limited her/his usual activities. Findings include: 1. Resident 41 was admitted to the facility in 2024 with diagnoses including pressure ulcer of the sacrum and chronic pain syndrome. A 5/2024 MAR revealed Resident 41 took oxycodone (narcotic pain medication) twice daily from 5/1/24 through 5/23/24. From 5/24/24 through 5/28/24 Resident 41 was not administered oxycodone. A quarterly MDS dated 8/30/24 confirmed Resident 41 was assessed to be cognitively intact. On 9/25/24 at 2:26 PM Staff 43 (CMA) stated she was frustrated the facility failed to order medications in a timely manner for Resident 41, and stated it consistently happened to other residents twice a month. She stated there was never an excuse for running out of medications, and stated if a physician was on vacation, there was an on-call physician available, and an order could be called in by the on-call physician to the pharmacy. The pharmacy provided the facility with a code to access the locked emergency medication cart. Staff 43 confirmed there was no code given to access the emergency supply of medication for Resident 41. Staff 43 confirmed from 5/24/24 through 5/28/24 Resident 41 did not receive her/his oxycodone that was ordered to be administered one tablet by mouth every four hours as needed and prior to wound care. On average Resident 41's pain level prior to receiving oxycodone was between seven and eight on a pain scale from one to 10. This constituted unresolved severe pain that prevented Resident 41 from doing her/his usual daily activities. On 9/26/24 at 9:28 AM Resident 41 stated from 5/24/24 through 5/28/24 (five days) the pain was unbearable because she/he was not given her/his usual pain medication (oxycodone) twice daily. She/he described the pain as burning, stabbing pain that was constant. Resident 41 stated her/his sacral pressure ulcer was the most painful, she/he could not get comfortable in bed, and she/he refrained from usual activity because of the severe pain. Resident 41 stated she/he "laid down and waited until Tuesday until they could get a code to get into the emergency supply." Resident 41 stated on 5/28/24 it took a couple of hours before the medication relieved the pain and it was two days before baseline pain level was achieved. On 9/27/24 at 11:10 AM Staff 2 (DNS) confirmed the emergency kit for medications was not accessed over the memorial weekend. , 2. Resident 52 admitted to the facility on 8/14/24 after spinal surgery. 8/13/24 hospital admission orders revealed Resident 36 was to be administered oxycodone (narcotic pain medication) every eight hours PRN. An 8/2024 MAR revealed on 8/14/24 (day of admission) staff did not administer oxycodone to Resident 52. On 8/14/24 Resident 52 reported severe pain. Progress Notes revealed no documentation related to resident 52's pain medication. An 8/16/24 admission MDS indicated Resident 52 was cognitively intact. On 9/25/24 at 3:10 PM Resident 52 stated she/he was always in pain related to her/his surgery. On 9/25/24 at 3:19 PM Witness 9 (Pharmacy Technician) stated on 8/14/24 the pharmacy authorized facility staff to remove three doses of oxycodone from the emergency supply. On 9/25/24 at 3:35 PM and 9/26/24 at 10:36 AM Staff 2 (DNS) stated the staff had authorization to pull the oxycodone from the emergency kit but did not. Staff 2 stated Resident 52 was sent to the emergency room for pain medication and returned. Staff 2 acknowledged there was no documentation in Resident 52's record related to Resident 52's transfer to the hospital and the rationale for not administering the pain medication.

F697 Pain Management How the nursing home will correct the deficiency as it relates to the resident. Resident #52 no longer resides in the facility. Resident #41s pain medications were reviewed and ensured to be available in the medication cart. How the nursing home will act to protect residents in similar situations. Audit will be completed for all residents to ensure pain medications were available Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Licensed Nurses were educated on the policy for Pain Assessment and Management and will be educated on the procedure for obtaining medications from the ekit/after hours. Any newly hired licensed nurses will receive the same education. How the nursing home plans to monitor its performance to make sure that solutions are sustained. DON or designee will randomly audit pain medication availability and administration, incl weekly x4 and monthly x2 or until compliance has been achieved. Results will be reported to QAPI The title of the person responsible to ensure correction: DON or designee

Based on observation, interview and record review it was determined the facility failed to ensure the staffing information was posted in a location easily accessible to residents and visitors. The facility also failed to post accurate and complete staffing information for 4 of 46 days reviewed for staffing. This placed residents and visitors at risk for incomplete, inaccessible, and inaccurate information. Findings include: On 9/23/24 at 11:00 AM the Direct Care Staff Daily Report was observed to be posted above standing eye level on a wall behind the nurse's station counter. On 9/24/24 at 3:12 PM the Direct Care Staff Daily Report was not filled out for the evening (2:00 PM to 10:00 PM) shift. On 9/26/2024 at 8:40 AM the Direct Care Staff Daily Report was posted without any data. Review of the Direct Care Staff Daily Reports for 8/12/24 through 9/26/24 revealed missing census data for 8/31/24 evening shift and missing nursing hours for the night shift on 9/16/24. On 9/26/24 at 12:25 PM Staff 34 (Staffing Coordinator/Admissions Coordinator) stated the staffing sheet was always posted in the observed location, and acknowledged it was hard to see from outside the nurse's station. She also acknowledged the missing data for the identified dates.

F732 Posted Nurse Staffing Information How the nursing home will correct the deficiency as it relates to the resident. Direct care staff posting has been moved to be more easily visible. How the nursing home will act to protect residents in similar situations. Charge nurses will complete daily staffing sheet at beginning of each shift. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Staffing Coordinator and Charge Nurses have received training on completing daily staffing sheets. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Weekly audits x4 then monthly until compliance is achieved. Results will be reported to QAPI The title of the person responsible to ensure correction: ED or designee

Based on interview and record review it was determined the facility failed to ensure non-pharmacological interventions were provided prior medication administration and document a rational for no gradual dose reduction for 1 of 5 sampled residents (#43) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 43 admitted to the facility in 2/2024 with a diagnosis of dementia. a. A 7/10/24 Pharmacy Consultation Report revealed Resident 43 was administered venlafaxine (antidepressant) daily, amitriptylline (antidepressant) every evening, citalopram (antidepressant) daily and mirtazapine (antidepressant; can be used to stimulate appetite) every evening for malnutrition. A recommendation was to decrease the citalopram. A physician response revealed the recommendations were accepted. Citalopram was to be tapered and discontinued. The response also indicated in approximately two months a gradual dose reduction was to start for Resident 43's venlafaxine. A 9/4/24 Pharmacy Consultation Report revealed venlafaxine was to be assessed to see if the medication was at the lowest dose. A physician response indicated the recommendations were declined because Resident 43 had a difficult time adjusting to her/his medical condition. 7/2024, 8/2024 and 9/2024 TARs revealed Resident 43 was documented to have behaviors on 7/20/24 (type of behavior was not identified), 8/23/24 and 8/24/24 (type of behavior not identified), and on 9/1/24 (behavior not identified). Resident 43's record revealed no rationale to support the declination of venlafaxine dose reduction. A request was made on 9/25/24 at 11:13 AM to Staff 2 (DNS) to provide a rationale to alter the plan in 7/2024 to decrease Resident 43's venlafaxine dose when she/he did not exhibit frequent behaviors. No additional information was provided. b. A 9/2024 MAR revealed Resident 43 was to be administered Ativan (antianxiety medication) PRN for anxiety. Ativan was administered on 9/9/24, 9/11/24, 9/14/24, 9/17/24 and 9/24/24. A 9/2024 TAR reveled no documented behaviors on 9/9/24, 9/11/24, 9/14/24, 9/17/24 and 9/24/24. On 9/25/24 at 11:13 AM Staff 2 (DNS) stated non-pharmacological interventions were to be provided prior to PRN Ativan administration. A request was made to provide documentation non-pharmacological interventions were provided on the above dates. No additional information was provided.

F758 Free from Unnecessary Psychotropic Meds/PRN Use How the nursing home will correct the deficiency as it relates to the resident. 1) Resident 43 has a progress note with rationale for declination of GDR by physician. 2) Resident 43 has an order to appropriately documentation prior to giving anti-anxiety medication. How the nursing home will act to protect residents in similar situations. 1) DNS audited pharmacy GDR recommendations for the last three months. Identified concerns will be addressed. 2) Audit of current anti-anxiety medications for appropriate documentation Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. 1) The facility will educate the Psychotropic Committee on GDR documentation. 2) Licensed Nursing staff will be educated on proper documentation of anti-anxiety use. How the nursing home plans to monitor its performance to make sure that solutions are sustained. GDR recommendations will be audited monthly until sustainable compliance is achieved. Anti-anxiety medications will be audited for appropriate documentation weekly x4 and then monthly until sustainable compliance is achieved. Results will be reported to QAPI. The title of the person responsible to ensure correction: The Director of Nursing Services and/or designee are accountable for compliance.

Based on interview and record review it was determined the facility failed to ensure a blood sample was obtained for 1 of 1 sampled resident (#21) reviewed for laboratory tests. This placed residents at risk for delayed treatment. Findings include: Resident 21 was admitted to the facility in 4/2023 with a diagnosis of a stroke. A 7/2024 TAR revealed on 7/10/24 staff were to obtain a blood sample for blood chemistry. Resident 33's record did not have blood chemistry results. On 9/25/24 at 1:58 PM a request was made to Staff 2 (DNS) and Staff 24 (LPN IP) to provide laboratory results. No additional information was provided.

F772 Lab Services Not Provided On-Site How the nursing home will correct the deficiency as it relates to the resident. Resident 21 no longer resides in the facility. How the nursing home will act to protect residents in similar situations. Current residents who have laboratory tests ordered in the last 30 days will be audited for completion and corrected, as necessary. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. All licensed staff will be in serviced on completion of laboratory tests. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Audits will be conducted on current residents for completion of laboratory tests weekly x4 and monthly until substantial compliance is achieved. Results will be reported to QAPI. The title of the person responsible to ensure correction: DON or designee

Based on interview and record review it was determined the facility failed to ensure a resident was offered a dental appointment for 1 of 2 sampled residents (#3) reviewed for dental services. This placed residents at risk for oral pain. Findings include: Resident 3 admitted to the facility in 7/2024 with a diagnosis of rib fractures. A 7/13/24 Nutrition: Assessment/Nutritional Data Collection form revealed Resident 3 had "Missing/broken/decaying" teeth. A 7/9/24 admission MDS revealed Resident 3 was cognitively intact and had no dental issues including cavities. On 9/23/24 at 10:00 AM and 11:57 AM Resident 3 was observed with missing bottom front teeth and Resident 3 reported she/he had cavities. Resident 3 stated the facility did not inquire if she/he wanted assistance scheduling a dental appointment On 9/25/24 at 10:23 AM Staff 4 (Social Service Director) stated if a resident was assessed to have dental issues she/he was notified and followed up with a resident for dental care. Staff 4 stated he was not notified Resident 3 had dental concerns. On 9/25/24 at 11:17 AM Staff 2 (DNS) acknowledged staff identified Resident 3 to have dental concerns, but there was no follow-up with the resident.

F791 Routine/Emergency Dental Services in NFs How the nursing home will correct the deficiency as it relates to the resident. Resident 3 has been offered dental services and care plan updated. How the nursing home will act to protect residents in similar situations. Current residents will have section L of MDS audited for accuracy, updates will be done, as necessary. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. In service with MDS on dental services. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Audits will be done weekly x4 then monthly until sustainable compliance is achieved. Results will be reported to QAPI. The title of the person responsible to ensure correction: DON or designee

Based on observation, interview and record review it was determined the facility failed to implement enhanced barrier precautions (EBP; requires staff to wear gown and gloves with resident contact) and transmission based precautions for 2 of 3 sampled residents (#s 3 and 9) reviewed for pressure and non-pressure ulcers. This placed residents at risk for cross-contamination. Findings include: 1. Resident 3 admitted to the facility in 7/2024 with a diagnosis of rib fractures. On 9/23/24 at 12:02 PM Resident 3 was observed to have scabs and a wound dressing on her/his right shin. Resident 3's room was not identified to require EBP. On 9/24/24 at 7:50 AM Staff 25 (LPN) stated each day staff were provided a list of residents who required EBP. Staff stated Resident 3 was not on the list. On 9/24/24 at 8:15 AM Staff 2 (DNS) stated residents who had wound care should be on EBP. 2. Resident 9 admitted to the facility in 7/2024 with a diagnosis of a leg fracture. On 9/25/24 at 8:32 AM Resident 9 was observed to have a sign on the door indicating EBP and droplet precautions (mask required) when staff entered the resident's room. Staff 27 (PT) was observed standing by Resident 9 with gloves on but no mask or gown. On 9/25/24 at 9:04 AM Staff 2 (DNS) stated staff were to wear a mask when they entered Resident 9's room, and if they had contact with her/him they were to don gloves and a gown. On 9/25/24 at 9:04 AM Staff 27 stated he was not notified Resident 9 was on droplet precautions and he did not see the new sign posted by Resident 9's door for droplet precautions.

F880 Infection Prevention & Control How the nursing home will correct the deficiency as it relates to the resident. Noted staff were provided education regarding proper use of personal protective equipment (PPE), including donning and doffing PPE in patient care areas requiring quarantine transmission-based precautions, and routine rounds conducted by IP and/or designee to ensure PPE used and discarded appropriately and hand hygiene performed per CDC guidelines. Residents 3 and 9 had proper signage for EBP placed on the door How the nursing home will act to protect residents in similar situations. Audit for current residents to ensure appropriate PPE signage for precautions was placed on each door for identified residents Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. The facility will educate therapy on appropriate infection control practices including transmission-based precautions, donning, doffing, and discarding PPE in accordance with current CDC guidelines. IP and nurses will be educated on EBP identification and requirements for placement of signs on the door. How the nursing home plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist and/or designee will conduct observational monitoring for compliance with PPE use, including donning, doffing and discarding of PPE and proper hand-hygiene when in resident contact weekly for 4 weeks, with oversight from the Director of Nursing Services or designee monthly for 2 months to validate staff adhere to the current standards of infection control practices and quarantine transmission-based precautions protocol. An audit will be done to ensure that residents meeting the requirement for EBP will have the correct signage on door. Any identified concerns will be addressed immediately. Results will be reported to QAPI The title of the person responsible to ensure correction: DON or designee

Based on interview and record review it was determined the facility failed to ensure antibiotics were not used unless indicated and failed to monitor antibiotic usage for 1 of 5 sampled residents (#48) reviewed for urinary catheters or UTIs. This placed residents at risk for unnecessary antibiotic usage and drug resistant infections. Findings include: Resident 48 admitted to the facility in 2024 with diagnoses including chemical imbalance affecting the brain and repeated falls. An Admission MDS dated 7/9/24 indicated Resident 48 was cognitively intact. The MDS also revealed Resident 48 had a history of falls. Review of progress notes revealed Resident 48 had two falls on 9/21/24, was sent to the hospital for evaluation and treatment, and returned with a diagnosis of UTI. Review of a 9/21/24 UA showed Resident 48's urine was cloudy and contained bacteria. No urine culture (test for type of antibiotic capable of killing the bacteria) was present. A 9/22/24 provider order revealed staff were to administer Cephalexin 500mg (an antibiotic) three times a day for 7 days for an infection. A 9/24/24 progress note revealed staff contacted the provider about concerns related to Resident 48's increasing confusion. Review of urine culture results dated 9/24/24 revealed the bacteria were not affected by Cephalexin and Meropenem (an antibiotic) was the only antibiotic capable of killing the bacteria. A 9/26/24 progress note revealed the provider would reevaluate the appropriateness of the Cephalexin. A 9/26/24 provider order revealed staff were to administer Meropenem 1 gram through a PICC line (a thin, flexible tube inserted into a vein in the upper arm and ending in a larger vein in the heart; used to administer medication directly into the bloodstream) every eight hours for seven days for a UTI. A 9/26/24 progress note revealed staff placed an IV (a flexible tube inserted into a vein to deliver fluids and medication directly into the bloodstream) in Resident 48's left arm to administer the Meropenem while an appointment was made for the PICC line insertion. Review of 9/26/24 and 9/27/24 MARs revealed Meropenem was administered, and Cephalexin was not administered on 9/26/24. The MARs also revealed both antibiotics were administered on 9/27/24. On 9/27/24 at 11:36 AM Staff 2 (DNS) acknowledged the Cephalexin was administered without a proper indication, and the Cephalexin was not discontinued when the Meropenem was started. She also acknowledged both antibiotics were administered on 9/27/24.

F881 Antibiotic Stewardship Program How the nursing home will correct the deficiency as it relates to the resident. Resident number 48 had oral antibiotic discontinued. How the nursing home will act to protect residents in similar situations. Audit of current residents on antibiotics, reviewed by nursing and MD to ensure appropriate antibiotics stewardship is being practiced. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. IP nurses will review antibiotics in morning meetings to ensure appropriate antibiotic stewardships are being practiced. IP was reeducated on antibiotic stewardship. How the nursing home plans to monitor its performance to make sure that solutions are sustained. DON or designee will review antibiotics weekly for 4 weeks then monthly until substantial compliance is met. Results will be reported to QAPI The title of the person responsible to ensure correction: DON and or designee

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 5 of 6 staff members (#s 11, 18, 38, 39 and 40) reviewed for in-service training. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: -Staff 11 (CNA), hired 5/25/18, had 10 hours and 46 minutes of documented training from 9/26/23 through 9/26/24 -Staff 18 (CNA), hired 5/18/22, had five hours and 36 minutes of documented training from 9/26/23 through 9/26/24 -Staff 38 (CNA), hired 8/2/23, had no documented training from 9/26/23 through 9/26/24 -Staff 39 (CNA), hired 3/29/18, had five hours and 52 minutes of documented training from 9/26/23 through 9/26/24 -Staff 40 (CNA), hired 4/13/22, had four hours and 41 minutes of documented training from 9/26/23 through 9/26/24 On 9/26/24 at 4:58 PM Staff 2 (DNS) stated all CNA staff were given competency evaluations upon hire and annually in March of each year. She stated in-service training was completed for CNA staff during staff meetings and via internet-based services. On 9/27/24 at 11:36 AM Staff 2 (DNS) acknowledged the identified CNA staff records did not show 12 hours of annual in-service training.

F947 Required In-Service Training for Nurse Aides How the nursing home will correct the deficiency as it relates to the resident. All CNA’s have completed 12 hours of annual in-services including dementia management, resident abuse prevention, and the care of cognitively impaired residents. How the nursing home will act to protect residents in similar situations. No residents were identified, but all residents could be affected. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. SDC will create a Calendar of monthly education to reach the 12 hours required for CNA’s. SDC was educated on 12-hour requirement for CNA education and on monitoring of CNA education. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Audits of CNA training will be monthly x3 and until substantial compliance is achieved. Results of audits will be reported to QAPI The title of the person responsible to ensure correction: DON or designee

Based on interview and record review it was determined the facility failed to ensure the State minimum bariatric CNA staffing requirements were maintained for 75 of 95 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: On 9/23/24 the facility had five residents approved for the state bariatric rate. Review of the Direct Care Staff Daily Reports for weekends from 1/6/24 through 6/30/24, and the Direct Care Staff Daily Reports for 8/12/24 through 9/26/24 revealed the following days when one or more shifts did not meet the state bariatric CNA staffing requirements: 1/2024: 1/6, 1/7, 1/13, 1/14, 1/20, 1/21, 1/27 and 1/28 2/2024: 2/3, 2/4, 2/10, 2/11, 2/17, 2/18, 2/24 and 2/25 3/2024: 3/2, 3/3, 3/9, 3/10, 3/16, 3/17, 3/23, 3/24, 3/30 and 3/31 4/2024: 4/6, 4/7, 4/13, 4/14, 4/20, 4/21, 4/27 and 4/28 5/2024: 5/4, 5/5, 5/11, 5/12, 5/18, 5/19, 5/25 and 5/26 6/2024: 6/1, 6/2, 6/8, 6/9, 6/15, 6/16, 6/22, 6/23, 6/29 and 6/30 8/2024: 8/13, 8/15 - 8/17, 8/19, 8/23 and 8/26 - 8/30 9/2024: 9/1, 9/3, 9/4, 9/7 - 9/10, 9/12, 9/14 - 9/16 and 9/18 On 9/26/24 at 10:48 AM Staff 34 (Staffing Coordinator/Admissions Coordinator) acknowledged the failure to meet the state minimum bariatric CNA staffing requirements for the identified dates.

M185 How the nursing home will correct the deficiency as it relates to the resident. Staffing coordinator monitors daily requirements for bariatric standards. How the nursing home will act to protect residents in similar situations. No bariatric residents were identified however bariatric residents have the potential to be affected by this alleged deficient practice. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Recruitment of open CNA positions and the facility is offering a CNA class How the nursing home plans to monitor its performance to make sure that solutions are sustained. Staffing will be audited weekly x4 then monthly until substantial compliance is achieved. Results will be reported to QAPI, The title of the person responsible to ensure correction: ED or designee

OAR 411-085-0310 Residents' Rights: Generally

Refer to F553 *************** OAR 411-086-0040 Admission of Residents Refer to F578 *************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 *************** OAR 411-085-0320 Residents' Rights: Charges and Rates Refer to F582 *************** OAR 411-087-0100 Physical Environment: Generally Refer to F584 *************** OAR 411-085-0360 Abuse Refer to F600, F609 and F610 *************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 *************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684 and F697 *************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F688, F689, F690, F692 and F758 *************** OAR 411-086-0100 Nursing Services: Staffing Refer to F732 *************** OAR 411-086-0010 Administrator Refer to F772 *************** OAR 411-086-0210 Dental Services Refer to F791 *************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 and F881 *************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F947 ***************

Based on interview and record review it was determined the facility failed to provide advance directive information, or follow up with or assist residents or resident representatives with formulation of an advanced directive for 4 of 7 sampled residents (#s 2, 3, 34 and 40) reviewed for advanced directives. This placed residents at risk for end of life choices not being honored. Findings include: 1. Resident 2 was admitted to the facility in 2022 with diagnoses including Palmar Fascial Fibromatosis (the tightening of connective tissue in the hand which pulls the fingers towards the palm) and peripheral vascular disease (a circulatory condition which reduces blood flow to limbs). A 7/8/22 unlabeled document indicated Resident 2 was given information on advance directives and offered assistance to complete the process. Resident 2's Care Plan Conference Records for 9/12/22, 12/12/22 and 3/30/23 indicated "POLST" (Physician Order for Life Sustaining Treatment) for her/his advance directive. A 3/3/23 Quarterly MDS revealed Resident 2 had moderate cognitive impairment. On 6/14/23 at 11:41 AM Staff 1 (Administrator) stated staff were expected to review a resident's advance directive at admission, quarterly and if there was a change of condition. On 6/14/23 at 12:27 PM Staff 4 (Director of Social Services) stated she offered a packet with information about advance directives at admission to residents and tried to remember to speak to them about their advance directive during quarterly care conferences. Staff 4 confirmed she had no documentation regarding follow up conversations about Resident 2's advance directive with the resident or her/his family. , 2. Resident 3 was admitted to the facility in 2016 with diagnoses including depression and anxiety. A 7/2022 questionnaire indicated Resident 3 refused information related to advance directives and stated she/he had an advance directive. The questionnaire also indicated social services would contact Resident 3's family member to obtain a copy of the advance directive. A review of the medical record did not include any information about contacting Resident 3's family member or additional information about an advance directive. On 6/14/23 at 11:53 AM Staff 4 (Director of Social Services) stated she asked Resident 3's family member to bring in the advance directive but did not document the request and did not believe the advance directive was provided to the facility. , 3. Resident 34 was admitted to the facility 6/2022 with diagnoses including dementia. A 6/30/22 Admission MDS indicated Resident 34 had severe cognitive impairment. A Care Plan initiated 6/24/22 indicated the resident had a power of attorney for health care (a designated person who has legal authority to make medical decisions). An untitled documented signed on 7/8/22 by Resident 34 indicated she/he was provided information on advance directives. Review of the resident's record revealed there was no power of attorney for health care. On 6/14/23 at 2:06 PM Staff 4 (Director of Social Services) stated the resident should not have been provided the advance directive information due to her/his cognitive impairment. Staff 4 indicated Resident 34 came from another facility and thought the resident already had an advance directive. Staff 4 indicated the information could be in the business office. On 6/14/23 at 2:09 PM Staff 29 (Business Office Manager) stated the business office did not have any power of attorney for health care or advance directive information related to Resident 34. 4. Resident 40 was admitted to the facility 2/2/23 with diagnoses including a leg fracture. Resident 40's 2/9/23 Admission MDS indicated the resident had moderate cognitive impairment. A Care Plan initiated 2/18/23 indicated Resident 40's advance directive would be honored. Review of Resident 40's clinical record revealed the resident did not have an advance directive or a power of attorney for health care (a designated person who has legal authority to make medical decisions). On 6/13/23 at 2:56 PM Staff 4 (Director of Social Services) reviewed Resident 40's clinical record and acknowledged the resident's adult child was only her/his financial power of attorney. Staff 4 indicated she would provide documentation the resident had an advance directive or a health care power of attorney. No additional information was provided.

Disclaimer Clause Preparation and execution of this plan of correction do not constitute the provider's admission of or agreement with the alleged facts or conclusion set forth in the the statement of deficiencies. The plan of correction is prepared and executed solely because the provision requires it of Federal and State law. 1. Advance Directives were offered to residents #2, 3, and 40 and or to their representative as applicable. Resident # 34 no longer resides at the facility. 2. The facility audited Advance Directives to validate that they had been offered to reflect the residents/and/or their representatives' wishes. Identified concerns will be addressed. 3. The Executive Director or designee will educate the clinical interdisciplinary team and SW on the requirement to review, clarify, and update residents' Advance Directives/Health Care Decisions, including but not limited to on admission, quarterly, after a life-altering illness and return from hospitalization to reflect the residents/representatives wishes. 4. The Social Services Director and/or designee, with the oversight from the Executive Director will conduct audits of new admissions and readmissions to validate to Advanced Directives were offered and reflect the residents’/ representatives’ wishes weekly for 4 weeks and then monthly for 2 months. The Social Services Director and or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Social Services Director is accountable for compliance.

Based on interview and record review it was determined the facility failed to provide written grievance communications and resolutions regarding care and treatment concerns for 1 or 4 sampled residents (#256) reviewed for abuse. This placed residents at risk for unresolved concerns and grievances. Findings include: Resident 256 was admitted to the facility in 2022 with diagnoses including Parkinson's disease (progressive disease of the nervous system marked by tremors). An 10/18/22 Admission MDS indicated Resident 256 was cognitively intact. An 10/13/22 care plan indicated to assist Resident 256 with mobility as needed. A 11/1/22 revised care plan indicated Resident 256 was able to ambulate with nursing assistance in the facility using a four wheel walker, self ambulate in her/his room and would call for setup assistance. The 11/21/22 Area of Focus: Concern and Comment Program indicated residents had the right to file grievances orally and the program was to be utilized anytime a concern, comment or grievance occurred that involved a resident. On 6/12/23 at 6:39 PM Resident 256 stated she/he filed a verbal complaint with Staff 2 (DNS) about staff's treatment of her/him. Resident 256 stated she/he needed to ambulate in the halls especially at night as a means to address her/his tremors and staff were not assisting her/him with this need consistently. Resident 256 further stated her/his concerns were not addressed and she/he was surprised there was no documentation of her/his complaint. On 6/14/23 at 7:29 PM Staff 27 (CNA) stated Resident 256 was often frustrated and impatient with staff because they would not allow her/him to walk independently or as frequently as Resident 256 wanted. On 6/15/23 at 4:41 PM Staff 2 stated Resident 256 was angry about her/his inability to walk in the halls, no specific staff were identified related to her/his frustration and she had multiple conversations with Resident 256 about how to address her/his concerns. Staff 2 confirmed any staff could fill out a grievance form, there was no grievance form or documentation completed or filed during any conversation with Resident 256 and the grievance process was not followed.

1. Resident #256 no longer resides in the facility. 2. The Clinical Interdisciplinary Team reviewed current residents’ grievances from May 2023 to date to validate verbal grievances were transcribed on the grievance card with an appropriate resolution. Identified concerns will be addressed. 3.The facility will educate staff on following the facility's grievance process and procedure. In addition, the interdisciplinary team will discuss grievances during daily stand-up meetings to validate appropriate documentation and follow-up. 4. The Social Services Director and/or designee, with the oversight of the facility’s Executive Director, will review and audit the grievance log weekly for 4 weeks and then monthly for 2 months. The Social Services Director and or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Social Services Director is accountable for compliance.

Based on interview and record review, it was determined the facility failed to protect residents' right to be free from verbal, and physical abuse for 1 of 4 sampled residents (#35) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 35 was admitted to the facility in 2022 with diagnosis including autism. Resident 37 was admitted to the facility in 2022 with diagnosis including cognitive communication deficit (difficulty thinking and how someone uses language). A 2/13/23 Communication with Physician note revealed Resident 37 scratched, hit and verbally attacked a CNA who was caring for her/him. A 3/3/23 Quarterly MDS revealed Resident 37's BIMS score was 11 indicating moderate cognitive impairment. An 4/28/23 Quarterly MDS revealed Resident 35 was hardly understood and was severely cognitively impaired. A 5/18/23 Alert Note indicated it was reported to Staff 2 (DNS) that Resident 14 witnessed Resident 37 hit Resident 35 in the shoulder twice and stated for her/him to stay the "fuck out of [her/his] room" and away from Resident 37. A 5/18/23 Abuse Adverse Event Investigation Packet revealed on 5/18/23 at 2:00 PM Resident 14 reported she/he witnessed Resident 37 tell Resident 35 to "keep [her/his] fucking mouth closed" and hit her/him with a closed fist on her/his shoulder and chest area. Resident 14 observed Resident 35 cower and bring her/his shoulders down. Resident 37 became agitated at times when people encroached on her/his space. Resident 37 admitted she/he should not hit. On 6/12/23 at 1:31 PM Resident 14 stated on 5/18/23 she/he observed Resident 35 and Resident 37 outside her/his room in the hallway. Resident 37 stated to Resident 35 "stay out of my fucking room". Resident 37 said this twice to Resident 35 and hit her/him in her/his chest area with a closed fist. Resident 35 cowered from Resident 37 and Resident 35's face grimaced when she/he was struck by Resident 37. On 6/14/23 at 12:48 PM Staff 17 (CNA) stated Resident 37 was "spicy", she/he cussed a lot and Resident 35 went into Resident 37's room. During one instance Resident 35 was in Resident 37's doorway and Resident 37 went out into the hallway screaming to staff to get Resident 35 out of her/his room. On 6/15/23 at 11:38 AM Staff 2 (DNS) stated the facility determined Resident 37 abused Resident 35 on 5/18/23.

1. Resident #37 no longer resides in the facility. 2. The Clinical Interdisciplinary Team reviewed residents with known behaviors toward others to validate that the facility can appropriately meet their needs. In addition, the Clinical Interdisciplinary Team will review clinical behavior alerts during daily clinical meetings to validate appropriate follow-up. No concerns were identified. 3. The facility staff will be educated on the prevention of abuse, monitoring of behaviors, and establishing a plan to prevent or mitigate risks of recurrence. 4. The facility will audit behavior alerts to ensure appropriate plans established to prevent and mitigate recurrence risks weekly for 4 weeks and then monthly for 2 months. The Social Services Director and or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Social Services Director is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to revise care plan interventions for 1 of 4 sampled residents (#2) reviewed for non-pressure skin conditions. This placed residents at risk for medical complications. Findings include: Resident 2 was admitted to the facility in 2022 with diagnoses including Palmar Fascial Fibromatosis (the tightening of connective tissue in the hand which pulls the fingers towards the palm) and peripheral vascular disease (a circulatory condition which reduces blood flow to limbs). A 3/3/23 Quarterly MDS revealed Resident 2 had impairment to both of her/his upper extremities. An 4/25/23 medical evaluation indicated Resident 2 had edema (swelling caused by excess fluid trapped in the body's tissue) in her/his left upper extremity which previously resolved when Resident 2's hand was elevated, but now the entire arm was edematous. A 5/30/23 revised care plan had no indication of staff interventions for Resident 2's edema. A 6/12/23 nutrition/dietary note indicated Resident 2 had pitting edema and the physician was aware. On 6/12/23 at 1:30 PM Resident 2 was observed with edema to her/his left arm and hand and no supportive devices or pillows were in place. Resident 2 stated her/his left arm and hand hurt. On 6/13/23 at 12:10 PM Staff 5 (CNA) stated the use of pillows for support of Resident 2's left arm and hand were in place for the last few months based on staff conversations, but acknowledged interventions for Resident 2's edema were not indicated on her/his care plan. On 6/13/23 at 12:25 PM Staff 11 (CNA) stated she started using pillows for Resident 2's arm to make her/him more comfortable on her own and Staff 28 (MDS Coordinator) was to update care plans. On 6/15/23 at 2:18 PM and 6/16/23 at 10:09 AM Staff 2 (DNS) stated the use of pillows to address Resident 2's edema and comfort was discussed during staff rounds but no conversations were documented. Staff 2 acknowledged Resident 2's care plan was not updated to ensure care interventions were provided consistently.

1. Care Plans for Resident #2 was updated to reflect current interventions. 2. The Clinical Interdisciplinary Team audited and reviewed current residents' skin-related care plans to validate that care plans reflect appropriate interventions. Identified concerns will be addressed. 3.The Director of Nursing Services and or designee will educate the clinical interdisciplinary team on the requirement to review and update residents' care plans to ensure residents' plan of care reflects current interventions. 4. Skin related Care Plans will be audited for appropriate interventions by the MDS Nurse and or designee weekly for 4 weeks and then monthly for 2 months. The MDS Nurse and or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5.The MDS Nurse is accountable for compliance.

Based on interview and record review it was determined the facility failed to complete discharge summaries including a recapitulation of stay and a final summary of residents' status upon discharge for 1 of 2 sampled residents (#53) reviewed for discharge. This placed residents at risk for unsafe discharges. Findings include: Resident 53 admitted to the facility in 2023 with diagnoses including kidney disease. A 5/5/23 Progress Note revealed Resident 53 discharged to home with her/his spouse, and was sent home with medication and discharge instructions. A 5/5/23 Discharge Summary Information assessment included no recapitulation of Resident 53's stay or final summary of her/his status at the time of discharge On 6/14/23 at 4:38 PM Staff 2 (DNS) reviewed Resident 53's Discharge Summary Information assessment and confirmed it did not include a recapitulation of stay. Staff 2 stated she expected staff to add information about the resident's progress with rehabilitation and nursing.

1. Discharge summary for Resident #53 was updated, and a copy was mailed to the resident. 2. The Clinical Interdisciplinary Team audited and reviewed discharged residents from May 2023 to date to validate resident discharge summaries, including but not limited to the recapitulation of stay and final summary of residents’ status-completed before discharge. Identified concerns will be addressed. 3. The facility will provide education to the clinical interdisciplinary team on the requirement to complete the recapitulation of stay and final summaries. 4. 25% of Discharge Summaries will be audited by the Director of Health Information Management and or designee weekly for 4 weeks and then monthly for 2 months. The Director of Health Information Management and or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Director of Health Information Management is accountable for compliance.

Based on interview and record review it was determined the facility failed to ensure treatments were provided for 1 of 4 sampled residents (#257) reviewed for non-pressure skin conditions. This placed residents at risk for adverse medical conditions. Findings include: Resident 257 was admitted to the facility on 7/18/22 with diagnoses including cellulitis (bacterial skin infection) and spina bifida (birth defect of the spine and spinal cord which could cause symptoms including weakness and paralysis). A 7/18/23 Admission Collection Tool indicated Resident 257 had a linear ulceration to the back of the right thigh which was 14 inches long. Review of the resident's TAR and Progress notes from 7/18/22 through 7/23/22 revealed there was no treatment or monitoring to the right thigh ulceration. A Progress Note dated 7/24/22 indicated, upon admission, the resident had an open area to the back of her/his thigh. The note indicated the resident reported, after admission to the facility, no one looked at the open area. The note described the back of the thigh to have an open area which was 14 cm long, 3 cm wide and 0.5 cm deep. There was a scant amount of green and bright red drainage which had a slight foul odor. The bed of the wound had slough (nonviable tissue) which was dark brown. The wound was cleaned and a dressing was applied. A 7/25/22 Communication with Physician note indicated the physician was notified of the thigh wound. The physician approved the requested treatment and authorized a wound consult. A wound clinic note dated 7/28/22 indicated Resident 257 had spina bifida with decreased sensation to the buttocks and the resident was dependent on a wheelchair for mobility. The resident had a shear injury to the right thigh due to self transfers which worsened while in the facility. The wound was described as a full thickness wound which measured 5 cm by 10 cm by 0.4 cm and had 26 to 50 percent slough. On 6/14/23 at 7:42 AM Staff 21 (LPN) stated if a resident was admitted to the facility with an open area, the staff documented the skin impairment on the data collection tool and ensured orders were in place or obtained. Staff were to monitor the skin changes and and document on the TAR. Staff 21 stated she did not recall Resident 257. On 6/14/23 at 7:47 AM Staff 3 (LPN Resident Care Manager) stated she did not work with Resident 257. Staff 3 acknowledged the resident was admitted to the facility with an open area to the back of the thigh. Upon admission to the facility staff put an order in the resident's electronic record which directed staff to change the dressing every three days. When staff entered the order into the electronic record, they did not designate when the treatment was to be done. As a result the nursing treatment for the wound did not propagate to the TAR. A request was made to Staff 3 to provide documentation to show staff provided treatment or monitored the open thigh wound from 7/18/22 through 7/23/22. No additional information was provided.

1. Resident #257 no longer resides in the facility. 2. The Clinical Interdisciplinary Team audited current treatments to ensure licensed staff correctly entered treatment orders into the resident's electronic treatment administration record (eTAR). No concerns were identified. 3. The facility will educate the licensed nurses on entering treatment orders into residents' eTAR that accurately reflects the provider's orders. 4. 25% of new treatment orders will be audited by the Director of Nursing Services and or designee weekly for 4 weeks and then monthly for 2 months. The Director of Nursing Services and/or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The title of the person responsible to ensure correction: The Director of Nursing Services is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to address RD recommendations for 2 of 7 sampled residents (#s 9 and 40) reviewed for unnecessary medications and nutrition. This placed residents at risk for weight loss. Findings include 1. Resident 9 was admitted to the facility in 2021 with diagnoses including dementia and protein-calorie malnutrition. A 12/23/22 Annual MDS indicated Resident 9 required set-up assistance for eating and she/he was rarely understood. The 6/2023 Task: ADL-Snacks indicated no snacks were offered to Resident 9 from 6/1/23 through 6/15/23. A 6/2/23 revised care plan indicated Resident 9 was at risk for weight fluctuation and to assist her/him with meals as needed. A 6/13/23 Resident at Risk Meeting Note and revised care plan indicated to provided fortified snacks to Resident 9 twice a day. On 6/12/23 at 12:28 PM Resident 9 was observed in her/his room with untouched food in front of her/him on a bedside table. Resident 9's hands were tucked under her/his blanket. On 6/12/23 at 3:08 PM Resident 9 was observed in bed with no food and her/his hands remained tucked under her/his blanket. On 6/14/23 at 4:51 PM Staff 2 (DNS) stated no interventions were in place for snacks to be offered for Resident 9 and the kitchen usually sent out snacks that were scheduled because of weight loss interventions. On 6/15/23 at 10:38 AM Staff 14 (Dietary Manager) stated Resident 9 was not on the list of those residents who required scheduled snacks. Staff 14 stated based on Resident 9's cognition she/he was unable to request snacks so scheduled snacks were necessary and not provided. , 2. Resident 40 was admitted to the facility in 2/2023 with diagnoses including a fractured leg. An 4/25/23 Nutrition Assessment Summary indicated the resident was reviewed for a significant weight loss. The resident lost over 6 percent of her/his weight in 30 days and her/his weight declined significantly since admission to the facility. The resident was already on fortified foods and juice supplements three times a days with meals. Additional interventions already implemented included staff supervision of the resident in the dining room for meals to ensure she/he received assistance as needed and an appetite stimulant. A new intervention the RD recommended was staff were to provide fortified snacks twice a day between meals. Review of the resident's record from 5/13/23 through 6/13/23 revealed no documentation snacks were provided twice a day. On 6/13/23 at 3:13 PM Staff 3 (LPN Resident Care Manager) stated when the RD made recommendations the nursing staff were to review the recommendations. If the recommendations were not accepted they were to document the rationale for not implementing the intervention. Staff 3 indicated Resident 40 had many interventions in place for weight loss and some of the recent weight loss could have been attributed to the removal of her/his leg cast. Staff 3 acknowledged the RD recommended fortified snacks twice a day and there were no snacks provided or a rationale for not implementing the snacks. On 6/13/23 at 3:29 PM Staff 30 (CNA) stated if a snack was provided it was documented in the resident's clinical record.

1. Recommendations were updated for Resident #9 and #40. 2. The Clinical Interdisciplinary Team audited RD recommendations from April 2023 and to date to ensure recommendations were reviewed and implemented per the provider’s approval. Identified concerns will be addressed. 3. The Director of Nursing Services and/or designee will educate the clinical interdisciplinary team on the process and procedure for initiating RD recommendations, including but not limited to entering RD recommendations into the direct care staff point-of-care task list to ensure residents nutritional needs are met. 4. RD recommendations will be audited by the Director of Nursing Services and or designee bimonthly for 1 month and then monthly for 2 months. The Director of Nursing Services and/or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Director of Nursing Services is accountable for compliance.

Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 2 of 3 halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: On 6/12/23 at 11:41 AM Resident 23 stated she/he had to wait 30 minutes for staff to answer her/his call light and staff told her/him it was because they were short-staffed. Resident 23 stated the facility was short-staffed since she/he admitted to the facility two years ago. On 6/12/23 at 12:35 PM Resident 1 stated she/he turned on her/his call light, waited, and ended up falling asleep. An hour later the call light was still on. Resident 1 stated she/he did not activate the call light often as she/he did not want to "bug" the staff, and the staff would "get in trouble" if they stayed late. On 6/12/23 at 1:31 PM Resident 14 stated recently a CNA had three hallways to herself and residents waited an hour and a half to two hours on night shift for assistance. Resident 14 stated she/he had to wait two hours. During random observations on 6/14/23 the following occurred: Room 9: -10:08 AM the call light was on, and at 10:25 AM, 17 minutes later, the light was turned off. -10:26 AM the call light was back on and was turned off at 10:31 AM, 23 minutes after it was originally activated. -10:34 AM the resident in room nine stated her/his call light was on and it was taken care of and long call light wait times happened "once in a while" The resident in room nine stated staff were having a busy day. Room 10: -10:11 AM the call light was activated and at 10:34 AM, 23 minutes later, the light was turned off. -10:57 AM the resident in the room stated she/he had the call light on as she/he wanted to get off the bed pan and it was uncomfortable. The resident in room 10 stated long call light wait times happened periodically during shift changes and meal times. On 6/14/23 at 7:56 AM Staff 15 (CNA) stated most of the time she completed her assigned duties, but she got stressed and had to work in a panicked type of atmosphere to attempt to get everything done. Staff 15 stated if she could not complete everything it was personal hygiene tasks that did not get completed, and she stayed late to complete her charting for the residents. Staff 15 stated it was nice when Staff 2 (DNS) and Staff 25 (Life Enhancement Director) assisted and passed out food trays but stated they did not always assist. On 6/14/23 at 12:09 PM Staff 20 (CNA) stated residents complained of long call light wait times of around 30 minutes during the evening shift. Staff 20 stated there was a culture in the facility on the evening shift for staff to talk with their co-workers instead of answering call lights. Staff 20 stated she observed residents being left on their bed pans for long periods of time which included a resident in Room 19. On 6/14/23 at 12:48 PM Staff 17 (CNA) stated the facility was almost always short of staff on evening shift. Staff 17 stated she could not spend enough time with residents and if their call light wait time was long the staff members were not to tell the residents the facility was short on staff. During 5/2023 a resident was left on their bedside commode for a half an hour. A 6/14/23 Direct Care Staff Daily Report revealed the facility was short one CNA on evening shift. On 6/15/23 at 11:45 AM Staff 2 (DNS) confirmed the facility was short-staffed.

1. All residents have the potential to be affected by this failed practice. 2. All residents have the potential to be affected by this failed practice. 3. The facility has placed an ad to hire PRN NAC’s in an effort to hire additional on-call staff that could help fill open positions when staff call off sick. The facility will utilize COVR labor management software, staffing incentive programs, local advertising venues, web-based employment recruiting platforms, and third-party staffing agencies for CNA staffing needs and ongoing recruitment efforts. In addition, the Executive Director educated direct care and non-clinical staff on the importance of responding to call lights promptly and the responsibility of facility staff to respond to call lights. 4. The Staffing Coordinator will review and audit the CNA staffing schedule and will conduct random audits on resident call light response times weekly for 4 weeks and then monthly for 2 months. The Staffing Coordinator and/or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Staffing Coordinator is accountable for compliance.

Based on interview and record review it was determined the facility failed to ensure resident food preferences were honored for 1 of 4 sampled residents (#23) reviewed for food preferences. This placed residents at risk for unmet needs. Findings include: Resident 23 was admitted to the facility in 2021 with diagnoses including diabetes and macular degeneration (blurred or no vision). A 2/3/23 Annual MDS indicated Resident 23's BIMS score indicating she/he 15 was cognitively intact. A 2/8/23 care plan indicated Resident 23 needed assistance with ordering her/his food. Review of the 11/3/22 and 5/4/23 Quarterly Nutritional Data Collection indicated Resident 23 liked cheerios and bananas, and "Does not like this writer [writer of the report] or foods offered by facility. Very negative and has many food complaints." No documentation of Resident 23's food dislikes were documented. On 6/12/23 at 11:43 AM Resident 23 stated CNA staff went over the menu with her/him and took her/his order and every day she/he never received what she/he ordered. Resident 23 stated one day she/he ordered soup and got crackers and no soup. Resident 23 stated she/he did not want vegetables and every time vegetables were on the menu she/he received them. At 12:25 PM Resident 23 had one slice of pizza, soup, a cookie and salad. Resident 23 drank the juice out of the soup since it was mainly vegetables and did not eat his/her salad. On 6/13/23 at 12:02 PM Resident 23 stated the kitchen did not have a menu for her/him so a staff member from the kitchen came and collected Resident 23's preferences for lunch. She/he ordered soup and stir-fry without rice. Resident 23 did not receive her/his soup, so Staff 2 (DNS) went to the kitchen and obtained Resident 23's soup. Resident 23's stir fry was mainly vegetables and only two small pieces of meat were visible on the plate. On 6/14/23 the following occurred: -8:21 AM Resident 23's breakfast plate had two fried eggs and two slices of bacon. Resident 23 stated she/he ordered something else but it was not on her/his plate. -8:52 AM when asked if it was French Toast she/he stated "yes" that was the other item she/he ordered and did not receive. -12:23 PM Resident 23's food ticket indicated she/he disliked vegetables. Resident 23 had approximately a cup of peas and carrots on her/his plate. Resident 23 stated she/he did not receive the soup she/he ordered so the CNA went back to the kitchen and obtained the soup. -12:25 PM Staff 18 (CNA) stated Resident 23's soup was not on her/his tray and she had to go back to the kitchen to get it. On 6/15/23 at 8:23 AM Resident 23 stated the facility "out did themselves this morning." Resident 23 did not receive her/his yogurt, cereal and banana and only one piece of bacon instead of two. Staff went back and got the yogurt and cereal but she/he never received the second piece of bacon or her/his banana. On 6/15/23 at 10:28 AM and 10:39 AM Staff 14 (Dietary Manager) stated upon admission staff spoke to the residents about their preferences and their preferences were printed on their meal ticket. There was a menu which was circled for each meal order. If a resident did not fill out a menu the resident received the meal which was on the spread sheet. Staff 14 stated on 6/15/23 there were a lot of meal tickets missing and Resident 23's breakfast meal ticket was one of them.

1. Food preferences were reviewed and updated with Resident #23. 2. The Clinical Interdisciplinary Team conducted a review and audited resident food preference. Identified concerns will be addressed. 3. The facility will educate the Dietary Manager on the policy for food preferences to ensure residents' likes and dislikes are honored. 4. The Dietary Manager, with oversight by the Executive Director and or designee, will conduct random audits in the dining room to validate residents are served food items according to their food preferences for 4 weeks and then monthly for 2 months. The Dietary Manager and/or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Dietary Manager is accountable for compliance.

Based on observation, interview and record review it was determine the facility failed to provide adaptive eating equipment for 1 of 2 sampled residents (#2) reviewed for position and mobility. This placed residents at risk for loss of dining independence. Findings include: Resident 2 was admitted to the facility in 2022 with diagnoses including Palmar Fascial Fibromatosis (the tightening of connective tissue in the hand which pulls the fingers towards the palm) and peripheral vascular disease (a circulatory condition which reduces blood flow to limbs). A 3/3/23 Quarterly MDS revealed Resident 2 had impairment to both of her/his upper extremities. A 1/18/23 revised care plan indicated Resident 2 was to wear her/his hand splint for all meals, utensils slid into the pocket on the palm side of the splint and Resident 2 should be able to eat with minimal assistance. Staff were to assist Resident 2 with meals as needed. A 5/23/23 MR (Magnetic Resonance) Cervical Spine without Contrast revealed Resident 2 had degenerative changes to the spine at all levels which explained her/his muscle weakness and difficulty with ambulation. A 5/29/23 Occupational Therapy Treatment Encounter Note indicated Resident 2 actively participated in the use of her/his right wrist splint, staff were educated in the dining hall regarding the use of the splint and there were no barriers impacting the sessions. On 6/13/23 at 8:26 AM Resident 2 was observed in the dining room with a plate of food in front of her/him wearing no splint with no staff assisting. On 6/13/23 at 11:51 AM Witness 3 (Family Member) stated she was in the facility weekly and did not see Resident 2 use her/his splint for some time. On 6/13/23 at 12:25 PM Staff 11 (CNA) stated Resident 2 was to wear her/his splint, she applied the splint when she worked with Resident 2, but things in the facility changed often. On 6/13/23 at 1:41 PM Staff 12 (CNA) stated the splint for Resident 2 was not offered on 6/13/23 at lunch but Resident 2 often refused the splint. Staff 12 acknowledged Resident 2's refusal of the splint was not documented. On 6/13/23 at 2:01 PM Staff 13 (OT) stated she instructed multiple staff regarding the use of Resident 2's splint. Staff 13 stated Resident 2 was always receptive to use the splint and was only discharged from therapy on 5/29/23 with success indicated for increased dining independence when the splint was used. Staff 13 stated therapy was not informed of any refusals of the splint by Resident 2 from staff, otherwise additional support or further assessment would be offered. On 6/14/23 at 8:22 AM Resident 2 was observed in the dining room with no splint while waiting for her/his meal. Resident 2 stated no splint was offered prior to coming into the dining room and the splint helped to provide comfort to her/his hand. On 6/15/23 at 2:18 PM Staff 2 (DNS) stated Resident 2's nerves were pinched which impacted the use of her/his extremities. Staff 2 acknowledged the process for changes in Resident 2's ROM and assessment needs needed to be addressed. On 6/15/23 at 4:00 PM Staff 10 (Director of Rehabilitation) stated Resident 2 was brought to therapy only because of her/his decline in eating and the 5/23/23 MR did not change what was already known about Resident 2's condition. Staff 10 stated because therapy staff did not hear there was a lack of success with Resident 2's splint, therapy staff were not able to appropriately reapproach and readdress Resident 2's needs until now.

1. Therapy Services screened Resident #2 to re-evaluate the need for eating equipment/utensils. 2. The facility conducted a review and audited residents who required adaptive feeding equipment. Identified concerns will be addressed. 3. The facility will educate the Clinical Interdisciplinary Team to ensure that residents with new recommendations/orders for adaptive feeding equipment are communicated promptly to the Dietary Manager and or designee. 4. The facility will conduct random audits to validate residents with new orders for adaptive feeding equipment are communicated to the Dietary Manager and that residents received their adaptive feeding equipment weekly for 4 weeks and then monthly for 2 months. The Executive Director and or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Executive Director is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to ensure resident snacks were removed after discharge and/or labeled for 1 of 1 unit refrigerator (East Hall). This placed residents at risk for decreased quality of food. Findings include: On 6/13/23 at 1:54 PM Staff 14 (Dietary Manager) stated the food brought in by resident families had to be in single serving packages. The food was kept in the East Hall refrigerator. The kitchen staff monitored the refrigerator temperatures but the nursing staff were responsible for ensuring the food was dated, not expired and labeled with residents' names. On 6/14/23 at 12:44 PM with Staff 28 (MDS Coordinator) the East Hall resident snack refrigerator was observed to have one box of frozen pastries with a "use-by date" of 11/11/22. The pastries were not labeled with a resident's name. The refrigerator had five yogurts labeled with Resident 108's name with "use-by dates" which were dated before 6/14/23. Staff 28 indicated Resident 108 was discharged from the facility and the yogurt should have been removed. Review of Resident 108's clinical record revealed she/he was discharged on 5/10/23.

1. Unlabeled and expired food items were immediately removed from the East Hall resident refrigerator and appropriately discarded. 2. The Nurse Managers and or designee audited the resident's community refrigerator to ensure the residents' food items were appropriately labeled, discharged residents, and expired food items discarded. Identified concerns will be addressed. 3. The facility will educate the Clinical Interdisciplinary Team and the Dietary Manager to ensure residents' food items, including food items brought in by residents, are appropriately labeled, discharged residents, and expired food items discarded promptly. 4. The facility will conduct random audits to validate that residents' food items, including food items brought in by residents are appropriately labeled and expired food items discarded promptly weekly for 4 weeks and then monthly for 2 months. The Director of Nursing Services and or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Dietary Manager is accountable for compliance.

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 9 of 28 days reviewed for RN staffing. This placed residents at risk for lack of RN oversight including resident care and services. Findings include: The Direct Care Staff Daily Reports reviewed for 5/16/23 through 6/12/23 revealed 9 out of 28 days when the facility failed to have an RN scheduled on day or evening shift and a waiver was not in place. On 6/15/23 at 1:43 PM Staff 2 (DNS) confirmed the lack of RN coverage.

1. No residents were identified to have been affected by this failed practice however all residents have the opportunity to be affected. 2. No residents were identified to have been affected by this failed practice however all residents have the opportunity to be affected. 3. The facility will place an ad for RN’s online and is currently advertising on the local radio and movie theatre. A wavier to allow the RNs working from 10 PM to 6 AM was requested and granted on 6/27. 4. The Facility will review and audit the RN staffing schedule weekly for 4 weeks and then monthly for 2 months. The Staffing Coordinator and/or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. 5. The Staffing Coordinator is accountable for compliance.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing requirements were maintained for 24 of 84 shifts reviewed for staffing. This placed residents at risk for not receiving care or care in a timely manner. Findings include: A review of the Direct Care Staff Daily Reports from 5/16/23 through 6/12/23 revealed the facility did not have sufficient CNA staff to meet the minimum CNA to resident staffing ratio for 24 of 84 shifts. On 6/15/23 at 1:43 PM Staff 2 (DNS) confirmed the facility did not meet minimum staffing requirements.

1. All residents have the potential to be affected by this failed practice. 2. All residents have the potential to be affected by this failed practice. 3. The facility has placed an ad to hire PRN NAC’s in an effort to hire additional on-call staff that could help fill open positions when staff call off sick. 4. Audits to be conducted daily at the morning meeting (M-F) weekly for 4 weeks and monthly x 2 to ensure accuracy of the staffing posting for NAC Staffing. Results of these audits will be reported to the QAPI committee x 3 months. Negative findings will be addressed for opportunities for improvement. 5. The Staffing Coordinator is accountable for compliance.

OAR-411-086-0040 Admission of Residents (Advance Directive)

Refer to F578 ***** OAR-411-085-0310 Residents' Rights: Generally Refer to F585 ***** OAR-411-085-0360 Abuse Refer to F600 ****** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ***** OAR 411-086-0160 Nursing Services: Discharge Summary Refer to F661 ***** OAR-411-086-0110 Nursing Services: Resident Care Refer to F684 ***** OAR-411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F692 ***** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ****** OAR-411-086-0250 Dietary Services Refer to F806, F810 and F812

Based on observation interview and record review it was determined the facility failed to ensure resident needs were accommodated for 1 of 3 sampled residents (#21) reviewed for activities of daily living. This placed residents at risk for lack of accommodation with needs and preferences. Findings include: Resident 21 was admitted to the facility in 6/2021 with diagnoses of dementia and malnutrition. A 5/25/21 care plan indicated Resident 21 required one-person total assist for meals and offer fluids with each care opportunity. An observation on 6/13/22 at 12:47 PM revealed Resident 21 was asleep in bed and her/his bedside table was out of reach (farther then arm length apart) and was up against the wall. The bedside table had upon it a cup of water and a second cup with a straw in it. At 1:40 PM Resident 21 was in bed awake and the bedside table was out of reach. An observation on 6/15/22 at 12:45 PM revealed Resident 21 was in bed awake, lying on her/his back and the TV was on. Resident 21's bedside table was out of reach. The bedside table had upon it a cup of water with lid and a straw in it. On 6/13/22 at 8:23 PM Witness 3 (Family Member) stated at times Resident 21's bedside table was out of reach when she visited and she had concerns regarding Resident 21's fluid intake. On 6/16/22 at 12:05 PM Staff 9 (CNA) and at 1:09 PM Staff 11 (CNA) stated Resident 21 was dependent on her/his ADL care needs but could eat and drink on her/his own with some encouragement. Staff 11 and Staff 9 stated all items including the call light switch and bedside table should be within reach. On 6/17/22 at 3:30 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected the bedside table for Resident 21 to be within her/his reach and staff were expected to follow the care plan.

Immediate corrective action taken: Resident 21 over bed table was put with in reach Identification of others that could be effected: Room rounds were made to ensure over bed tables and needed items were within reach. Staff education was started on 6/17/2022 to ensure staff is aware of the importance of keeping the Residents items within reach. Systemic changes to correct the issue: Room rounds are completed one times a week X4weeks, then monthly X/3months by department managers that include checking to ensure the table is within reach. Findings will be evaluated at QAPI to determine results of systemic changes.

Based on interview and record review it was determined the facility failed to assess the presence of, obtain copies as appropriate, provide information and periodically review advance directives for 3 of 4 sampled residents (#s 8, 10 and 24) reviewed for advance directives. This placed residents at risk for not having health care choices honored. Findings include: 1. Resident 24 admitted to the facility in 1/2022 with diagnoses including Chronic Obstructive Pulmonary Disease. A 1/21/22 MDS revealed Resident 24 had a BIMS score of 15 out 15 which indicated she/he was cognitively intact. An 4/20/22 Care Plan Conference Form revealed "medications, POLST and care plan reviewed", there was no documentation regarding an advance directive being present, offered, or reviewed. In an interview on 6/16/22 at 10:06 AM Staff 5 (Social Services) stated the advance directive was to be reviewed and offered quarterly. Staff 5 also stated she did not believe Resident 24 had an advance directive and there was no documentation of the advance directive being reviewed with Resident 24 at the initial care meeting and the advance directive was not requested on the quarterly assessment. In an interview on 6/16/22 at 3:35 PM Resident 24 reported the facility did not ask about an advance directive, but she/he had completed one in the past. , 2. Resident 10 was admitted to the facility in 2018 with diagnoses including pressure ulcer and weakness. On 6/14/22 at 2:55 PM Resident 10 stated she/he did not remember if she/he had an advance directive or if the facility asked about an advance directive. On 6/14/22 a review of Resident 10's medical record revealed she/he was cognitively intact and on 9/6/18 she/he was provided information related to an advance directive. There was no additional information to indicate Resident 10 executed or declined an advance directive or advance directives were reviewed with Resident 10 periodically. On 6/16/22 at 10:06 AM Staff 5 (Social Services) was asked about advance directives. Staff 5 stated she tried to offer advance directives when the resident did not have a power of attorney. Staff 5 added advance directives should be reviewed and offered on a quarterly basis. , 3. Resident 8 was admitted to the facility in 3/2022 with diagnoses including dementia and muscle weakness. On 6/13/22 a review of Resident 8's medical record revealed she/he was not cognitively intact and there was no additional information to indicate Resident 8 executed or declined an advance directive, or an advance directive was reviewed with the resident quarterly. On 6/16/22 at 10:06 AM Staff 5 (Social Services) was asked about advance directives. Staff 5 stated she tried to offer an advance directive when the resident did not have a power of attorney. Staff 5 added advance directives should be reviewed and offered on a quarterly basis.

Immediate action: Social service provided information on Advance Directives to Resident 8, 10 and 24. Identification of others: Social Service performed an audit to determine which Residents were in need of information on Advance Directives. All Residents that were in need of an Advance Directive were offered information and assistance of the Ombudsman, if needed to complete an Advance Directive. Systemic changes to correct the issue: During Care plan conference with the Resident/Responsible Party; Advance Directives will be discussed and information will be provided as needed. Proof of this will be in the social service tab and care plan notes. Monitoring: A monthly audit will be completed X 3 months to assess that copies of the advance directive have been obtained, information on advanced directives has been provided and periodically review of advance directives is completed. Findings will be reviewed in QAPI to monitor the effectiveness of the systemic changes X3 months.

Based on interview and record review it was determined the facility failed to ensure residents received appropriate ADL care assistance for 2 of 3 sampled residents (#s 34 and 45) reviewed for activities of daily living. This placed residents at risk for unmet needs. Findings include: 1. Resident 45 was admitted to the facility in 4/2021 with diagnoses of dementia, congestive heart failure and she/he was legally blind. A 5/14/21 care plan indicated Resident 45 was dependent on staff to assist with meals, required a scoop plate and staff were to tell Resident 45 where her/his food and drinks were located in a clock pattern. A Document Survey Report on 12/2021 revealed the following: -Resident 45 had 93 opportunities to eat meals. -81 times the report indicated Resident 45 was independent and set up only. -six times the report indicated Resident 45 was supervision and set up only. -12 times the report indicated Resident 45 refused her/his meals. On 6/13/22 at 3:23 PM Witness 1 (Complainant) stated staff did not assist Resident 45 with her/his meals and she/he was legally blind. Witness 1 stated staff would bring a meal and not let Resident 45 know where her/his food was on her/his plate and she/he would struggle with eating. On 6/16/22 at 12:05 PM Staff 9 (CNA) stated Resident 45 was not always able to state her/his needs and was dependent on staff for her/his ADL care needs. Staff 9 stated for meals she/he was independent and she would tell her/him where her/his food was located on the plate. On 6/16/22 at 1:32 PM Staff 5 (Social Services) stated the family had concerns regarding Resident 45 consuming enough food at meals. Staff 5 stated Resident 45 was dependent on staff assisting her/him with meals but at times would get agitated when you attempted to assist her/him eat. On 6/16/22 at 2:20 PM Staff 4 (CNA) stated Resident 45 was extensive assist or dependent on staff for eating meals because she/he was legally blind. On 6/17/22 at 11:57 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to follow the care plan related to Resident 45's eating habits and if her/his eating habits had changed then the care plan should have been updated to reflect the changes. , 2. Resident 34 was admitted to the facility in 3/2022 with diagnoses including Alzheimer's Disease and a leg fracture. The Care Plan dated 11/18/16 directed staff to keep nails trimmed and short. The Annual MDS dated 5/4/22 indicated Resident 34 required one-person assistance for ADLs. Observations from 6/13/22 through 6/16/22 on day and evening shifts revealed Resident 34's fingernails were long with dark brown debris underneath them. On 6/16/22 at 12:52 PM Staff 9 (RN) acknowledged Resident 34's fingernails were long with dark brown debris underneath them and in need of trimming and cleaning.

Immediate corrective action: resident 45 is no longer at the facility, resident 34's nails were cleaned Identification of others: All residents with visual impairments and/or ADL impairments were reviewed to re-evaluate their plan of care that included; assistant needed with meals, ADL care that included fingernails and toenails, hygiene and having items within reach. Those residents identified where update as needed and the KARDEX to guide the CNAs was also updated. Systemic changes: Education was done with Staff on the care needs of the visually impaired and/or ADL impaired Monitoring: Residents fingernails will be checked weekly X3months The systemic changes will be re-evaluated in QAPI for 3 months.

Based on interview and record review it was determined the facility failed to assess a pressure ulcer for 1 of 4 sampled residents (#45) reviewed for pressure ulcers. This placed residents at risk for pressure ulcers. Findings include: Resident 45 was admitted to the facility in 4/2021 with diagnoses of dementia and congestive heart failure. An 4/30/21 Pressure Injury CAA revealed Resident 45 did not admit with any pressure injuries. However, on 4/29/21 the physician was notified because Resident 45 had a small area of MASD (Moisture Associated Skin Damage) on her/his bilateral buttocks. Additionally, on 4/30/21 a Weekly Skin Integrity Tool indicated Resident 45 had slight redness observed on her/his tailbone. Resident 45 was at risk for pressure injuries due to impaired mobility, decreased activity, potential for friction and shearing, pain, incontinence, suboptimal appetite, weight loss, dementia and edema. Resident 45 was on a pressure redistribution mattress and staff encouraged frequent repositioning and turning in bed to ensure tissue remained intact. An 10/20/21 Alert Note revealed Resident 45 had an open area on her/his tailbone measuring "1.7 cm long x .75cm long and .3 mm deep", little to no drainage was noted. Treatment orders were initiated and implemented. A review of Resident 45's clinical records revealed wound rounds were initiated on 10/21/21 and treatment was put into place to address a new pressure wound. No information was found as to how the Stage 2 (partial thickness skin loss, a shallow open ulcer with a red, pink wound bed) pressure ulcer occurred. On 6/16/22 at 9:41 AM Staff 6 (RN) and at 10:43 AM Staff 7 (LPN) both stated they did not recall if Resident 45 had a pressure ulcer but any sort of wound that was new or facility acquired would be investigated as to how the wound occurred. Staff 6 and Staff 7 stated they were not sure why an incident report was not initiated to determine the cause of the new wound. On 6/17/22 at 11:57 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they could not locate an incident report related to Resident 45's Stage 2 pressure ulcer but expected staff to complete an incident report to determine what caused or contributed to the new wound.

Immediate corrective action: Resident 45 is no longer at the facility. Identification of others: No other residents were identified. Systemic changes: Education was done with Nursing staff on reporting skin issues, completing a risk assessment and doing an investigation to determine cause that could then be used to provide interventions to aide in healing of skin break down. All new skin issues will be audited to confirm that a risk assessment and investigation has been done. Monitoring: During weekly RAR all skin break down will be reviewed to ensure a risk assessment was completed, an investigation completed and interventions on the plan of care put in place that will benefit the resident's well being. This will be done weekly x 1 month and then monthly x 3. Audit will be reviewed in QAPI for the effectiveness of systemic changes X3 months.

Based on interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 3 sampled residents (#45) reviewed for activities of daily living. This placed residents at risk for foot injury. Findings include: Resident 45 was admitted to the facility in 4/2021 with diagnoses of dementia and congestive heart failure. Resident 45's medical record revealed staff provided Weekly Skin Integrity checks and no skin issues were identified on 7/6/21 or 7/13/21. A 7/16/21 Communication Note revealed Resident 45's right great toenail became dislodged when her/his sock was being pulled on by a CNA. The base of the toenail was still connected. Weekly Skin Integrity forms were completed from 7/17/21 through 11/9/21 but failed to identify concerns regarding Resident 45's toenails. A 11/12/21 Podiatrist visit revealed Resident 45 was seen for a foot exam and nail debridement. Resident 45 had onychomycosis (a nail fungus causing thickened, brittle, crumbly, or ragged nails), nails were discolored, thickened, painful and curved under. Bilateral toenail debridement was performed. On 6/13/22 at 3:23 PM Witness 1 (Complainant) stated they had concerns regarding Resident 45's toenail care and stated Resident 45's right toenail was "ripped off" at one point when a CNA placed a sock on her/his foot. Witness 1 visited Resident 45 on 10/21/21 and removed Resident 45's socks and her/his toenails were "1/2 inch past each of her/his toes, and her/his toenails were thick" and showed Resident 45's toenails to staff in the building and "insisted" the toenails be taken care of. On 6/16/22 at 1:32 PM Staff 5 (Social Service) stated Witness 1 reported concerns to her regarding poor nail care. Staff 5 further stated once Witness 1 reported the concerns regarding foot care the facility staff initiated the Podiatrist visit. On 6/16/22 at 4:44 PM Staff 8 (LPN) stated she remembered the 7/2021 incident with Resident 45's right great toenail being pulled off because the nail had a fungus and was dead. Staff 8 stated she recalled an incident when asked to observe Resident 45's toenails by Witness 1. Staff 8 stated Resident 45's toenails "were pretty bad" and she thought Resident 45 was put on a list to see a Podiatrist after the incident. On 6/17/22 at 11:57 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected toenail care to be provided one time weekly and could be provided by a CNA if the resident was not a diabetic. Staff 1 stated weekly skin checks were to be completed by the nurses and that included looking at toenails. Staff 1 stated it had been difficult getting a Podiatrist to come to the facility because of where they were located but stated staff should have attempted other alternatives to ensure Resident 45's toenail care was provided.

Immediate corrective action: Resident 45 is no longer in the facility. Identification of others: All residents toes were checked on 6/27/2022 Podiatry care to the Residents was offered and received on 7/7/2022 Systemic changes: Education to License staff that included feet and toe nails condition be required on the Weekly Skin Integrity form was done. Education to CNAS on reporting feet and toe nail problems on the shower sheet was also done. Education was also done on proper foot care to the Residents, soaking, washing, filing of nails and moisturizing of feet during showers. Monitoring: Weekly Skin Integrity sheets will be audited weekly by the DNS/Designee for compliance that the sheet include the feet and toes on the weekly form. DNS/Designee will also monitor the shower sheets weekly X 4 weeks to ensure compliance of the feet and toes included the body check. Feet and toe checks will continue every 2 weeks by the DNS/Designee X 3 months and then monthly there after. Podiatry visit will be schedule to provide toe nail care as needed and every 45 -60 days. Audits and reviews will be evaluated in QAPI X3 for effectiveness of systemic changes.

Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to falls for 1 of 3 sampled residents (#34) reviewed for accidents. This placed residents at risk for falls. Findings include: Resident 34 was admitted to the facility in 3/2022 with with diagnoses including Alzheimer's Disease and a leg fracture. The Annual MDS dated 5/4/22 identified Resident 34 had significant cognitive impairment and was a one person assist for ambulation and toileting. Resident 34's care plan dated 4/26/21 and revised 7/1/21 identified the resident to be at risk for falls related to cognitive deficit, impaired mobility, balance and attempts to self-transfer. Interventions on the care plan included: Staff were to offer and assist with toileting frequently, keep call light and personal items within reach, lock brakes on the bed and remain outside the bathroom and assist with peri care, remind Resident 34 and reinforce safety awareness, provide activities to minimize the potential for falls, provide appropriate non-skid footwear and place an "eyeball sign" on the door for staff to perform frequent checks. Resident 34 had an unwitnessed fall with injury on 12/11/21. Resident 34 complained of left hip pain and was unable to move her/his leg. Resident 34 was sent to the hospital. An Incident report dated 12/11/21 indicated Resident 34 had an unwitnessed fall in her/his room and was found by a CNA who walked past the resident's room. Resident 34 stated she/he had to go to the bathroom. The nurse entered the resident's room and completed a head to toe assessment. Resident 34 was helped up by the staff and taken to the bathroom. Staff 20 (RN) indicated she checked the care plan to make sure it was followed. Staff 20 noticed the resident was care planned to have an "eyeball" sign on her/his door for frequent checks, the sign was not on the door. Staff 20 stated she educated staff to complete frequent checks and to toilet the resident more frequently. On 6/17/22 at 12:41 PM Staff 20 acknowledged the "eyeball" sign was on the care plan but not on the resident's door and frequent checks were on the care plan but that was not happening. Staff 20 acknowledged staff were not following the care plan .

Immediate corrective action: "eyeball" symbol was placed on door Identification of others: fall risk residents were reviewed and found in compliance with the eyeball. Systemic changes: Care plan audit was done to ensure "eyeball" symbol was in place on the door. Monitoring: Care plan audit will be done monthly X 3 months to ensure "eyeball" symbols are place on the door. Audits will be reviewed in QAPI for compliance of systemic changes.

Based on observation, interview, and record review it was determined the facility failed to ensure the dishwasher was maintained for 1 of 1 kitchen reviewed. This placed residents at risk for food borne illness. Findings include: In an interview on 6/16/22 at 12:51 PM Staff 12 (Certified Dietary Manager) stated the kitchen dishwasher was temperature based and must wash at 150 degrees and rinse at 180 degrees to ensure the dishes were sanitized. Staff 12 also stated the dietary staff were to log the dishwasher wash and rinse temperatures at each meal. On 6/16/22 at 12:51 PM the dishwasher was observed to wash at 130 degrees and rinse at 166 degrees. Multiple wash cycles were observed, and the temperatures did not reach the appropriate temperatures. A review of the 6/2022 dishwasher temperature log revealed the following: - 6/7/22 Lunch: wash 122 degrees, rinse 102 degrees - 6/8/22 Lunch: wash 122 degrees, rinse 102 degrees - 6/11/22 Dinner: wash 112 degrees, the rinse temperature was unable to be read - 6/13/22 Dinner: wash 112 degrees, rinse 111 degrees - 6/14/22 Dinner: wash 112 degrees, rinse 111 degrees In an interview on 6/17/22 at 8:31 AM Staff 12 stated the dietary staff were to notify her or the Maintenance Director if there was a low temperature reading on the dishwasher. Staff 12 stated she was not notified of low temperatures and did not know if the Maintenance Director was notified. In an interview on 6/17/22 at 10:11 AM Staff 13 (Maintenance Director) stated he was not notified regarding the low dishwasher temperatures. Staff 13 indicated the temperature gauge was not working properly. In an interview on 6/17/22 at 12:22 PM Staff 1 (Administrator) reviewed the temperature log and verified the low temperature readings. Staff 1 stated the dietary staff should have notified the Dietary Manager and put in a maintenance request, but this was not done.

Immediate corrective action: The dishwasher was put out of service and the three sink method was used to clean all dishware. The repair was ordered and done by the end of the day. The water temp was adjusted to the dishwasher to increase the temperature Identification of others: Temperature changes were identified and addressed with education on 6/16/22 with Dietary staff. Systemic changes: Education for the maintenance staff and dietary staff 7/14/2022 Monitoring: Maintenance will monitor the dishwasher temp 5X/WK times one month and then weekly thereafter. Audits will be reviewed during QAPI for effectiveness of systemic changes X 3 months

Based on interview and record review it was determined the facility failed to ensure background checks were completed for newly hired staff for 1 of 5 staff (#14) reviewed for background checks. This placed residents at risk for abuse. Findings include: A 2/16/22 Background Check Unit letter revealed Staff 14's (RN) "Hiring on a Preliminary Basis" status was revoked, and the facility was to remove Staff 14 from work immediately. Records revealed Staff 14 began working at the facility on 2/17/22. A review of the 2/2022 schedule revealed Staff 14 worked on 2/17/22, 2/18/22, 2/19/22, 2/20/22 and 2/24/22. In an interview on 6/15/22 at 2:47 PM Staff 15 (Accounting Clerk) stated she was responsible for completing the background checks prior to employees working. Staff 15 stated Staff 14 began work on 2/17/22, worked a few shifts, and was removed from work as soon as Staff 15 read the 2/16/22 Background Check Unit letter. In an interview on 6/17/22 at 12:26 PM Staff 1 (Administrator) confirmed Staff 14 worked without a completed background check.

Immediate corrective action Staff 14 is no longer at the facility, she moved. She was under supervision during her orientation period. Identification of others: A complete check was done on all employees to confirm that their background check was done. Current employees had completed background checks. Systemic changes: No employee will be allowed to start employment until the background checks are completed. Monitor: Compliance will be checked at QAPI X3 months HR will monitor background check for completion prior to allowing the employee to start work or orientation.

OAR-411-086-0360 Resident Furnishings, Equipment

Refer to F558 ***** OAR-411-085-0310 Admission of Residents (Advance Directive) Refer to F578 ***** OAR-411-086-0110 Nursing Services: Resident Care Refer to F677 and F687 ***** OAR-411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686 and F689 ***** OAR-411-086-0250 Dietary Services Refer to F812

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/13/2021 and 12/19/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.