Curry Village Health And Rehabilitation of Cascadia

Resident 20 was admitted to the facility in 2/2026 with a diagnosis of Alzheimer's Disease.-á -á The resident's BIMS assessment completed in 3/2026 revealed a score of 5 (cognitively impaired).-á -á The resident's representative with power of attorney (POA) was not available for an interview.-á -á The resident's clinical record revealed the resident had a tab alarm (a device that makes an audible warning when the resident attempts to stand without assistance).-á -á No assessment or informed consent for the tab alarm was located in the resident's clinical record.-á -á On 5/7/26 at 9:09 AM, Staff 9 (RN) stated an assessment should be completed prior to using a tab alarm with a resident and consent must be given by the resident or resident representative. Staff 9 stated it was nursing staff's responsibility to complete the assessment and obtain informed consent. -á On 5/7/26 at 10:23 AM, Staff 2 (DNS) stated nursing staff should complete an evaluation and get informed consent before using a tab alarm with a resident. Staff 2 stated she could not find an assessment or informed consent for the tab alarm in Resident 20's clinical record.-á -á -á

Resident #20 was evaluated and consented to use of tab alarm on 5/8/2026. Resident interview states "It does not bother me; I don't mind using it." Family (Daughter) informed, did not voice concerns.  Provider has signed off on the orders in agreement of use.  Will continue to evaluate quarterly and as needed. Right to be informed/make treatment decisions. Current residents have the potential to be affected. DON/Designee will complete baseline audit of current residents’ records to verify evaluation and signed consents in place for devices in use. Identified issues will be corrected. DON/Designee will provide further education to Licensed Nurses by 5/31/2026 related to assessments and consent requirements for device use and resident/family involvement in the care planning process prior to the use of devices. Check list created to outline all required items for prior to the initiation of devices that can be used to ensure compliance. DON/Designee will conduct an audit of residents who utilize devices to verify assessment and consent are in place and that residents with impaired cognition have family involvement in the decision and care planning process, weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Director of Nursing responsible for compliance

-á 3. Resident 29 was admitted to the facility in 4/2026 with a diagnosis of sepsis (body's life-threatening response to an infection). -á Resident 29's 4/19/26 Admission MDS revealed Section F-Preferences for Routine and Activities was not assessed. -á On 5/6/26 at 4:10 PM Staff 5 (Activities Director) stated she was responsible for interviewing residents for their MDS Section F. Resident 29 was able to voice her/his preferences. Staff 5 verified Resident 29's 4/19/26 Admission MDS Section F was not completed.-á-á -á On 5/7/26 at 11:48 AM Staff 3 (MDS Coordinator) stated she was responsible to ensure residents' MDS assessments were completed. She gathered the MDS information from staff assessments which were to be completed before the ARD (Assessment Reference Date-end date of an observation period). Staff 3 stated if the information was not available in a resident's clinical record, she communicated to the staff member who was responsible for a particular section. Staff 3 stated Staff 5 was responsible to assess Resident 29's daily routines and activity preferences, the information was not available before the ARD, and she was not able to complete Section F.-á -á On 5/7/26 at 2:59 PM Staff 2 (DNS) stated the MDS Assessments were to be complete when submitted. , 1.Resident 2 was admitted to the facility in 11/2025 with a diagnosis of heart failure. -á Resident 2's 2/24/26 Significant Change in Status MDS revealed section F - preferences for routine and activities was not assessed. On 5/7/26 at 11:49 AM, Staff 3 (MDS Coordinator) stated she was responsible for the oversight of MDS completion, including follow up with staff regarding incomplete sections. Staff 3 confirmed the activity section for Resident 2 was incomplete. -á -á On 5/7/26 at 1:32 PM, Staff 5 (Activity Director) stated she completed the activity evaluation and submitted it to the MDS coordinator, who put the information into the residents' MDS assessment. Staff 5 said she did not know preferences for routine and activities was incomplete for Resident 2.-á -á 2. Resident 39 was admitted to the facility in 1/2025 with a diagnosis including pain and personality and behavioral disorders. Resident 39's 2/8/26 Annual MDS revealed Section C, Cognitive Patterns; Section D, Mood; Section F, Preferences for Routine and Activities; and Section J, Health Conditions, were not assessed. On 5/7/26 at 11:49 AM, Staff 3 (MDS Coordinator) stated she was responsible for the oversight of MDS completion, including follow up with staff regarding incomplete sections. Staff 3 confirmed Resident 39GÇÖs cognition, mood, activity, and pain sections were incomplete. Staff 3 further stated she notified the DNS regarding the incomplete MDS. -á -á

F636 Resident # 2 preference for routine and activities was assessed 5/29/26. Resident #29 preference for routine and activities was assessed 4/21/26 Resident #39 cognitive pattern, mood, preference for routine and activities and health conditions were assessed Cog and mood preference completed on 5/8/2026, Activity evaluation 5/29/26. Comprehensive Assessments and Timing Current residents have the potential to be affected. ADMINISTRATOR/Designee will complete baseline audit of last 30 days of completed MDS to verify they were completed timely and were complete. Identified issues will be corrected. ADMINISTRATOR/Designee will provide further education to staff responsible for evaluation and MDS completion by 5/31/2026. ADMINISTRATOR/Designee will conduct an audit of residents with comprehensive MDS assessments due to verify that all information is timely and complete. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. ADMINISTRATOR responsible for compliance

Resident 50 was admitted to the facility on 9/3/25 with a diagnosis of rib fractures.-á Resident 50's 9/3/26 hospital Discharge Medication List revealed staff were to administer Resident 50 Tylenol (non-narcotic pain medication) every six hours for 10 days and Robaxin (muscle relaxant) every six hours for 10 days.-á Resident 50's Progress Notes revealed she/he was admitted to the facility on 9/3/25 at 4:30 PM, was alert, able to communicate needs, and reported she/he only had pain with movement.-á Resident 50's 9/2025 MAR revealed her/his Robaxin and Tylenol were scheduled to be administered at 6:00 PM, 12:00 AM, 6:00 AM and 12:00 PM. Resident 50 was not administered Robaxin on 9/3/25 at 6:00 PM or on 9/4/25 at 12:00 AM. Resident 50's Tylenol was not administered on 9/3/25 at 6:00 PM.-á-á On 5/4/26 at 12:41 PM Resident 50 stated on 9/3/25 at approximately 5:00 PM she/he was admitted to the facility. Resident 50 stated she/he did not receive all her/his pain medication until 9/4/25 in the morning and she/he was very painful.-á On 5/6/26 at 9:47 AM Staff 2 (DNS) stated if a resident had scheduled pain medication, staff should administer the medication if it was available in the facility. Staff 2 stated Tylenol was always stocked in the facility. Staff 2 stated the nurses did not verify Resident 50's orders until 9/3/25 at approximately 7:00 PM, therefore the 6:00 PM dose of Tylenol was not administered. Staff 2 stated Resident 50 did not receive any pain medication until 9/4/25 at 12:00 AM.-á On 5/7/26 at 2:41 PM Staff 8 (Corporate RN) verified in 9/2025 Robaxin was available in the facility's automated medication dispensing system and staff should have pulled the Robaxin from the dispensing system to administer to Resident 50.

Resident #50 no longer resides at the facility. Pain management Current residents have the potential to be affected. DON/Designee will complete baseline audit of residents who admitted in the last 7 days to verify they received ordered medication Identified issues will be corrected. DON/Designee will provide further education to Licensed Nurses by 5/31/2026 related to order confirmation timing and contents of the e kit and to notify provider if medication is not available for further directions. DON/Designee will conduct ongoing audit of residents that admit to the facility to verify they received their ordered medications upon admission to the facility and that if a medication was not available, the provider was notified for further direction weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Director of Nursing responsible for compliance

A review of the Direct Care Staff Daily Reports dated 10/1/25 through 10/31/25, 11/1/25 through 11/31/25, 12/1/25 through 12/31/25 and 4/1/26 through 4/30/26 revealed there were 6 days:10/4/25, 11/22/25, 12/27/25, 4/4/26, 4/11/26 and 4/18/26 without 8 consecutive hours of registered nurse coverage on any shift in a 24-hour period.-á -á On 5/7/26 at 10:53 AM Staff 1 (Administrator) acknowledged there was no RN coverage on those above days. -á -á -á -á -á -á -á -á -á

F727 RN 8hr/7days/wk., Full time DON. Current residents have the potential to be affected by unmet assessment needs. Administrator/Designee will complete audit of last 2 weeks to verify RN was scheduled for 8 consecutive hours per day 7 days a week. Identified trends will be analyzed. Administrator/Designee will provide further education to scheduler by 5/31/2026 related to completion of staffing sheet accuracy and ensuring there is RN coverage. Administrator/Designee will conduct ongoing audits weekly to verify RN was scheduled for 8 consecutive hours per day , 7 days a week for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Administrator responsible for compliance

On 5/7/26 at 12:01 PM, Staff 10 (Dietary Aide) was observed washing her hands. Staff 10 failed to practice correct hand-washing techniques by using a paper towel to turn off the faucet, a potentially contaminated surface, then drying her hands with the same paper towel.-á On-á 5/07/2026 at 12:04 PM, Staff 12 (Cook) completed buttering rolls and moved to a new task. Staff 13 changed her gloves between tasks but did not re-wash her hands. Staff 13 then removed her gloves, went to the walk-in refrigerator to remove juice and pour a glass of juice for a resident that was given to another staff person. Staff 13 did not wash her hands prior to getting the juice for the resident.-á On 5/7/26 at 12:17 PM, Staff 11 (Culinary Manager) was observed washing his hands. Staff 11 failed to practice correct hand-washing techniques by using a paper towel to turn off the faucet, a potentially contaminated surface, then drying his hands with the same paper towel. Staff 11 was shown proper hand-washing technique and stated, ""Oh, now I understand."" On 5/17/26 at 12:24 PM, Staff 10 was observed delivering a food cart to a resident hall. When Staff 10 returned to the kitchen she resumed prepping lunch trays without washing her hands. On 5/7/26 at 12:25 PM, Staff 12 removed her gloves, left the steam table and performed another task. Staff 12 returned to the steam table and re-gloved without washing her hands.-á On 5/7/26 at 12:27 PM, Staff 10 was observed to go into the dishwashing area and return carrying dish covers pressed against her clothing. Staff 10 resumed setting up the tray line without washing her hands. The dish covers were then used on plates going out to residents.-á On 5/7/26 at 12:34 PM, Staff 10 and Staff 12 stated they had not received recent training on hand hygiene. Staff 10 stated she was not aware she should not carry dishes against her clothing. Staff 10 stated she found the hand-washing technique demonstrated confusing and did not understand why she needed to dry her hands before turning off the faucet with the paper towel.-á On 5/7/26 at 1:06 PM, Staff 13 (Dietary Manager) stated staff needed to wash their hands each time they came into the kitchen and after changing gloves or touching a potentially contaminated surface. Staff 13 agreed staff should not use a paper towel to dry their hands after it has been used to turn off the faucet. Staff 13 stated she had not performed recent observations of kitchen staff related to proper hand hygiene.-á

F812 Food procurement, store/prepare/serve sanitary. Current residents have the potential to be affected. Dietary Manager/designee will complete service line and meal prep observations to verify hand hygiene performed appropriately. Identified issues will be corrected. Dietary Manager/designee will provide further education to dietary staff by 5/31/2026 related to appropriate Hand Hygiene with food handling. Dietary Manager/Designee will conduct audits weekly of service line and meal prep observations to verify hand hygiene performed appropriately for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Dietary Manager responsible for compliance

Resident 1 was admitted to the facility in 7/2025 with diagnoses including stroke and lack of coordination. Resident 1's 7/22/25 Admission MDS revealed a BIMS assessment with a score of 14 (cognitively intact). Resident 2 was admitted to the facility in 8/2025 with diagnoses including cognitive impairment and cancer. Resident 2's 8/10/25 Admission MDS revealed a BIMS assessment with a score of 15 (cognitively intact). A 9/26/25 Facility Investigation Summary and Conclusion revealed on the morning of 9/26/25, Resident 1 and Resident 2 were in their shared room asleep when Resident 1 woke up and was found hitting Resident 2 with a book and her/his fists. Resident 1 fell and hit her/his head. Emergency Services and the Police were called. Both residents were sent to the hospital. Prior to the incident, Resident 1 was placed on intensified monitoring (15-minute checks) due to a statement she/he made regarding hurting her/his roommate. A room change request was submitted to Social Services by Victim's Advocate Staff on 9/22/25, but there was no follow up regarding the room change. The facility identified a room change was requested on 9/22/25 and scheduled to occur on 9/24/25 due to Resident 1's statement of intent to harm Resident 2 . The facility did not adhere to the policy related to room change or the urgency necessitated by the potential for resident-to-resident aggression. Based on witness statements Resident 1 struck Resident 2 with a book and her/his fists. The facility identified a room change was requested on 9/22/25. The room change was to occur on 9/24/25 due to Resident 1's statement of her/his intention to harm Resident 2. The facility did not follow the policy related to room change or the urgency needed when there was potential the residents could become aggressive. The deficient practice was identified as Past Noncompliance. The facility identified and corrected the deficient practice on 9/26/25 by implementing the following measures to mitigate risk and prevent further incidents of resident-to-resident abuse: -Resident 1 and Resident 2 were separated. -The facility implemented auditing through alert charting. -The facility reviewed and updated Resident 1's care plan. On 10/16/25 at 12:45 PM Staff 1 (Administrator) acknowledged when a room change was requested it was mandated-áto be completed, and when a resident threatens to harm another resident, immediate relocation and physician notification were required. Staff 1 concluded the incident met the definition of abuse.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed to self-administer medications for 1 of 1 resident (#2) observed during dining observations. This placed residents at risk for an unsafe medication regimen. Findings include: Resident 2 was admitted to the facility in 6/2006 with a diagnosis of paralysis of the lower body. A 1/19/25 quarterly MDS revealed Resident 2 was cognitively intact and did not have difficulty swallowing. On 1/30/25 at 8:22 AM Resident 2 was observed in the dining room sitting alone at a table with her/his breakfast tray. Next to Resident 2's tray on a paper napkin were 12 medications and a staff member was not by her/his side to ensure she/he swallowed the medications. On 1/30/25 at 8:23 AM Staff 10 (RN) stated she always left Resident 2's medications on a napkin at breakfast because Resident 2 liked to take them while she/he ate. Staff 10 stated Resident 2 sat alone at meals. On 1/30/25 at 8:25 AM with Staff 2 (Chief Nursing Officer) and Staff 3 (Clinical Resource) Staff 2 stated if medications were left with a resident the resident was to be assessed to ensure she/he was safe to self-administer medications. Staff 3 stated a self-medication administration assessment was not completed and not in Resident 2's clinical record. On 1/30/25 at 8:59 AM Resident 2 stated she/he preferred to take her/his morning medications on her/his own time, she/he was very capable of taking the medications, and did not have issues with swallowing. Resident 2 stated she/he sat alone and other residents did not interrupt her/him during meals.

F554 Resident #2 Resident was left with medications to take unattended without an assessment. Current residents have the potential to be affected. DON/Designee will complete baseline audit of current residents to observe post medication pass to ensure there are not medications left unattended, will interview staff to determine if other residents prefer to take medication unattended and ensure administration assessments are completed/updated. Identified issues will be corrected. DON/Designee will complete baseline observations of medication pass to verify medications are not left unattended with resident unless they have been assessed for unsupervised administration of their medication. DON/Designee will provide further education to Licensed Nurses and CNAs by 2/14/2025 related to: Medications left at bedside. DON/Designee will conduct an audit of determined residents to ensure assessments are in place random audit of medication pass to verify medications are not left unattended with resident unless they have been assessed to be unsupervised when taking their medication. DON/Designee will conduct observations: weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Director of Nursing responsible for compliance

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#36) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 36 was admitted to the facility in 1/2025 with diagnoses of Alzheimer's disease and diabetes. A review of the Admission MDS with an Aessment Review date of 1/7/25 revealed Resident 36's BIMS was six, indicating a severe cognitive impact. Resident 36 required partial to moderate assistance with personal hygiene. A review of Resident 36's care plan dated 1/7/25 revealed she/he had an ADL self-care performance deficit and required partial to moderate assistance with personal hygiene and bathing. A Documentation Survey Report from 1/2025 revealed Resident 36 received bathing on Saturdays and Tuesdays. On 1/25/25 there was no record Resident 36 was offered or refused bathing. An unnamed document dated 1/25/25 indicated Resident 36 was not assigned to a staff member for bathing on 1/25/25. On 1/27/25 at 1:00 PM Witness 2 (Family) stated she would prefer Resident 36 not have facial hair. Witness 2 did not know staff could remove the resident's facial hair. On 1/27/25 at 11:51 AM Resident 36 was observed in her/his room with facial hair approximately two inches long. Resident 36 stated she/he did not remember the last time she/he received a shower. On 1/28/25 the following occurred: -9:07 AM: Resident 36 stated she/he used to use a razor to shave but she/he no longer owned one. She/he wanted her/his facial hair removed. -12:11 PM Resident 36 was observed in the main dining room with other residents. Resident 36's facial hair was approximately two inches long. On 1/29/25 the following occurred: -7:36 AM Staff 9 (CNA) stated if a resident was diabetic, he would ask a nurse to shave the resident while in the shower. Staff 9 stated he did not have Resident 36 assigned for a shower on 1/25/25 so he did not provide her/him a shower. -7:48 AM Staff 22 (LPN) stated nurses would shave diabetic residents' facial hair if they did not have an electric razor. CNAs sometimes did not know how to get a nurse while the resident was showering. -9:02 AM Staff 17 (CNA) assisted Resident 36 into her/his room. Resident 36 was observed with approximately two-inch long facial hair. Staff 17 stated some residents had an electric razor for facial hair, but she did not know the process for residents without an electric razor. -3:20 PM Staff 1 (Chief Executive Officer), Staff 2 (Chief Nursing Officer), and Staff 3 (Clinical Resource) expected staff to offer and provide shaving for the residents. Staff 2 stated the staff member who was responsible for the assignment sheet for bathing had left unexpectedly and Resident 36's shower was missed.

F677 Resident # 36 Resident appeared to not receive facial grooming. Current residents have the potential to be affected. DON/Designee will complete baseline audit and observations of current residents by interviewing residents for shaving preference. Care plan tasks will be updated accordingly. DON/Designee will complete baseline audit of current residents last week to verify they were offered bathing opportunity as scheduled. Identified issues will be corrected. DON/Designee will provide further education to Licensed Nurses and CNAs by 2/14/2025 related to: providing facial grooming and offering bathing. DON/Designee will conduct ongoing audit of 10 residents scheduled for bathing to verify they were offered bathing opportunity and facial hair trimmed per preference. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Director of Nursing responsible for compliance

Based on observation, interview, and record review it was determined the facility failed to ensure a resident received ROM for 1 of 2 sampled residents (#18) reviewed for mobility. This placed residents at risk for decreased ROM. Findings include: Resident 18 was admitted to the facility in 2/2024 with a diagnosis of incomplete quadriplegia (limited movement below the neck). An 8/5/24 significant change MDS revealed Resident 18 had dementia, was blind, and required assistance with ADLs due to her/his quadriplegia. Resident 18 had functional limitations in ROM to both sides to the arms and legs. A 10/22/24 quarterly MDS revealed Resident 18 continued to have functional limitation in ROM to both sides to the arms and legs. A care plan initiated 11/4/24 revealed Resident 18 had Parkinson's disease and quadriplegia. Goals included Resident 18 would remain free of complications related to Parkinson's disease and maintain optimal quality of life within limitations imposed by her/his neurological deficits. Interventions staff were to provide included passive ROM with AM and PM care. A current (as of 1/29/25) Kardex (CNA guide for resident specific care) revealed there was no ROM task set up for CNAs. On 1/29/25 at 11:14 AM Staff 17 (CNA) stated if a resident was to be provided ROM it was on the resident's Kardex. Staff 17 stated she was able to do ROM if it was on the Kardex and if there were directions for the type of ROM to be provided. On 1/29/25 at 3:04 PM Staff 14 (OT) stated Resident 18 did not tolerate therapy, had poor pain tolerance, poor insight, and was discharged from therapy services. When Resident 18 was discharged from therapy the facility did not have an RA program. Staff 14 stated CNAs were able to do simple, passive ROM. On 1/29/25 at 3:21 PM Staff 16 (CNA) stated he learned how to do ROM in her/his CNA certification class, was comfortable providing ROM, and provided ROM if it was on a resident's Kardex. On 1/29/25 at 4:01 PM Staff 14 (CNA) stated she worked with Resident 18 and she/he did not have ROM on the Kardex and she did not provide Resident 18 ROM. On 1/29/25 at 3:42 PM Staff 4 (Resident Care Manager RN) acknowledged Resident 18's care plan directed staff to provide ROM with AM and PM care. Staff 4 stated the ROM was not on the Kardex as a task and staff did not do the ROM. On 1/30/25 at 7:57 AM with Staff 2 (Chief Nursing Officer) and Staff 3 (Clinical Resource) Staff 2 stated CNAs could do ROM but were not doing ROM.

F688 Resident # 18 Range of motion listed in care plan, but not Kardex for CNA care direction. Current residents have the potential to be affected. DON/Designee will complete baseline audit of current residents with range of motion care plans to ensure that all range of motion interventions are in the tasks for staff direction and documentation: Identified issues will be corrected. DON/Designee will provide further education to Licensed Nurses and CNAs by 2/14/2025 related to: documentation of range of motion, Nurse Managers will receive education for entering interventions in care plans and tasks. DON/Designee will conduct additional audit of residents care plan interventions for range of motion to verify it was offered and documented weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Director of Nursing responsible for compliance

Based on observation, interview, and record review it was determined the facility failed to ensure residents did not receive unnecessary psychotropic medications and failed to monitor for side effects of psychotropic medications for 2 of 5 sampled residents (#s 7 and 28) reviewed for medications. This placed residents at risk for adverse side effects of medications. Finding include: 1. Resident 7 was admitted to the facility in 10/2017 with diagnoses including anxiety disorder. A review of Resident 7's signed physician orders dated 1/15/25 instructed staff to administer Xanax (to treat anxiety) every eight hours PRN for anxiety for 90 days, starting on 10/18/24. A review of the 1/2025 MAR instructed staff to administer Xanax every eight hours PRN for anxiety for 90 days, starting on 10/18/24. The MAR indicated Resident 7 was administered Xanax on 1/17/25, 1/18/25, 1/19/25 1/22/25, 1/23/25, 1/26/25, 1/27/25 and 1/28/25. Resident 7 was administered Xanax eight times after the end date of 1/16/25. No end date was documented on the MAR. On 1/30/25 at 6:28 AM, Staff 8 (LPN) stated staff should document the end date in clinical records. On 1/30/25 at 7:55 AM Staff 1 (Chief Executive Officer), Staff 2 (Chief Nursing Officer), and Staff 3 (Clinical Resource) expected staff to document an end date in clinical records for a medication that was ordered for 90 days. , 2. Resident 28 was admitted to the facility in 9/2024 with a diagnosis of cancer. A 1/2025 MAR revealed Resident 28 was administered trazodone (antidepressant) daily at bedtime for sleep. A care plan dated 10/1/24 indicated Resident 28 was administered an antidepressant and the goal was for her/him to be free from adverse reactions including sedation, agitation, and confusion. A 1/2025 MAR and TAR revealed staff did not monitor Resident 28 for side effects from her/his antidepressant. On 1/28/25 at 7:49 AM, 1/28/25 at 9:55 AM, and 1/28/25 at 12:05 PM Resident 28 was observed to be alert, sitting up, at the dining room, and conversing with others. On 1/28/25 at 3:56 PM Staff 11(LPN) stated the nurses monitored residents for side effects of medications and if they observed side effects they documented in residents' progress notes. Psychotropic medications with potential side effects which were to be monitored were on the MAR or TAR. Staff 11 stated Resident 28 was administered an antidepressant but did not have side effects which were to be monitored listed on the MAR or TAR. On 1/28/25 at 4:01 PM Staff 4 (Resident Care Manager RN) stated the monitoring of psychotropic medication side effects were to be completed on the MAR or TAR. Staff 4 stated Resident 28 did not have antidepressant side effect monitoring in her/his clinical record. On 1/28/25 at 4:11 PM Staff 2 (Chief Nursing Officer) and Staff 3 (Clinical Resource) verified Resident 28's psychotropic side effect monitoring was to be documented on the MAR and TAR but was not done.

F758 Resident #7 and #28 Resident #7  order for Xanax administered with expired duration date Resident #28- Missing side-effects monitoring for antidepressant use in the orders. Current residents have the potential to be affected. DON/Designee will complete baseline audit of current residents who receive PRN psychotropic medications to verify the PRN psychotropic medication has stop date in place that is not expired, and that psychotropic medications have side effects monitoring in place. Identified issues will be corrected. DON/Designee will provide further education to Licensed Nurses and CMAs on 2/7/2025 related to:PRN psychotropic medication administration with specific focus on ensuring that PRN psychotropic medication stop dates are entered into the MAR stop date section and that Psychotropic medications have side effect monitoring in place. Implemented review of duration for PRN psychotropic medications and presence of side effect monitoring with admission review each business day at clinical meeting. Weekend order changes to be reviewed on Mondays. Provider will be notified for review of PRN psychotropic medications well in advance of end date to allow for time to respond to request. DON/Designee will conduct additional audits to verify resident receiving PRN psychotropic medication have a stop date that is not expired, and that psychotropic medications have side effect monitoring in place weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Director of Nursing responsible for compliance

Based on observation, interview, and record review it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration error rate was 7.41% with two errors in 27 opportunities. This placed residents at risk for an ineffective medication regimen. Findings include: Resident 92 was admitted to the facility in 1/2025 with a diagnosis of malnutrition. A 1/27/25 hospital After Visit Summary form revealed Resident 92 was to be administered medications including Ferrous Sulfate EC (enteric coated) 324 mg (supplement) and Calcium with Vitamin D (supplement). On 1/28/25 at 7:48 AM Staff 11(LPN) was observed to administer Resident 92 medications including one Slow Iron 45 mg tablet. Staff 11 did not administer Calcium with Vitamin D. On 1/28/25 at 9:24 AM Staff 11 stated when a resident was admitted to the facility with new orders Staff 18 (Medical Records) entered the orders into a resident's clinical record and a nurse was to review the orders prior to administering the medications to ensure all the orders were entered correctly. Staff 11 reviewed Resident 92's admission orders and he acknowledged he administered the wrong dose of iron, stated the Calcium with Vitamin D was not transcribed onto the MAR, therefore, he did not administer the medication as ordered. On 1/28/25 at 9:26 AM Staff 1 (Chief Executive Officer) stated resident admission orders were entered into the clinical record by medical record staff and a nurse had to approve the orders before the medications could be administered. Staff 2 (Chief Nursing Officer) was notified the Calcium with Vitamin D was not transcribed onto the MAR. On 1/28/25 at 10:27 AM Staff 18 stated she did not enter the Calcium with Vitamin D order into Resident 92's clinical record and the nurse did not see the omitted order when they verified her/his orders.

F759 Medication error rate exceeds 5% Current residents have the potential to be affected. DON/Designee will complete baseline med pass audit verify medications were given per order. Identified issues will be corrected. DON/Designee will provide further education to Medical Records, Licensed Nurses and CMAs by 2/7/2025 related to following 6 Rights of Medication Administration. Implement orders to be reviewed by a second nurse on admission. Implement comparing admission orders with what is entered in to PCC for all admissions the next business day at clinical meeting. Weekend and Holidays to be reviewed on the next business day. DON/Designee will conduct additional random med pass audits to verify medications are given per the order weekly for 4 weeks, monthly for 2 months. DON/Designee will conduct additional audit of Newly admitted residents to verify all medications were transcribed correctly into PCC weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Director of Nursing responsible for compliance

Based on observation, interview and record review it was determined the facility failed to ensure food for the residents was prepared in a manner which preserved the nutritional value for pureed texture diets. This placed residents at risk for nutritional deficits. Findings include: An observation of lunch meal service on 1/29/25 at 11:43 AM revealed pureed cranberry chicken as a main course available to residents with puree texture diets. On 1/29/25 at 3:15 PM Staff 19 (Dietary Aid) stated food was mixed with water to create the puree texture. He also stated the puree texture consistency was determined by sight. On 1/29/25 at 3:27 PM Staff 12 (Culinary Manager) stated the recipes and texture guidelines for the kitchen came from Sysco (a kitchen food and non-food product supplier). He stated the kitchen staff were instructed to use water to make the puree texture. Staff 12 stated he would bring the survey team the recipes and guidelines from Sysco. No further information was provided to the survey team. A 1/30/25 review of pureed food recipes and texture guidelines on Sysco's website revealed the following: - Pureed food texture was determined by using a two-step testing method prior to serving it - Foods were to be mixed with gravy, sauce, broth, or milk to create a puree texture.

F804 Decreased Nutritional Value of Food Current residents who receive pureed texture food have the potential to be affected. Dietary Manager/designee will complete baseline audit of puree texture meal prep/tray line observations at each meal to verify puree food recipe is followed. Identified issues will be corrected. Dietary Manager/designee will provide further education to dietary staff by 2/14/2025 related to: appropriate preparation of pureed diets that do not decrease the nutritional value of meals. Dietary Manager/Designee will conduct food prep audits weekly to verify pureed foot texture was prepared per recipe guidelines for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Dietary Manager responsible for compliance

Based on observation and interview it was determined the facility failed to ensure food was stored properly in 1 of 1 resident refrigerators, failed to ensure food was stored, prepared, and handled properly in 1 of 1 kitchen, and failed to keep kitchen equipment clean. This put residents at risk for food borne illnesses. Findings include: During the initial kitchen observation on 1/27/25 at 8:15 AM the following items were found in the walk-in refrigerator: - A plastic wrapped white tube containing a soft white substance, a white tub of semi hard white substance, and a white tub with dark liquid inside did not have labels or open dates - A metal bowl covered with plastic wrap labeled streusel topping, a used jug of thickened orange juice (juice with a thickening agent mixed into it), a used jug of 1% milk, a used carton of almond milk, used bags of shredded cheddar and mozzarella cheese, a box containing opened and uncovered packages of meat, and a used package of cheese slices with hard edges wrapped in plastic wrap did not have open dates - Two uncovered trays of hamburger patties on a bottom shelf During an initial kitchen observation on 1/27/25 at 8:25 AM the walk-in freezer contained the following items without open dates: - A loosely covered pie tin containing partially eaten pie - A bag of meat opened and wrapped loosely with plastic wrap - An open bag of meat patties inside an open box On 1/27/25 at 8:32 AM Staff 12 (Culinary Manager) verified all items found and stated they would be removed and staff educated on the proper food storage policy. He stated he would bring the food storage policy to the survey team. No further documentation was provided. On 1/28/25 at 12:30 PM Staff 12 verified the following items were found in the resident refrigerator: - A used jug of 1% milk, a used carton of almond milk, two used containers of nectar consistency orange juice (juice with a thickening agent mixed into it), and a used jug of cranberry juice cocktail did not have open dates - Plastic wrapped sliced cheese with multiple hard slices did not have a label or an open date During the meal tray preparation and meal service on 1/29/25 at 11:43 AM the following were observed: - Staff 12 used a thermometer to check the temperatures for all items on the steam table without cleaning it between items or wearing gloves until instructed. When asked about the proper procedure for getting food temperatures, he stated the policy was to wear gloves and clean the thermometer between all items. He stated he would bring the food service policy to the survey team. No further documentation was provided. - Staff 20 (Dietary Aid) did not have her hair net properly in place until instructed. She stated she did not know if there was a policy for hair nets. - Staff 20 was not wearing gloves while portioning out brown sugar from a large container until instructed. She stated the policy was to wear gloves when handling food. - Staff 19 (Dietary Aid) collected supplies for preparation of salads while wearing gloves and did not change his gloves prior to touching the salad mix. He did not change gloves or throw away the contaminated mix until instructed. He stated he did not realize he needed to change his gloves before touching the salad mix and did not know if there was a glove wearing policy. - Staff 19 removed squashed grapes and grapes with fuzz from a large bag of grapes without wearing gloves, and did not wash his hands or put on gloves until instructed. He stated he did not think he needed gloves to remove the grapes from the bag. On 1/29/25 at 12:20 PM Staff 12 stated the expectation of all kitchen staff was to wear gloves while performing tasks involving food. He stated he would bring the glove wearing policy to the survey team. No further information was received by the survey team. On 1/29/25 at 3:15 PM Staff 19 stated the expectation of kitchen staff was to label and date all food items upon opening them, but he did not know if there was a policy for food storage. He also stated the kitchen was cleaned on an as needed basis with no set schedule for cleaning or deep cleaning. He revealed a cutting board in use on the steam table which had dark spots on the underside, and stated he could not get it clean and did not know how long it had been in that condition. A follow up observation of the kitchen walk-in refrigerator on 1/29/25 at 3:23 PM noted the items from the initial kitchen observation still present as well as a used container of skim milk and a used carton of liquid eggs without open dates. Staff 12 verified the identified items. On 1/29/25 at 3:27 PM Staff 12 stated he did not have cleaning audits or a cleaning schedule for the kitchen. He stated he did not know about the dark spots on the underside of the cutting board, and upon visualizing the dark spots he stated the cutting board would be cleaned or thrown away. A kitchen observation on 1/30/25 at 10:31 AM revealed the following: - The cutting board with the dark spots underneath was being used on the steam table - All verified undated and unlabeled items from previous observations were still in place in the walk-in refrigerator, walk-in freezer, and resident refrigerator A follow up kitchen observation on 1/30/25 at 11:08 AM noted Staff 21 (Regional Culinary Manager) taking the steam table cutting board to the dumpster. She stated the board would not be used again, a new board had been ordered, and a cleaning schedule had been made for the kitchen staff.

F812 Food storage, gloves, clean surfaces, hairnets Current residents have the potential to be affected. Dietary Manager/designee will complete baseline audit of service line observation at each meal for appropriate PPE, and post meal service for sanitation. Audit of sanitation logs will be completed as well. Dietary Manager/designee will complete baseline audit of food storage to verify items in the walk-In refrigerator/Freezer are labeled, dated and covered appropriately. Identified issues will be corrected. Dietary Manager/designee will provide further education to dietary staff by 2/14/2025 related to: appropriate sanitation of tray line surfaces and use of hairnets and gloves with meal prep and tray service. Additional education will also include food storage with specific focus on labeling, dating and covering food in the walk-in Fridge and Freezer. Dietary Manager/Designee will conduct ongoing auditof service line observation at each meal for appropriate PPE, and post meal service for sanitation to include sanitation logs. Dietary Manager/designee will complete ongoing audit of food storage to verify items in the walk-In refrigerator/Freezer are labeled, dated and covered appropriately. Audit will be conductedweekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Dietary Manager responsible for compliance

*************** OAR 411-086-0260 Pharmaceutical Services Refer to F554 *************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677 and F759 *************** 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to 688, F758 *************** OAR 411-086-0250 Dietary Services Refer to F804 and 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 09/18/2023 and 09/24/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 3 sampled residents (#2) and 2 of 4 halls (#s 1 and 3) reviewed for dignity and random observations. This placed residents at risk for lack of dignity. Findings include: 1. Resident 2 was admitted to the facility in 12/2010 with diagnosis including quadriplegia. A 7/24/23 Quarterly MDS revealed Resident 2 had an indwelling catheter. On 9/18/23 at 2:37 PM Resident 2 stated she/he preferred to have her/his urinary catheter bag covered with a privacy bag when she/he was in bed. The urinary catheter bag was observed hanging on the bed with no privacy cover and urine could be seen in the bag. Resident 2 stated people should not have to look at her/his urine. On 9/20/23 at 7:18 AM Resident 2 was in bed with urinary catheter bag hanging on the bed with no privacy bag. Urine could be observed in the bag from the hallway outside of Resident 2's room. On 9/20/23 at 10:48 AM Staff 4 (CNA) stated Resident 2's urinary catheter bag should have a privacy bag on it while she/he was in bed. On 9/21/23 at 10:59 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated it was expected urinary catheter bags should be covered with privacy bags. 2. During observations on 9/20/23 at 7:18 AM Staff 5 (CNA) was in Resident 2's room while Resident 2 was in her/his bed. Staff 5 stated to Resident 2 as soon as she got all the "feeders" (residents who require assistance with eating) up, she would come back and assist Resident 2 to get out of bed. At 11:15 AM when asked if the dining room was available for interview, Staff 5 stated it was stating she started to get the "feeders" ready around noon. When asked if "feeders" was the term that facility staff used to address residents who required assistance with eating Staff 5 stated she should address residents who require assistance as "assist." On 9/22/23 at 8:08 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) confirmed it was not appropriate for staff to call residents who required assistance with eating "feeders."

F550 Dignity and Respect Resident #2 Urinary catheter bag has a privacy cover Residents who require assistance with eating are not referred to as feeders. Current residents have the potential to be affected. DON/Designee will complete baseline audit of currents with catheters to verify all catheter bags have a privacy cover. Identified issues will be corrected. DON/Designee will complete baseline observations of resident who require assistance with eating to verify residents are not being referred to as feeders. Identified issues will be Corrected DON/Designee will provide further education to Licensed Nurses and CNAs on 10/25/2023 related to usage of institutionalized terminology such as feeder, pulling privacy curtains and closing doors during patient care and ensuring residents with catheter bags have a privacy cover applied. Corrected/Designee will conduct an audit of residents with catheter bags to verify catheter bags have a privacy cover. Corrected/Designee will conduct observations at mealtime to verify residents who require assistance with eating are not referred to as feeders. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. DON responsible for compliance

Based on observation, interview, and record review it was determined the facility failed to ensure preferences were honored for 1 of 2 sampled residents (#2) reviewed for choices. This placed residents at risk for lack of support for preferences. Findings include: 1. Resident 2 was admitted to the facility in 12/2010 with diagnosis including quadriplegia. The 7/24/23 Quarterly MDS revealed Resident 2's BIMS score was 15 which indicated the resident was cognitively intact. a. A revised 8/7/23 care plan indicated Resident 2 had a self-care performance deficit and needed assistance with her ADLs. Resident 2 preferred to be up in her/his wheelchair for breakfast and required two staff assist for morning care. Resident 2 prefered early morning showers. On 9/19/23 at 8:46 AM Resident 2 was observed in bed eating her/his breakfast. On 9/20/23 at 7:18 AM Staff 5 (CNA) was in Resident 2's room while Resident 2 was in her/his bed. Staff 5 stated to Resident 2 as soon as she got all the "feeders" (residents who require assistance with eating) up she would come back and assist Resident 2 to get out of bed. At 11:15 AM Staff 5 stated Resident 2 preferred to be out of bed for her/his breakfast and there were times she did not have the time to get her/him up. Staff 5 stated she was able to get Resident 2 up out of bed about 75 percent of the time. On 9/21/23 at 11:00 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated it was a rare exception when Resident 2 was not out of bed in the morning for breakfast. b. A 9/26/18 care plan indicated Resident 2 had a self-care performance deficit and needed assistance with her/his ADLs. Resident 2 preferred to have her/his lunch at 11:30 AM every day. On 9/19/23 at 12:10 PM Resident 2 was in her/his room and reported her/his lunch had not been served. No lunch tray was observed in the room. On 9/20/23 at 11:15 AM Staff 5 stated Resident 2 was provided lunch when all other residents' lunches were served between 12:30 PM and 1:00 PM. On 9/21/23 at 11:00 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated Resident 2's lunch should be set out early and provided by 11:30 AM. c. A revised 8/7/23 care plan indicated Resident 2 had a self-care performance deficit and needed assistance with her/his ADLs. Resident 2 preferred to have all evening care completed by 9:00 PM. On 9/18/23 at 2:33 PM Resident 2 stated the CNAs determined when she/he got up and went to bed. Resident 9 stated she/he preferred to be in bed and all cares and treatments to be completed by 9:00 PM. Resident 2 stated Staff 8 (LPN) did not always come in to assist her/him until 9:00 PM or 10:00 PM and all other nurses were able to complete treatments by 9:00 PM. On 9/21/23 at 9:20 AM Staff 8 stated sometimes it was difficult to get into Resident 2's room and complete her/his cares before her/his preferred bedtime. On 9/22/23 at 7:53 AM Staff 9 (CNA) stated Resident 2 became upset if staff did not have her/his evening cares completed by an exact time. When Staff 9 was asked if Resident 2 was care planned to have evening cares completed by a certain time Staff 9 stated she did not know Resident 2's care planned preferences for evening. On 9/21/23 at 11:00 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated in the evening it was a challenge for staff to complete all the diabetic treatments and staff attempted to get to Resident 2 for her/his care and treatment before her/his preferred time for sleep. d. An 10/21/22 Annual MDS indicated it was very important for Resident 2 to choose what clothes to wear. A revised 8/7/23 care plan indicated Resident 2 had a self-care performance deficit and needed one-person staff assistance with dressing. On 9/18/23 at 2:33 PM Resident 2 stated when she/he did not pick out her/his clothing with the evening CNA, the morning CNA picked her/his clothing without allowing her/him to choose what to wear. On 9/21/23 at 7:04 AM Staff 5 (CNA) stated she usually picked out Resident 2's clothing for the day and if the night shift helped Resident 2 pick them out, they would be set out for the morning. Staff 5 also stated she asked Resident 2 what she/he wanted and got the clothing out. On 9/21/23 at 11:00 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated Resident 2 should have the choice of what to wear for her/his clothing in the mornings.

F561 Self-Determination Resident #2 preferences for being up in wheelchair for breakfast, preferences for lunch service time, preferences for evening care times and preference to choose clothing are being met. Current residents have the potential to be affected. DON/Designee will complete baseline audit of current residents to verify care planned preferences are being met. Identified issues will be corrected. DON/Designee will provide further education to Licensed Nurse CNAs on 10/25/2023 related to care planned preferences and honoring resident choices. DON/Designee will conduct an audit of 10 residents weekly to verify choices for care planned preferences have been met. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. RCM/Designee responsible for compliance

Based on interview and record review it was determined the facility failed to ensure a resident was provided advance directive information for 1 of 2 sampled residents (#3) reviewed for advance directives. This placed residents at risk for end-of-life decisions not being honored. Findings include: Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. An 8/10/23 Clinical Evaluation Admission form revealed the resident did not have an advance directive. An 8/15/23 Admission MDS indicated Resident 15 was cognitively intact. An 8/31/23 Care Plan revealed staff were to review advance directive information with Resident 3 and/or her/his appointed representative on admission, with a change of condition and at least quarterly. There was no documentation on the care plan to indicate advance directive information was provided. On 9/20/23 at 12:26 PM Staff 3 (Social Services Coordinator) stated if a resident had an advance directive it was scanned into the record. If the resident did not have one, the information was offered and then documented in the resident's record. Staff 3 thought she offered the information to Resident 3 and the resident declined, but there was no documentation in the resident's record.

F578 Resident Rights/ Advance Directives Resident #3 has been offered information on Advance Directives. Current residents have the potential to be affected. NHA/Designee will complete baseline audit of current residents to verify advance directives have been reviewed and offered. Identified issues will be Corrected. NHA/Designee provided further education on 10/25/2023 to Social Services and Admission Staff related to offering of Advance Directives and follow-up required on those that have or want Advance Directives. NHA/Designee will conduct an audit of new admissions to verify Advance Directives have been offered with follow up documentation on choices. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Social Service responsible for Compliance

Based on observation, interview, and record review it was determined the facility failed to ensure resident privacy was provided for 1 of 3 sampled residents (#2) reviewed for dignity. This placed residents at risk for lack of privacy. Findings include: Resident 2 was admitted to the facility in 12/2010 with diagnosis including quadriplegia. The 7/24/23 Quarterly MDS revealed Resident 2 had a BIMS score of 15 which indicated the resident was cognitively intact with no behavioral concerns. An 8/27/23 revised care plan revealed Resident 2 had an ADL self-care performance deficit with interventions including the resident required one staff for bathing, and two staff for AM shift care. On 9/18/23 at 2:49 PM Resident 2 stated she/he felt exposed as staff only partially closed her/his privacy curtain and not her/his room door during cares. Resident 2 indicated when she/he could see people in the hallway, the people in the hallway could see her/him. On 9/20/23 at 10:48 AM Staff 4 (CNA) stated when only one staff member assisted Resident 2, staff left the room door ajar because Resident 2 was care planned to have two staff for cares. Resident 2 had a history of threatening she/he would get staff fired. On 9/20/23 at 11:15 AM Staff 5 (CNA) stated Resident 2 was care planned to have two people assist with care. On 9/21/23 at 7:14 AM Staff 4 (CNA) came out of Resident 2's room, obtained the mechanical transfer lift from the hall and went back into Resident 2's room. The privacy curtain and door were open and Resident 2 was observed being transferred from her/his bed to her/his wheelchair by Staff 4 and Staff 5 with the mechanical lift. On 9/21/23 at 9:44 AM Resident 2 stated staff also left the door open to the shower room while the staff assisted her/him to shower and she/he felt it was inappropriate. On 9/21/23 at 11:00 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated it was expected for a resident not to be seen from the hallway while cares were provided to the resident.

F583 Personal Privacy/Confidentiality of Records Resident #2s Residents privacy is being maintained and any preferences updated in the care plan Current residents have the potential to be affected. DON/Designee will complete baseline audit of current residents to verify privacy is being maintained during cares and transfers. Identified issues will be Corrected. DON/Designee will provide further education to Licensed Nurses and CNAs 10/25/2023 related to pulling privacy curtains and closing doors during patient care. DON/Designee will conduct an audit of 10 residents weekly to verify privacy is being maintained during cares and transfers. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. RCM responsible for compliance

Based on interview and record review it was determined the facility failed to follow-up on a resident grievance in a timely manner for 1 of 1 sampled resident (#8) reviewed for personal property. This placed residents at risk for missing personal items. Findings include: Resident 8 was admitted to the facility in 2020 with diagnoses included muscle weakness. A 7/17/23 Admission MDS revealed the resident was cognitively intact. An 8/2/23 Concerns/Complaints/Compliments/Grievances Follow-up form revealed the resident reported she/he was missing four shorts, three sweat pants, three shirts, one underwear and two jeans. The form indicated the CNAs, housekeeping and social services searched the facility for the missing clothing. There was no resolution documented on the form. On 9/18/23 at 3:45 PM Resident 8 stated she/he received clothing for her/his birthdays and holidays and many items were missing including jeans. She/he submitted a grievance and did not have a resolution yet. Resident 8 stated all her/his clothing were marked with her/his name. On 9/20/23 at 12:07 PM Staff 3 (Social Services Coordinator) stated if a resident reported missing clothing and the clothing was not found, the items would be replaced. Generally, staff tried to resolve grievances in approximately two weeks. Facility staff looked for Resident 8's missing clothing, found some but not all of the missing items. Staff 3 acknowledged the grievance was not completely resolved at this time and the missing clothes were reported more than one month ago.

F585 Grievances Resident #8 grievances have been resolved on 9/28/2023 Current residents have the potential to be affected. NHA/Designee will complete baseline audit of current residents with most recent BIMS of 9 or higher to verify if any grievances have been reported and not Corrected. Identified issues were Corrected. NHA/Designee provided further education 10/25/2023 to current facility staff related to facility grievance process and follow up. NHA/Designee will audit grievance log weekly to verify all grievances have been Corrected/resolved. NHA/Designee will conduct an audit of the current months grievance log to verify grievances are followed up on timely. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. NHA/Designee responsible for compliance

Based on interview and record review it was determined the facility failed to ensure a resident was permitted timely return to the facility after a scheduled outpatient medical procedure for 1 of 1 sampled resident (#83) reviewed for change of condition. This placed residents at risk for loss of rights to return to the facility. Findings include. Resident 83 was admitted to the facility in 2023 with an arm fracture. Resident 83's 4/12/23 and 4/13/23 Progress Notes revealed the ward clerk made arrangements for the resident to go the the hospital emergency department to have her/his cast removed because the resident refused to attend the scheduled orthopedic office appointment to have the cast removed. The resident's physician was notified and the resident was agreeable to go to the hospital via non-emergent transport to be evaluated for x-rays and cast removal. There was no indication in Resident 83's record she/he was discharged from the facility. An 4/14/23 Emergency Department Note revealed the resident was sent to the emergency department because the resident refused to be seen at the orthopedic office. The facility was frustrated with the resident and refused to allow her/him to return. An e-mail dated 4/25/23 from the LTCO (Long Term Care Ombudsman) to the former facility administrator indicated the resident was in the hospital emergency department for 11 days and the resident reported she/he wanted out of the emergency department. On 9/20/23 at 4:03 PM Staff 2 (DNS) stated the former administrator made the decision to not accept the resident back after the resident was evaluated in the emergency department for the cast removal and the resident was not allowed to return until the LTCO became involved. On 9/21/23 at 10:28 AM a request was made to Staff 1 (Chief Executive Officer) to provide documentation to demonstrate the resident was discharged from the facility, was provided a 30 day notice or was not safe to return because she/he was a danger to her/himself or others. No additional information was provided.

F622 Transfer and Discharge Requirements Resident #83 no longer resides in the facility. Administrator at the time of this complaint no longer at facility Current residents who are discharged have the potential to be affected. NHA/Designee will complete a baseline audit of discharges in the last 30 days to verify residents who wish to return have been permitted to return timely. NHA/Designee will provide further education to Admissions Staff related to residents right to return rules and regulations. NHA/Designee will conduct an audit of any discharge from facility to verify residents who wish to return within facility scope were permitted. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. NHA responsible for Compliance

Based on interview and record review it was determined the facility failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalization for 1 of 1 sampled resident (#15) reviewed for hospitalization. This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: Resident 15 was admitted to the facility in 7/2023 with diagnosis of kidney disease. The 7/11/23 Health Status Note indicated Resident 15 was sent to the hospital. The 7/18/23 Admission Summary Note indicated Resident 15 readmitted to the facility. No evidence was found in the resident's clinical record to indicate the Office of the State Long Term Care Ombudsman was notified of Resident 15's hospitalization. On 9/21/23 at 11:15 AM Staff 1 (Chief Executive Officer) stated historically the facility did not send out written hospital notifications for the Office of the State Long Term Care Ombudsman.

F623 Notice Requirements Before Transfer/Discharge Resident #15 Ombudsman has been notified of resident's hospitalization from 7/11/23 Current residents with planned and unplanned discharges are at risk. NHA/Designee will complete baseline audit of residents who have been discharged or have been transferred to hospital in last 3 months to verify notification to Ombudsman has been made. NHA/Designee has provided further education to Medical Records Coordinator and Social Services Director 9/24/2023 related to hospital transfer checklist items and notification to the Ombudsman for any discharges from the facility. NHA/Designee will conduct an audit of all transfers out of the facility to ensure appropriate notice of transfer has been provided to the Ombudsman. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. NHA responsible for compliance

Based on interview and record review it was determined the facility failed to ensure a significant change MDS was completed for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 5 was admitted to the facility in 2023 with diagnoses related to adult failure to thrive. Resident 5's Progress Notes dated 8/14/23 and 8/16/23 revealed the resident's physician discontinued all non-essential medications, she/he was discharged from skilled therapy and placed on comfort care. On 9/20/23 at 10:53 AM Staff 15 (RNCM) stated on 8/14/23 Resident 5 elected end of life care provided by the facility versus hospice services. Staff 15 stated a significant change MDS should have been completed but was not done.

F637 Comprehensive Assessments After Significant Change Resident #5 Has a significant change MDS assessment completed. Current residents with significant changes have the potential to be affected. DON/Designee will complete baseline audit of current residents with a significant change in the current quarter to verify an MDS significant change assessment has been completed. DON/Designee will provide further education 10/25/2023 to Care Managers and MDS Coordinators related to RAI manual processes and timely completion of significant change assessments. DON/Designee will conduct audits of significant changes to verify a comprehensive significant change assessment/MDS has been completed. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. DON responsible for Compliance

Based on interview and record review it was determined the facility failed to develop a care plan with interventions to address resident care needs for 2 of 5 sampled residents (#s 8 and 19) reviewed for medications. This placed residents at risk for unmet care needs and unnecessary medications. Findings include: 1. Resident 8 was admitted to the facility in 2023 with diagnoses including anxiety. A 7/24/23 Admission MDS and CAAs revealed the resident took antianxiety medications and the goal was for the resident to not have adverse medication reactions. A care plan last updated 8/15/23 revealed the resident had an emotional support cat related to anxiety. The care plan indicated the resident was able to care for the cat and enjoyed talking to staff about the cat. Staff were to monitor the resident for mood changes and side effects of the resident's antianxiety medications. There were no triggers listed in the resident's care plan related to the resident's anxiety and no non-pharmacological interventions listed which could be effective to reduce the resident's anxiety. A 9/2023 MAR revealed Resident 8 was administered PRN alprazolam (to treat anxiety) at least daily. On 9/19/23 at 3:59 PM Staff 15 (RNCM) stated the resident was alert, anxious and had multiple triggers for her/his antianxiety. Staff 15 acknowledged the care plan did not address interventions or triggers related to the resident's anxiety. Refer to 758 , 2. Resident 19 was admitted to the facility in 2023 with diagnoses including pneumonia. Resident 19's current care plan identified problems of diabetes, use of an intravenous line for the delivery of antibiotics, dehydration related to poor intake and pain related to skin conditions. The care plan did not include: -The use of two diuretics (medication to increase urination) to treat lymphedema (blockage in the lymph system causing swelling in the arms or legs) which could lead to dehydration. -Lymphedema, diabetic neuropathy (nerve damage leading to pain and numbness), peripheral vascular disease (plaque build up restricting blood flow causing pain and leg cramps) and immobility which could cause pain. -Visual problems due to glaucoma and a cataract. -Severe kidney disease with recent consideration for dialysis (a process to eliminate toxins from the blood). -Sleep apnea (condition that causes a person to stop breathing while sleeping). On 9/22/23 at 8:55 AM Resident 19's care plan was discussed with Staff 2 (DNS). Staff 2 stated she expected resident conditions being treated at the facility and pertinent to a resident's care to be included in the care plan.

F656 Develop/Implement Comprehensive Care Plans Resident #8 Has an updated care plan to address triggers and interventions Resident #19 Care plan has been updated to address current conditions Current residents have the potential to be affected. DON/Designee will complete baseline audit of current residents with antianxiety medications to verify triggers have been identified and resident centered interventions are in place. DON/Designee will complete a baseline audit to verify resident conditions are included on the care plan. DON/Designee will provide further education to Licensed Nurses and RCMs related to listing triggers and resident centered interventions on care plans and listing resident conditions on the care plan. DON/Designee will conduct an audit of 10 resident weekly to verify resident with antianxiety medications have resident centered signs and symptoms and interventions on the care plan. DONDesignee will conduct an audit of 10 residents weekly to verify resident conditions are included on the care plan. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. RCM responsible for compliance

Based on interview and record review it was determined the facility failed to ensure a care conference with the interdisciplinary team occurred and failed to ensure a resident's care plan related to a UTI and medications were revised for 5 of 8 sampled residents (#s 1, 3, 5, 8, and 14) reviewed for care planning and medications. This placed residents at risk for adverse medication reactions and unmet needs. Findings include: 1. Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. An 8/15/23 Admission MDS indicated Resident 3 was cognitively intact. An 8/24/23 Progress Note indicated the resident refused to schedule a care conference. Resident 3's record did not reveal the Interdisciplinary Team met to develop the resident's care plan. On 9/20/23 at 3:22 PM Staff 2 (DNS) stated a care conference was to be held to develop the resident's care plan and was based on the MDS schedule. A request was made to Staff 2 to provide documentation a care conference was held to develop Resident 3's care plan. No additional information was provided. 2. Resident 5 was admitted to the facility in 2023 with diagnoses including failure to thrive. A Care Plan initiated 7/20/23 revealed Resident 5 was administered an antidepressant for depression. An 8/14/23 Progress Note revealed all Resident 5's non-essential medications were discontinued. A 9/2023 MAR revealed Resident 5 was not administered an antidepressant. On 9/20/23 at 10:53 AM Staff 15 (RNCM) stated Resident 5 had a decline in health and all her/his medications were discontinued except for the resident's seizure medication. Staff 15 acknowledged the care plan was not revised to reflect the discontinuation of the antidepressant. 3. Resident 8 was admitted to the facility in 2020 with diagnoses including a muscular disease. A 7/17/23 Admission MDS indicated the resident was cognitively intact. Resident 8's record revealed the last care conference held with the resident was on 11/3/22. On 9/18/23 at 3:45 PM Resident 8 stated she/he did not have a care conference for "a while." On 9/19/23 at 2:13 PM Staff 15 (RNCM) stated Staff 3 (Social Services Coordinator) scheduled and documented all the care conferences for residents. Staff 15 stated she did not see a recent care conference documented in Resident 8's record. On 9/20/23 at 12:19 PM Staff 3 stated each resident was to have a quarterly care conference. Staff 3 stated Resident 8 was due for her/his last care conference 5/2023 and it did not occur. , 4. Resident 14 was admitted to the facility in 2023 with diagnoses including heart failure. On 9/19/23 at 9:28 AM Resident 14 was asked about participation in care planning and she/he stated she/he did not remember a care plan conference with facility staff. There was no evidence in the clinical record to indicate a care plan conference occurred for Resident 14. On 9/20/23 at 4:34 PM Staff 2 (DNS) was asked about care conferences and she stated care conferences should follow the MDS schedule. Staff 2 added she was unable to find evidence of a care conference for Resident 14. , 5. Resident 1 was admitted to the facility in 6/2002 with diagnosis including cerebral palsy (a movement disorder). An 8/3/23 Multidisciplinary Care Conference form revealed the following: -Meeting time and date were blank. -Attendance was blank. -Key review section was blank. -Resident and responsible party expectations and concerns were blank. -Comments and recommendations had notes with names of two other people who were not the resident and information about the two other people. -Recommendation section was blank. -The check boxes for care plan reviewed and updated and current orders and care plans reviewed with resident or representative and copies provided were not marked. A review of Social Services Notes for 7/2023 and 8/2023 revealed no social service notes pertaining to care conferences. On 9/21/23 at 12:52 PM Staff 3 (Social Services Coordinator) stated Resident 1's care conference date was noted as 8/3/23 on her hand-written calendar. Staff 3 stated she would have to look for additional information about the care conference. No additional information was provided. On 9/22/23 at 8:13 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) were informed of the findings.

F657 Care Plan Timing and Revision Resident #1 Care conference completed. Resident #3 Documentation that the care conference was held is completed Resident #5 Care plan has been completed. Resident #8 Has a current care conference completed Resident #14 Has a current care conference completed Current residents have the potential to be affected. DON/Designee will complete baseline audit of current residents to verify discontinued medications/treatments have been resolved from the care plan. DON/Designee will complete baseline audit to verify residents have a current care conference and the form is completed accurately. DON/Designee provided further education to Social Services, Nurse Managers and other members of the IDT 9/21/2023 related to maintaining residents care conference schedule. DON/Designee provided further education to Licensed Nurses 9/21/2023 related to updating care plans when medications are discontinued. DON/Designee will audit the care conference schedule weekly to verify care conferences were held and documented accurately. DON/Designee will audit residents with discontinued medications to verify care plans have been updated. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. Social Services responsible for compliance

Based on interview and record review it was determined the facility failed to ensure a resident was provided supplies for independent in-room activities for 1 of 2 sampled residents (#8) reviewed for activities. This placed residents at risk for lack of meaningful activities. Findings include: Resident 8 was readmitted to the facility in 2023 with diagnoses including heart disease. A 7/17/23 Admission MDS revealed Resident 8 was cognitively intact and it was somewhat important for her/him to do her/his favorite activities. Resident 8's 8/23/23 through 9/20/23 activity documentation revealed Resident 8 participated in two group activities. There was no one to one activity or self directed activity documented. A Care Plan initiated 5/26/23 revealed staff were to invite the resident to activities of choice, provide an activity calendar and respect the resident's wishes to decline activities. The care plan did not specify the type of activities the resident liked or the type of supplies the resident may need. On 9/18/23 at 3:38 PM Resident 8 stated the facility had supplies in a bin, but did not have the type of supplies that she/he preferred. Resident 8 stated she/he would like to paint by number or other types of art that she/he could do independently in her/his room. Resident 8 stated she/he had to buy her/his own supplies. On 9/19/23 at 3:21 PM Staff 13 (Activity Assistant) stated Resident 8 did not like the activities that she provided for the other residents in the facility and Resident 8 did not have a common bond with the other residents. Resident 8 preferred to do her/his own activities in her/his room, go into the community to shop or go out with her/his family. Staff 13 stated the resident mentioned she/he would like to do more crafts in her/his room and Staff 13 did not provide the resident with the specific supplies the resident requested. Staff 13 stated she should not expect the resident to buy all her/his art supplies since the resident had a limited income. Staff 13 stated the resident was able to voice her/her needs but acknowledged the care plan was not resident specific to the types of activities the resident preferred and staff should know what types of supplies to provide.

F679 Activities Met Interest/Needs of Each Resident Resident #8 has a resident specific care plan for activities and has been provided supplies for activities of choice Current residents have the potential to be affected. NHA/Designee has complete baseline audit of current resident Activity Evaluations to verify residents are receiving activities that meet their preferences and care plans reflect resident specific activity preferences. NHA/Designee provided further education to activities coordinator 9/22/2023 related to providing residents with supplies needed to meet their activity needs and care plans include resident specific activity preferences. NHA/Designee will interview 5 residents weekly to verify activity needs are being met and care plans reflect resident specific activity preferences. Audits will be conducted weekly for 4 weeks, monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations. Activities responsible for compliance

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 5 sampled residents (#s 1 and 8) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 1 was admitted to the facility in 6/2002 with diagnoses including diabetes. A signed 9/1/23 physician order instructed staff to check Resident 1's BMP (basic metabolic panel, a group of blood tests to show how well the kidneys work), CPK (creatine phosphokinase, a blood test that measures the creatine in the blood, an enzyme required for muscle function and energy production) and ALT (alanine transaminase, a blood test which measures the amount of ALT in the blood to help with early detection of liver disease) every three months in March, June, September and December with an order date of 4/17/19. No documentation was found in clinical record to indicate Resident 1's 6/2023 BMP, CPK and ALT tests were completed. On 9/22/23 at 8:14 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated it was expected of staff to follow physician orders. , 2. Resident 8 was admitted to the facility in 2023 with diagnoses including heart disease. A 7/7/23 Order Summary Report revealed the resident was to receive Metoprolol Succinate ER/Extended Release (treats high blood pressure). The medication was to be held if the heart rate was less than 60 "and" the systolic blood pressure (top number) was less than 100. A 9/2023 MAR revealed Resident 8's Metoprolol Succinate ER was held when the heart rate was less than 60 but the systolic blood press was not less than 100 on 9/3/23, 9/8/23, 9/9/23, 9/10/23, 9/11/23, 9/12/23 and 9/15/23. On 9/19/23 at 2:58 PM Staff 15 (RNCM) stated the resident would not take the medication if her/his heart rate was less than 60. A request was made to Staff 15 to provide documentation the order was clarified with the resident's physician to hold the Metoprolol Succinate ER if only the heart rate was less than 60. No additional information was provided.

F684 Quality of Care  Physician order processing Resident #1 Lab orders were verified Resident #8 Blood Pressure Parameters were clarified. Current residents that receive medications with blood pressure parameters and have lab orders are at risk. DON/Designee will complete baseline audit of current residents with lab orders to verify labs have been completed. DON/Designee will complete baseline audit of current residents to verify medications with parameters have been given/held per orders and the physician has been notified of DON/Designee will provide further education to Licensed Nurses related to following physician orders are clarified in a timely DON/Designee will conduct an audit of 10 residents medication administration to verify it is administered per provider orders. DON/Designee will audit lab orders weekly to verify labs were collected. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. DON responsible for compliance.

Based on observation, interview, and record review it was determined the facility failed to ensure sufficient fluids were provided for 1 of 1 sampled resident (#3) reviewed for hydration. This placed residents at risk for dehydration. Findings include: Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. A Care Plan initiated 8/15/23 indicated the resident was at risk for dehydration due to the use of diuretics (medications to help remove extra fluids from the body) and staff were to monitor the resident. An 8/25/23 Nutrition Evaluation Comprehensive form revealed the resident's most recent laboratory studies and meal intakes were reviewed. The resident's fluid consumption was assessed to average 120 to 240 ml per meal. The resident was assessed to require 1650 to 1850 mL each day. The recommendation was for the resident to be on a hydration pass. Resident 3's Care Plan was not updated to include a hydration pass after the 8/25/23 nutrition evaluation. Resident 3's record did not include additional documentation to indicate the resident received additional fluids between meals. Resident 3's 8/19/23 through 9/18/23 meal monitoring revealed the resident received less than 1000 ml of fluids each day and not the recommended 1650 to 1850 ml per day. On 9/18/23 at 2:18 PM Resident 3 was observed with dry lips and teeth. A water pitcher with a straw was on the resident's bedside dresser but not within reach. On 9/20/23 at 10:41 AM and 9/21/23 at 11:12 AM Staff 15 (RNCM) stated after the RD assessed a resident the recommendations were implemented if the recommendations did not require a physician order. A hydration pass did not require an order. The CNAs provided additional fluids throughout the day and would document in the meal section of the resident's chart or the fluids between meal section. Staff 15 stated the care plan was not updated to include a hydration pass and a place for the staff to document fluids between meals was not created. Staff 15 stated the CNA staff may not have documented all the fluids provided to the resident. Staff 15 acknowledged the resident received approximately half the fluids recommended by the RD. On 9/20/23 at 10:47 AM Staff 11 (Nurse Manager) stated if the staff did not document the extra fluids provided during a hydration pass the RD would not be able to determine the effectiveness of the intervention. On 9/20/23 at 11:14 AM Staff 19 (NA) stated all residents received a hydration pass when she did their vital signs. She made sure the water pitchers were full and offered other fluids when she interacted with the residents. Staff 19 stated if there was not a spot to document the fluids between meals she added the extra fluids the residents drank in the meal intake section.

F692 Nutrition/Hydration Status Maintenance Resident # 3 Is receiving tasks have been updated to include hydration pass. Current residents that require fluid monitoring are at risk. DON/Designee will complete baseline audit of current residents have hydration pass task, that are not on fluid restrictions. DON/Designee will provide further education to Licensed Nurses 10/25/2023 related to adhering to hydration pass, care planning and documentation in EMR. DON/Designee will conduct an audit of NAR report for any recommendations to verify all residents on hydration pass monitoring have had their care plans updates, and the tasks made available to document on. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. RCM responsible for compliance.

Based on interview and record review it was determined the facility failed to ensure a RN was available for at least eight consecutive hours per day seven days per week for 9 out of 32 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: Direct Care Daily Staff Reports reviewed from 8/19/23 through 9/19/23 indicated there was no RN coverage on the following dates: 8/25/23, 8/26/23, 8/30/23, 9/1/23, 9/7/23, 9/8/23, 9/9/23, 9/15/23, and 9/16/23. On 9/21/23 at 10:45 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) stated one of the facility's RNs retired and there were now some days without the required RN staffing.

F727 RN 8HR/7 days/WK, Full Time DON Facility has contracted with staffing agencies to aid in providing RN staffing. Facility is actively recruiting RN staff. Current residents are at risk. NHA/Designee completed a baseline audit of last 14 days to verify required RN hours were scheduled. NHA Educated DON and IDT 9/22/2023 related to RN requirement to meet regulation. DON/Designee will audit daily staffing sheets to verify RN coverage is scheduled. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations

Based on interview and record review it was determined the facility failed to follow up on pharmacy recommendations for 3 of 5 sampled residents (#s 1, 8, and 19) reviewed for medications. This placed residents at risk for ineffective and adverse medication reactions. Findings include: 1. Resident 1 was admitted to the facility in 6/2002 with diagnoses including schizoaffective disorder (a mental health disorder with symptoms such as delusions and hallucinations), and depression. a. An 8/4/23 Behavior Psychoactive Meeting revealed pharmacy and physician recommendations. Resident 1 was due for a gradual dose reduction of risperidone (used to treat certain mental and mood disorders), fluoxetine (used to treat depression), and divalproex sprinkles (used to treat epilepsy and bipolar disorder). A letter was sent to the physician. A 9/6/23 Consultation Report indicated a repeat recommendation from 8/9/23: Resident 1 received risperidone, fluoxetine, and divalproex sprinkles and was due for an annual review of the medications. The report had a fax date on the top of 9/19/23 and handwritten across the top was "No response from August". Handwritten on the bottom of the form indicated "Missing signature called 9/20 @ 10 AM to req Dr. to sign or provide verbal see prog notes." On 9/22/23 at 8:14 AM Staff 1 (Chief Executive Officer) and Staff 2 (DNS) expected staff to follow up timely with pharmacy recommendations. b. A 9/1/23 signed physician order instructed staff to check Resident 1's BMP (basic metabolic panel, a group of blood tests to show how well the kidneys work, and including serum creatinine) every three months in March, June, September, and December with an order date of 4/17/19. It also instructed staff to administer metformin two times a day for diabetes with a start date of 6/23/20. A 9/2023 MAR instructed staff to administer metformin two times a day for diabetes. It was documented as administered from 9/1/23 through 9/19/23. A 9/6/23 Consultation Report indicated the recommendation was repeated from 7/5/23 and 8/9/23. Resident 1 received metformin twice daily but did not have a recent serum creatinine lab documented in the medical record, and to "Please monitor serum creatinine." No documentation was found in clinical records to indicate a BMP for Resident 1 was obtained in 6/2023, 7/2023 or 8/2023. On 9/22/23 at 8:14 AM Staff 1 (Chief Executive Officer) and Staff 2 (DON) expected staff to follow up timely with pharmacy recommendations. , 2. Resident 8 was admitted to the facility in 2023 with diagnosed including anxiety. a. A pharmacy Consultation Report dated 3/21/23 revealed the recommendation was repeated from 2/21/23. The recommendation was to notify the physician the resident required a 90 day re-evaluation for the use of the PRN alprazolam (antianxiety medication). The physician did not review the recommendation until 3/29/23. This was over one month after the recommendation was originally sent. On 9/20/23 at 3:53 PM Staff 2 (DON) stated Resident 8's physician was known for not responding timely to the pharmacy recommendations. If the resident's physician did not respond the facility physician was to address the recommendations. Staff 2 stated the recommendation responses should be received from the physician within a week, and Resident 8's recommendation response was not received in a timely manner. b. A pharmacy Consultation Report dated 3/21/23 revealed the recommendation was repeated from 2/21/23. The recommendation was to attempt a gradual dose reduction on the resident's bupropion (antidepressant). The physician did not sign the recommendation until 5/25/23, three months after the original recommendation. On 9/20/23 at 3:53 PM Staff 2 (DNS) stated Resident 8's physician was known for not responding timely to the pharmacy recommendations. If the resident's physician did not respond the facility physician was to address the recommendations. Staff 2 stated the recommendation responses should be received from the physician within a week, and Resident 8's recommendation response was not received in a timely manner. , 3. Resident 19 was admitted to the facility in 2023 with diagnoses including pneumonia. A 7/5/23 Pharmacy Consultation Report instructed staff to include special instructions related to the administration of two eye medications for glaucoma (pressure in the eye that could cause optic nerve damage). An 8/9/23 Pharmacy Consultation Report repeated the request for special instructions to be added to the eye medications. On 9/14/23 Staff 15 (RNCM) responded to the 8/9/23 recommendation stating Resident 19 instructed staff regarding the administration of the two eye drops and per Resident 19's instructions staff waited longer than the recommended time frame. On 9/20/23 at 3:57 PM Staff 2 (DNS) stated pharmacy recommendations should be acted upon within a couple days and special instructions should have been added to Resident 19's MAR.

F756 Drug Regimen Review Resident #1 Physician and pharmacy recommendations are being followed Resident #8 Drug Regimen reviews are being monitored for timely responses Resident #19 No longer in the facility. Current residents that receive medications are at risk. DON/Designee will complete baseline audit of current residents with pharmacy recommendations for medications and labs to verify recommendations are responded to timely and followed. DON/Designee provided further education to Licensed Nurses 10/25/2023 related to the follow up process for pharmacy recommendations and ensuring orders are followed. DON/Designee will conduct an audit of 10 residents with pharmacy recommendations to verify the recommendations have been sent to the provider, have timely follow up and orders are followed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. DON responsible for compliance

Based on interview and record review it was determined the facility failed to ensure residents were provided non-pharmacological interventions prior to the use of PRN psychotropic medications for 2 of 5 sampled residents (#s 5 and 8) reviewed for medications. This placed residents at risk for sedation. Findings include: 1. Resident 5 was admitted to the facility in 2023 with diagnoses including failure to thrive. Resident 5's Progress Notes dated 8/14/23 and 8/16/23 revealed the resident's physician discontinued all non-essential medications, the resident was discharged from skilled therapy and placed on comfort care. A 9/2023 MAR from 9/1/23 through 9/19/23 revealed the resident was administered lorazepam (antianxiety medication) up to four times a day for anxiety/restlessness. The documentation indicated the medication was effective. The MAR also had directions for staff to try non-pharmacological interventions prior to use of PRN medications including repositioning, offer warm blankets, distraction and to decrease environment stimulation, and staff were to document the interventions. There were no interventions documented prior to the use of the antianxiety medication. Resident 5's Progress Notes dated 9/1/23 through 9/19/23 revealed one note on 9/2/23 which indicated the resident was inconsolable. No additional notes indicated non-pharmacological interventions were provided prior to the administration of the PRN lorazepam. On 9/20/23 at 10:53 AM Staff 15 (RNCM) stated staff may have provided interventions but there was no documentation. 2. Resident 8 was re-admitted to the facility in 2023 with diagnoses including anxiety. A MAR from 9/1/23 through 9/18/23 revealed the resident was administered alprazolam up to two times a day PRN for anxiety. The MAR also had directions for staff to try non-pharmacological interventions prior to the use of PRN medications including repositioning, offer warm blankets, distraction and to decrease environmental stimulation. Staff were to document interventions. There was no documentation non-pharmacological interventions were provided. Resident 8's Progress Notes dated 9/1/23 through 9/18/23 revealed one note on 9/2/23 which indicated the resident was inconsolable. No additional notes indicated non-pharmacological interventions were provided prior to the administration of the PRN alprazolam On 9/19/23 at 2:58 PM Staff 15 (RNCM) stated Resident 8 was alert, oriented and asked for the antianxiety medication. Staff 15 stated most anything could cause the resident anxiety. Staff 15 stated she did not ask the resident if there was anything the staff could do prior to the administration of the PRN alprazolam which could decrease the resident's anxiety.

F758 Free from Unnecessary Psychotropic Meds/PRN use Resident # 5 Non-pharmacological interventions are being attempted and documented prior to PRN use of psychotropic medication. Resident # 8 Non-pharmacological interventions are being attempted and documented prior to PRN use of psychotropic medication. Current residents that receive PRN psychotropic medications are at risk. DON/Designee will complete baseline audit of current residents with PRN psychotropic medication orders and ensure that there are non-pharmacological interventions are in place and attempted prior to administration of medication. DON/Designee will provide further education to Licensed Nurses 10/25/2023 related to attempting non-pharmacological interventions prior to administering psychotropic medications. DON/Designee will conduct an audit of 10 residents PRN psychotropic medication administration to verify non-pharmacological interventions are established and documented to prior to psychotropic medication administration. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. DON responsible for compliance

Based on observation, interview, and record review it was determined the facility failed to ensure 2 of 2 staff (#s 12 and 13) wore appropriate PPE for a resident who required aerosol generating proceduress (AGPs). This placed residents at risk for cross contamination. Findings include: On 9/20/23 at 9:15 AM Room 403 was observed with a sign on the door. The sign included the resident had AGPs completed at 7:47 AM, precautions ended at [no time was written]. The sign instructed authorized, trained staff to wear a gown, N95 mask, eye protection and gloves. Staff 12 (Housekeeper) was observed to enter the room with only a surgical mask and gloves. Staff 12 stated she only wore eye protection and a gown if a resident had COVID-19. On 9/20/23 at 9:30 AM Staff 13 (Activities Assistant) was observed to enter Room 403 with only a surgical mask. On 9/20/23 at 9:32 AM and 10:15 AM Staff 14 (LPN IP) stated all staff were to wear PPE as directed on the sign for two hours after the AGPs stopped.

F880 Infection Control Staff #12 uses appropriate PPE when entering a room with aerosol generating procedures. Staff #13 uses appropriate PPE when entering a room with aerosol generating procedures. Current staff who enter resident rooms with aerosol generating procedures are at risk. DON/Designee will complete baseline of all residents with AGP to verify staff are compliant with required PPE when entering/exiting the room. DON/Designee will provide further education to all staff regarding infection control practices with specific focus on following AGP (Aerosol Generating Procedure) precaution protocols to include required PPE. DON/Designee will complete 10 random observations of AGP rooms to verify staff follow proper protocols for required PPE when entering and exiting AGP rooms. Observations will be weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. IP responsible for compliance

Based on interview and record review it was determined the facility failed to ensure an antibiotic stewardship program was implemented for 1 of 1 facility and for 1 of 1 sampled resident (#3) reviewed for UTI. This placed residents at risk for worsening infections. Findings include: An Antibiotic Stewardship Policy last revised on 10/15/22 revealed the IP would track cultures and sensitivity reports routinely as part of the surveillance of the infection. Resident 3 was admitted to the facility in 2023 with diagnoses including heart disease. Resident 3's 9/15/23 and 9/16/23 Progress Notes revealed the resident had increased confusion, the physician was notified and a urine sample was obtained to rule out a UTI. The resident was started on Levofloxacin (antibiotic) per physician orders. The 9/15/23 final urine culture was received at the facility via fax on 9/20/23. This was five days after the culture was verified. The culture results revealed the resident was on the appropriate antibiotic to eliminate Resident 3's infection. On 9/20/23 at 2:07 PM with Staff 2 (DNS) and Staff 14 (LPN IP), Staff 14 stated the nurses who worked with the residents watched for the culture results when they were ordered for residents. Staff 14 stated she did not have a system in place to track and monitor the current residents to ensure the urine cultures came back in a timely manner. Staff 14 acknowledged the culture for Resident 3 was resulted on 9/15/23 and the facility did not receive the culture results until staff requested the results for this surveyor.

F881 Antibiotic Stewardship Program Resident #3 Antibiotic Stewardship is being followed and cultures have been reviewed. Current residents who are taking antibiotics are at risk. DON/Designee will complete baseline of all residents who are taking antibiotics to verify the Antibiotic Stewardship guidelines are being followed and culture reports are received/reviewed timely. DON/Designee will provide further education to Licensed Nurses 10/25/2023 regarding infection control practices with specific focus on following antibiotic stewardship program practices for tracking and trending infectious organisms. DON/Designee will audit residents with antibiotic orders to verify any culture report have been received/reviewed and Antibiotic Stewardship guidelines are being followed. Audits will be weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. IP responsible for compliance

Based on interview and record review it was determined the facility failed to ensure residents received vaccines, education, and risk and benefits for 5 of 5 sampled residents (#s 2, 7, 11, 15, and 16) reviewed for immunizations. This placed residents at risk for infections and lack of information. Findings include: 1. Resident 2 was admitted to the facility in 2010 with diagnoses including paralysis. Resident 2's record revealed the resident received a pneumonia vaccine but the consent with risk and benefits was not located in the resident's record. The record also did not indicate which pneumonia vaccine the resident received. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated Resident 2 received the PPSV23 vaccine, acknowledged Resident 2's pneumonia series was not complete and the record did not include the consent with risk and benefits. 2. Resident 7 was admitted to the facility in 2018 with diagnoses including heart failure. Resident 7's record revealed the resident received the PPSV23 vaccine but the consent with risk and benefits was not in the resident's record. The resident was eligible for an additional pneumonia vaccine but the record did not indicate it was offered. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she did not locate the resident's previous vaccine consent form and documentation to indicate additional vaccines were offered. 3. Resident 11 was admitted to the facility in 2020 with diagnoses including kidney failure. Resident 11's record revealed the resident received PPSV23 vaccine in 2021 by facility staff but the consent with risk and benefits was not in the record. The resident was eligible for another pneumonia vaccine but there was no documentation it was offered. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she did not find the resident's consent for the previous vaccine and no additional pneumonia vaccines were documented as offered. 4. Resident 15 was admitted to the facility in 2022 with diagnoses including kidney disease. Resident 15's record revealed she/he refused the PPSV23 and PCV20 vaccine on two occasions. Dates of the refusals were not documented and there was no documentation education was provided on the risks and benefits for the refusals. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she did not have documentation related to the residents refusals and if the resident was provided risk and benefits for the vaccine refusals. 5. Resident 16 was admitted to the facility in 2022 with diagnoses including a stroke. Resident 16's record revealed she/he refused the flu and PCV20 vaccines in 2022. There was no education found in the resident's record including the risks and benefits of the vaccines. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she did not locate documentation related to the risk and benefits of vaccine refusals.

F883 Influenza and pneumococcal immunizations Resident #2 Pneumonia vaccines are up to date and has consent with risks and benefits in the medical record. Resident #7 Has been offered the next in series Pneumonia vaccine and has consent with risks and benefits in the medical record. Resident #11 Has been offered the next in series Pneumonia vaccine and has consent with risks and benefits in the medical record. Resident #15 Education on risks and benefits has been provided related to declination of Pneumonia vaccine with a documented response in the medical record. Resident #16 Education on risks and benefits has been provided related to declination of Pneumonia vaccine and flu vaccine with a documented response in the medical record. Current residents that are eligible for Flu and Pneumonia vaccines are at risk. DON/Designee will complete baseline of current residents eligible for the pneumonia vaccination and flu shot to verify education was provided and consent/declination with risks and benefits is in the medical record. DON/Designee will provide further education to Licensed Nurses 10/25/2023 regarding completion of the consent form for flu and pneumonia vaccines and education with risks and benefits is provided to the resident or responsible party and documented in the medical record. DON/Designee will audit 10 resident vaccination records to verify flu and pneumonia vaccines have been offered with education on risks and benefits and consent is present in the medical record. Observations will be weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. IP responsible for compliance.

Based on interview and record review it was determined the facility failed to ensure residents received risk and benefits of the COVID-19 vaccine for 3 of 5 sampled residents (#s 7, 15, and 16) reviewed for immunizations. This placed residents at risk for uninformed decisions. Findings include: 1. Resident 7 was admitted to the facility in 2018 with diagnoses including heart failure. Resident 7's record revealed the resident received the COVID-19 vaccines and boosters in 2021 and 2022. The record did not include education was provided to the resident including the risks and benefits. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she was not able to find documentation to indicate staff provided education to Resident 7 prior to the vaccines. 2. Resident 15 was admitted to the facility in 2022 with diagnoses including kidney disease. Resident 15's record revealed she/he refused the COVID-19 vaccines and boosters, dates were not listed. The record did not include education was provided to the resident including the risks and benefits. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she was not able to find documentation to indicate staff provided education to Resident 15 prior to the vaccine refusals. 3. Resident 16 was admitted to the facility in 2022 with diagnoses including a stroke. Resident 16's record revealed the resident refused the COVID-19 vaccines, and dates were not listed. The record did not include education was provided to the resident including the risks and benefits. On 9/20/23 at 4:00 PM and 9/21/23 at 12:33 PM Staff 2 (DNS) stated she was not able to find documentation to indicate staff provided education to Resident 16 prior to the vaccine refusals.

F887 Covid-19 Immunizations Resident #7 has been provided education related to the risks and benefits of the Covid-19 vaccine. Resident #15 has been provided education related to the risks and benefits of the Covid-19 vaccine. Resident #16 has been provided education related to the risks and benefits of the Covid-19 vaccine. Current residents who are eligible for the COVID-19 Vaccines are at risk. DON/Designee will complete baseline audit of current resident to verify education has been provided related to the risks and benefits of the Covid-19 vaccine. DON/Designee will provide further education to Licensed Nurses 10/25/2023 regarding completion of the consent form and education related to the risks and benefits of the vaccine are provided to the resident and documented in the medical record. DON/Designee will audit 10 resident vaccination records to verify education has been provided and documented in the medical record related to the risks and benefits of the Covid-19 vaccine Observations will be weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations. IP responsible for compliance

Based on interview and record review it was determined the facility failed to complete reference checks for 4 of 5 facility staff (#s 16, 17, 19, and 20) reviewed for hiring practices. This placed residents at risk for unqualified staff. Findings include: A random sample of five newly hired staff members was reviewed for hiring practices. The review identified no evidence Staff 16 (LPN), Staff 17 (Business office Manager), Staff 19 (NA), and Staff 20 (Dietary Aide) had reference checks conducted prior to employment at the facility. On 9/21/23 at 10:16 AM Staff 1 (Chief Executive Officer) stated she could not locate evidence reference checks for four of the five staff were conducted.

M141 Employee Reference Checks and Verifications Staff #16 have reference checks completed Staff #17 have reference checks completed Staff #19 have reference checks completed Staff #20 have reference checks completed. New employees are at risk. NHA/Designee completed a baseline audit all new hires since 4/1/23 to verify reference checks have been completed. NHA has hired a new HR manager and provided education 10/10/2023 regarding completing reference checks prior to extending an offer of employment. NHA/Designee will audit perspective employees to verify reference checks have been completed prior to an offer of employment. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations HR resonsible for compliance

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained on 6 of 96 shifts reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the Direct Care Staff Daily Reports from 8/19/23 through 9/19/23 revealed the facility did not have sufficient CNA staff to meet the minimum CNA to resident staffing ratios for 6 of 96 shifts on the following days: 8/19/23, evening shift, 8/20/23 night shift, 8/27/23 day shift, 9/1/23 night shift, 9/8/23 night shift, and 9/15/23 night shift. On 9/21/23 at 10:42 AM Staff 1 (Chief Executive Officer) and Staff 2 (DON) stated sometimes CNAs call off and staff who were on call to cover were not available.

M183 Minimum CNA Staffing Facility has contracted with staffing agencies to aid in providing CNA staffing. Facility is actively recruiting CNA staff. Current residents are at risk. NHA/Designee completed a baseline audit of last 14 days to verify required CNA hours were scheduled. NHA Educated DON and IDT 9/22/2023 related to CNA staffing requirement to meet regulation. DON/Designee will audit daily staffing sheets to verify CNA coverage is scheduled. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations DON responsible for compliance

Based on interview and record review it was determined the facility failed to have a full time administrator for 1 of 1 facility. This placed residents at risk for lack of administration. Findings include: An e-mail exchange dated 9/11/22 through 9/22/23 between the corporate paralegal to the state agency licensing unit revealed the former facility administrator left 8/22/23. On 9/11/23 the facility indicated they were requesting a provisional administrator license for the current DNS. However it was later determined the current DNS did not have the credentials to be an administrator. An administrator was to start in the facility on 9/22/23. On 9/22/23 at 11:36 AM Staff 1 (Chief Executive Officer) stated the former administrator left without notice on 8/22/23. Staff 1 stated she started to work at the facility on 9/5/23 but was not a licensed administrator. She was scheduled to take the examination 9/22/23 but the examination was rescheduled. Staff 1 stated the corporate administrator would be in the facility on 9/25/23 and the facility did not have an administrator in the building for 30 days.

M490 Administrator Provisional Administrator of Record has been established There is currently a Licensed Nursing Home Administrator in place. Provisional Administrator to educate incoming NHA r/t administrator of record requirements. NHA to audit license is active and in place for 4 weeks then monthly for 2 months Audit trends reported to facility QAPI X3 month for review and further recommendations. NHA to ensure compliance

*************************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F550, F561, F583 and F585 **************************************** OAR 411-086-0040 Admission of Residents Refer to F578 **************************************** OAR 411-088-0020 Basis for Involuntary Transfer Refer to F622 **************************************** OAR 411-088-0080 Notice Requirements Refer to F623 **************************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F637, F656 and F657 **************************************** OAR 411-086-0230 Activity Services Refer to F679 **************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F692, F758, F883 and F887 *************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F727 *************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F756 *************************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 and F881 ***************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/05/2023 and 06/11/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to have a system in place to evaluate a resident's ability to execute an advance directive or offer, assist, obtain and periodically review advance directives for 4 of 4 sampled residents (#s 12, 18, 21 and 22) reviewed for advance directives. This placed residents at risk for not having their health care wishes honored. Findings include: 1. Resident 12 was admitted to the facility in 2022 with diagnoses including stroke. A review of the resident's medical record revealed Resident 12 was her/his own decision maker and no information could be found related to advance directives. Reviews of residents' medical records revealed a pattern of the facility using the POLST as an advance directive as evidenced by: When copies of resident advance directives were requested from medical records, the facility provided copies of POLST forms. On resident Face Sheets under the heading of Advance Directives: POLST information was listed. On resident MAR/TARs under Advance Directives: POLST information was listed. A Care Conference Note dated 5/26/22 indicated Resident 12's POLST (physician's order for life sustaining treatment) was verified. On 7/27/22 at 12:10 PM Staff 4 (Social Services) stated she asked about a POLST and advance directives at admission. Staff 4 added she confirmed the resident did not change their mind regarding their POLST. On 7/27/22 at 12:17 PM Staff 5 (Health Information Manager) stated residents were asked about advance directives at each care conference. Staff 5 agreed only the POLST was reviewed at Resident 12's care conference. 2. Resident 21 was admitted to the facility with diagnoses including lung disease. A Social Services Assessment dated 7/11/22 indicated Resident 21 was her/his own decision maker. No information could be found in Resident 21's medical record related to advance directives. Reviews of residents' medical records revealed a pattern of the facility using the POLST (Physician Order for Life Sustaining Treatment) as an advance directive as evidenced by: When copies of resident advance directives were requested from medical records, the facility provided copies of POLST forms. On resident Face Sheets under the heading of Advance Directives: POLST information was listed. On resident MAR/TARs under Advance Directives: POLST information was listed. A Care Conference Note dated 7/26/22 included information related to Resident 21's POLST (physician's order for life sustaining treatment) and code status. On 7/27/22 at 12:10 PM Staff 4 (Social Services) stated she asked about a POLST and advance directives at admission. Staff 4 added she confirmed the resident did not change their mind regarding their POLST. On 7/27/22 at 12:17 PM Staff 5 (Health Information Manager) stated residents were asked about advance directives at each care conference. Staff 5 agreed only the POLST was reviewed at Resident 21's care conference. 3. Resident 22 was admitted to the facility in 2002 with diagnoses including a mental disorder. An Advance Care Planning note dated 3/15/19 documented the family member was healthcare power of attorney for Resident 22 and a copy was requested. The note further indicated a POLST (physician's order for life sustaining treatment) was discussed with Resident 22 and her/his family and they did not want to fill anything else out at this time. A review of the resident's medical record did not contain evidence of a POA, revealed Resident 22 was her/his own decision maker and no additional information could be found related to advance directives. Reviews of residents' medical records revealed a pattern of the facility using the POLST (Physician Order for Life Sustaining Treatment) as an advance directive as evidenced by: When copies of resident advance directives were requested from medical records, the facility provided copies of POLST forms. On resident Face Sheets under the heading of Advance Directives: POLST information was listed. On resident MAR/TARs under Advance Directives: POLST information was listed. A Care Conference Note dated 7/7/22 indicated neither family or the resident were present. The note further indicated Resident 22's POLST was confirmed. The note did not indicate who confirmed the POLST. On 7/27/22 at 12:10 PM Staff 4 (Social Services) stated she asked about a POLST and advance directives at admission. Staff 4 added she confirmed the resident did not change their mind regarding their POLST. On 7/27/22 at 12:17 PM Staff 5 (Health Information Manager) stated residents were asked about advance directives at each care conference. Staff 5 agreed only the POLST was reviewed at Resident 22's care conference. , 4. Resident 18 was admitted to the facility in 2022 with diagnoses including respiratory failure and kidney failure. Resident 18 was on Hospice. On 7/28/22 at 9:10 AM Resident 18's medical record was reviewed and no advance directive information was found. Resident 18 had a Durable Power of Attorney for finances on file but not for medical decision making. A reviews of residents' medical records revealed a pattern of the facility using the POLST (Physician Order for Life Sustaining Treatment) form as an advance directive as evidenced by: When copies of resident advance directives were requested, the facility provided copies of POLST forms. On resident Face Sheets under the heading of Advance Directives: POLST information was listed. On resident MAR/TARs under Advance Directives: POLST information was listed. On 7/27/22 at 12:10 PM Staff 4 (Social Services) stated she asked about a POLST and advance directive at admission. She asked if they had one or if they wanted the information. If there were questions they were to let her know. No documentation was found in Resident 18's medical record or social services notes to verify the facility offered, assisted, obtained or periodically reviewed advance directives.

Preparation and execution of this response and plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and / or executed solely because it is required by the provisions of federal and state law. For the purposes of any allegation that the center is not in substantial compliance with federal requirements of participation, this response and plan of correction constitutes the center’s allegation of compliance in accordance with section 7305 of the State Operations Manual. 1. Social Services Coordinator met with resident #12 and #21 and their respective responsible parties to discuss their advance directive wishes which were then documented in the residents’ Advance Directive progress notes. Resident #18 is deceased. The resident’s medical provider will be notified if any order changes are indicated to honor resident’s wishes. Resident #22 is not able to make informed decisions about her healthcare due to a severe psychological impairment and has no designated Durable Power of Attorney for Healthcare. 2. All residents have the potential to be affected by this deficient practice. All current resident’s medical records were reviewed for documentation of current advance directive wishes separate from and in addition to documentation of the POLST. 3. The Social Services Coordinator will be re-educated on GSS Advanced Care Planning Policy and Procedure and Advanced Directive Policy and Procedure by GSS Regional Clinical Services Director by 9/20/2022. Advance Directives will be discussed with residents and documented upon admission, re-admission, during quarterly care conferences, and with significant changes of condition. 4. The Administrator or designee will audit 100% of current residents’ medical records for advance directives and/or care conference notes for the inclusion of advance directive discussions with resident and or responsible party by 9/20/2022. Audits will be completed 1 X / week for 4 weeks, then 1 X / month X 2 months, then 1 X / quarter for 3 quarters. Any deficient practice identified will be immediately addressed. All audit results will be submitted to QAPI Committee for review and recommendations. 5. Compliance Date: September 20, 2022

Based on interview and record review it was determined the facility failed to have a system in place to notify the physician of resident weight loss for 1 of 1 sampled resident (#128) reviewed for weight loss. This placed residents at risk for not having their providers informed. Findings include: Resident 128 was admitted to the facility in 2022 with diagnoses including hip fracture and nutritional deficiency (not ingesting enough nutrients with food). A review of the residents weights from admission date 7/6/22 through 7/25/22 revealed a weight loss of eight percent. Nutrition parameters indicate a greater than five percent weight loss in one month (or less) is identified as a severe weight loss. A review of the resident's medical record found no documentation the physician was notified of the resident's weight loss. On 7/29/22 at 11:44 AM Staff 2 (DNS) stated they had no process in place to notify the physician of weight loss in residents.

1. On July 27, 2022 resident #128 was referred to consulting dietitian and her medical provider was notified regarding the significant weight loss on 08/04/2022. 2. All residents with weight loss have the potential to be affected by this deficient practice. All current resident’s medical records will be reviewed for significant weight loss. 3. The facility implemented a new practice that only Director of Food & Nutrition and/or the consulting dietitian will clear the nutrition-related clinical alerts in PCC (electronic medical record system). In addition Director of Food & Nutrition or designee will notify consultant dietitian of new admissions and re-admissions to ensure dietitian assessments are completed in a timely fashion. As of 8/2/2022 the facility’s clinical interdisciplinary team meets weekly to review all residents who are at risk of or have had significant weight loss. The consulting dietitian and medical provider will be notified as indicated using GSS fax form “Notification to Physician for Malnutrition” or by other appropriate means of sharing information. 4. The facility’s HIM will audit to verify that the weekly clinical IDT meeting is being held, will review PCC weight report verifying that any significant weight loss is addressed with consulting dietitian, and that the medical provider is notified if applicable. HIM will also audit to verify timely completion of dietitian assessments. Audits will be completed 1 X / month for 3 months, then 1 X / quarter for 3 quarters. Any deficient practice identified will be immediately addressed. All audit results will be submitted to QAPI Committee for review and recommendations. 5. Compliance Date: September 20, 2022

Based on interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 5 sampled residents (#19) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 19 was admitted to the facility in 2022 with diagnoses including GERD (reflux disease), hypertension and nutritional deficiency. The 7/2022 MAR indicated Resident 19 received pantoprazole for reflux disease, amlodipine and lopressor for hypertension and Remeron (antidepressant) for insomnia. A review of the comprehensive care plan did not include information related to pertinent conditions for which Resident 19 was being treated including GERD, hypertension and refusal of medications. The care plan further identified the use of Remeron as an appetite stimulant for poor intake. On 7/28/22 at 11:01 AM Staff 3 (RNCM) was asked about the care planning process and stated she did not care plan for GERD and hypertension. Staff 3 further stated she did not consider GERD as a potential factor impacting Resident 19's appetite. Staff 3 was asked about the use of Remeron and stated it was used to stimulate Resident 19's appetite but the resident often missed doses due to spitting out the medication. Staff 3 acknowledged Resident 19's behaviors were not included in her/his care plan. On 7/28/22 at 1:10 PM Care planning was discussed with Staff 2 (DNS) who stated she expected residents to be care planned for all pertinent conditions, medications and behaviors that impacted the resident's care.

1. On 07/28/2022 Resident #19’s care plan was updated to include GERD, hypertension, and refusal of medications. 2. All residents have the potential to be affected by this deficient practice. All current resident’s care plans will be reviewed and updated if indicated to include all pertinent diagnoses being treated and or monitored, along with resident’s preferences and behaviors if applicable. 3. The clinical interdisciplinary team will be re-educated on GSS Comprehensive Care Planning and Care Conference policy and procedure by GSS Regional Clinical Services Director by 9/20/2022. 4. DNS or designee will audit ¼ of current residents’ care plans to verify they include all pertinent conditions, medications, and behaviors that impact resident care. Audits will be completed 1 X / week for 4 weeks, then 1 X / month for 2 months, then 1 X / quarter for 3 quarters. Any deficient practice identified will be immediately addressed. All audit results will be submitted to QAPI Committee for review and recommendations. 5. Compliance Date: September 20, 2022

Based on interview and record review it was determined the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 1 sampled resident (#128) reviewed for nutrition. This failure resulted in Resident 128 having a severe weight loss of 8 percent in 20 days. Findings include: Resident 128 was admitted to the facility on 7/6/22 with diagnoses including hip fracture and nutritional deficiency (not ingesting enough nutrients with food). A review of the residents weights from Admission date 7/6/22 through 7/25/22 revealed Resident 128 had a weight loss of eight percent. Nutrition parameters indicate a greater than five percent weight loss in one month (or less) was designated as a severe weight loss. Resident 128's Weight Summary Report printed on 7/29/22 included the following weight loss alert indicators in red ink adjacent to the resident's weights: On 7/7/22 at 10:16 AM a weight loss alert was triggered to indicate a change from last weight of -3.6%. The alert was cleared by an LPN. On 7/9/22 at 9:52 AM a weight loss alert was triggered to indicate a change of weight of -6%. The alert was cleared by an LPN. On 7/11/22 at 10:15 AM a weight loss alert was triggered to indicate a change of -7.1%. The alert was cleared by an RN. On 7/18/22 at 9:17 AM a weight loss alert was triggered to indicate a change of -7.5%. The alert was cleared by an LPN. On 7/25/22 at 9:00 AM two weight loss alerts were triggered to indicate a change of -7.9%. The alerts were cleared by an LPN. There was no documentation found to indicate any steps were taken by nursing staff to address the severe weight loss alerts in the report. Resident 128's 5-day/Admission MDS dated 7/12/22 contained a Nutritional Status CAA which indicated the resident weighed 97 pounds and did not have a loss of five percent or more in the last month. Review of the MDS revealed the facility did not use the resident's weight on admission of 104.2 pounds. Using the resident's actual admission weight of 104.2 pounds would indicate the resident had a seven percent weight loss on 7/12/22. On 7/26/22 at 2:50 PM a review of Resident 128's medical record revealed there was no initial Dietician Assessment found in the record. The Dietician Assessment was due within 14 days of the resident's admission. There were also no NAR (Nutrition at Risk) notes or Nutritional Status Notes located in the record as of 7/26/22. No documentation was found in the medical record to indicate the resident's initial weight of 104.2 lbs was not accurate. An Initial Nutritional Status Dietitian Assessment was located in progress notes on 7/27/22 and included the following: Effective Date: 7/18/2022 10:36 AM Department: Dietary Created By: Registered Dietician Created Date : 7/27/2022 1:22 PM The Created Date was 7/27/22 or 21 days after Resident 128's admission. Dietician Assessments were due on or before 14 days. The assessment included the resident's admission weight of 104 pounds and current weight of 96 pounds. The resident's caloric intake, protein intake and fluid intake were inadequate. A review of the resident's medical record found no documentation to indicate the physician was notified of Resident 128's weight loss. On 7/29/22 at 10:10 AM Staff 7 (RD) indicated she did not provide onsite visits for the residents at the facility. She attended the facility's NAR meeting virtually when it was held once a month. She acknowledged the initial assessment was done on 7/27/22 and not within the 14 day requirement. She agreed the resident had an eight percent weight loss and understood it was considered a severe weight loss per regulation. Staff 7 also indicated the Resident 128 received fortified meals and an afternoon health shake as interventions but continued to lose weight.

1. On July 27, 2022, resident #128 was referred to consulting dietitian and her medical provider was notified regarding the significant weight loss on 08/04/2022. On 8/29/2022 resident #128’s 5-day/admission MDS from 7/12/2022 was modified to reflect a weight loss of 5% or more in that month. 2. All residents with weight loss have the potential to be affected by this deficient practice. All current resident’s medical records will be reviewed for significant weight loss. 3. The facility implemented a new practice that only Director of Food & Nutrition and/or the consulting dietitian will clear the nutrition-related clinical alerts in PCC (electronic medical record system). In addition Director of Food & Nutrition or designee will notify consultant dietitian of new admissions and re-admissions to ensure dietitian assessments are completed in a timely fashion. As of 8/2/2022 the facility’s clinical interdisciplinary team meets weekly to review all residents who are at risk of or have had significant weight loss. The consulting dietitian and medical provider will be notified as indicated using GSS fax form “Notification to Physician for Malnutrition” or by other appropriate means of sharing information. 4. The facility’s HIM will audit to verify that the weekly clinical IDT meeting is being held, will review PCC weight report verifying that any significant weight loss is addressed with consulting dietitian, and that the medical provider is notified if applicable. HIM will also audit to verify timely completion of routine assessments and to verify the accuracy of the MDS related to weight loss. Audits will be completed 1 X / month for 3 months, then 1 X / quarter for 3 quarters. Any deficient practice identified will be immediately addressed. All audit results will be submitted to QAPI Committee for review and recommendations. 5. Compliance Date: September 20, 2022

Based on interview and record review it was determined the facility failed to ensure antibiotic medications had adequate indications for use for 1 of 5 sampled residents (#79) reviewed for medications. This placed residents at risk for receiving unnecessary medications. Findings include: Resident 79 was admitted to the facility in 2022 with diagnoses including broken ribs. A hospital discharge summary dated 7/13/22 indicated Resident 79 received two intravenous (IV) antibiotics. There was no indication why the resident received the antibiotics. The 7/2022 MAR indicated Resident 79 received Augmentin and Doxycycline (antibiotics) ordered at the time of admission. No diagnoses were included on the MAR. On 7/28/22 at 11:24 AM Staff 3 (RNCM) stated when a resident came to the facility with antibiotic orders, the facility was not likely to stop them. Staff 3 further added she could not find an indication for the the use of the antibiotics. On 7/29/22 at 7:27 AM Staff 1 (Administrator) stated the facility could not find an indication for the use of the antibiotics.

1. Resident # 79 is no longer receiving antibiotics. 2. All residents have the potential to be affected by this deficient practice. All current residents’ medication orders were reviewed for antibiotics to verify a diagnosis or indication for use was included in the order on 8/26/2022. Order clarification was not indicated upon completion of the audit. 3. The facility implemented a system whereby all new orders for antibiotics are reviewed for diagnosis / indication for use as the orders are entered into the resident’s health record by HIM or designee. Clarification will be requested from the resident’s medical provider if indicated. All licensed nurses will be re-educated by DNS or designee on antibiotic stewardship by 9/20/2022 or prior to their next scheduled shift. 4. DNS or designee will audit 100% of current residents for antibiotic orders, verify diagnoses, indication for use and or other supporting documentation. Audits will be completed 1 X / week for 4 weeks, then 1 X / month for 2 months, then 1 X / quarter for 3 quarters. Any deficient practice identified will be immediately addressed. All audit results will be submitted to QAPI Committee for review and recommendations. 5. Compliance Date: September 20, 2022

Based on observation and interview it was determined the facility failed to handle PPE and perform aerosol generating procedures (AGPs) based on infection control standards for COVID-19 for 1 of 1 facility reviewed for infection control. This placed residents at risk for contracting COVID-19. Findings include: 1. According to CDC guidance: eye protection should be disinfected, stored in labeled plastic containers or bags, not removed from the facility and if plastic bags were used, they should be stored in separate labeled bins or cubbies. Face masks should be discarded at the end of a shift or if reused stored in paper bags. No other items should be stored in the storage bins or cubbies. On 7/27/22 at 9:22 two AM staff members entered the facility with their goggles on top of their heads. On 7/27/22 at 2:05 PM several PPE storage cubbies were observed. One contained a labeled plastic bag with a face mask. Another cubby contained an unlabeled plastic bag with a face mask. Another unlabeled cubby contained an empty plastic bag and an un-bagged face shield. Two labeled cubbies contained un-bagged masks and two additional labeled cubbies contained un-bagged goggles. On 7/29/22 at 10:34 AM the PPE storage area was observed with Staff 2 (DNS). Staff 2 stated the facility had enough masks and staff should not save used masks. Staff 2 further indicated eye protection should be stored inside labeled plastic bags and nothing else should be in the storage cubbies. 2. According to CDC guidance: Staff were to fully remove PPE during breaks and may place their PPE on a paper towel on a table within eye sight. A separate disinfection station should be available in the breakroom. On 7/29/22 at 9:48 AM a staff member was observed seated at a table in the breakroom. The table contained an opened box of donuts and disinfection supplies. The staff member had her face mask pulled under her chin and her goggles on top of her head while she consumed a donut. On 7/29/22 at 10:34 AM Staff 2 (DNS) was asked to observe the breakroom. Staff 2 admitted the PPE storage was not sufficient, there where no bags available if staff wanted to store their eye protection during breaks and there should not be any communal food. Staff 2 agreed there should be a separate disinfection area in the break room. 3. According to CDC guidance: Aerosol Generating Procedures (AGPs) have been associated with an increased risk for transmission in healthcare settings. Facilitate private rooms for all residents utilizing AGPs as able. a. During an AGP implement the following procedure. i. Only one staff member present during the procedure. ii. Door closed during the procedure and for two hours afterwards unless the facility's air exchange rate is known. iii. Staff who enter the room during and for up to two hours after the treatment should wear full PPE including an N95. iv. Staff should remove PPE prior to leaving the resident's room, discard the N95 mask and replace with an acceptable face mask and disinfect their eye protection. v. Disinfection of surfaces should be implemented for the resident's room after completion of the treatment. Resident 22 had orders for nebulizer (AGP) treatments twice a day. Observations of Resident 22's room revealed no AGP signs related to needed PPE and no PPE or disinfection supplies were available near the resident's room. On 7/29/22 at 10:34 AM Staff 2 (DNS) was asked about AGPs. Staff 2 stated they were not following the recommendations and the facility needed to work on protocols.

1. On 7/29/2022, PPE storage areas were cleared of all items that were not properly stored, eyewear was bagged and storage instruction signage was posted. All employees will be re-educated on the appropriate storage of PPE while not in use, including during meal periods in the breakroom and upon exiting the facility. The facility developed a protocol for AGP on 8/26/2022. 2. RCA was completed on 08/25/2022 by the Administrator, clinical leadership, GSS Quality Advisor, GSS Regional Clinical Services Director, GSS Accreditation Specialist and GSS Lead Infection Preventionist. 3. All residents have the potential to be affected by this deficient practice. 4. All new hires will be trained on proper PPE use and storage, including facility-specific PPE storage areas and practices, as part of their general orientation. Signage will be developed to instruct staff on the appropriate procedure for removing and/or storing PPE during work breaks. Facility will provide PPE station in breakroom which will include disinfectant and fresh PPE. All staff will be re-educated by DNS or designee on proper PPE storage and the new facility practices. All licensed nurses will be educated on the AGP protocol by 9/20/2022 or before their next scheduled shift following that date. Designated staff will routinely monitor and re-stock PPE stations. Facility leadership will observe for proper PPE use during rounding and any deficient practice identified will be immediately addressed. 5. The facility Administrator or designee will audit new employee orientation to verify PPE use and storage training is provided. Audits will be conducted 1X / month for 3 months, then 1 X / quarter for 3 quarters. Administrator or designee will conduct observation audits of breakroom for presence of PPE storage signage, inspection of storage cubbies, and PPE stations for presence of disinfectant and fresh PPE. Audits will be conducted 1 X/ week for 4 weeks, 1 X / month for 2 months, then 1 X /quarter for 3 quarters. DNS or designee will conduct observation audits of residents receiving AGP for door closure and signage both during and 2 hours post-treatment, and use of proper PPE by staff who enter the room during this period of time. Audits will be conducted 1 x / week for 4 weeks, then 1 X / month for 2 months, then 1 X / quarter for 3 quarters. Any deficient practice identified will be immediately addressed. Audit findings will be submitted to QAPI Committee for review and recommendations. 6. Compliance Date: September 20, 2022

Based on interview and record review it was determined the facility failed to provide on-site Registered Dietician visits for 1 of 1 facility reviewed for nutrition services. This placed residents at risk for unmet nutritional needs. Findings include: On 7/27/22 at 12:28 PM Staff 1 (Administrator) stated the facility had no on-site visits by the Registered Dietician. On 7/29/22 at 10:10 AM Staff 7 (RD) indicated she did not provide on-site visits at the facility.

1. The consulting dietitian has agreed to conduct on-site visits monthly with her first visit conducted on 08/29/2022. 2. All residents have the potential to be affected by this deficient practice. 3. The facility has made arrangements for the consulting registered dietitian to visit the facility monthly on an on-going basis. The consultant dietitian will be re-educated on GSS Responsibilities of Dietitian policy and procedures by facility’s Administrator on 08/29/2022. 4. Administrator or designee will audit consulting registered dietitian visits with consultant report of visit 1 X / month for 6 months then 1 X / quarter for 2 quarters. Any deficient practice identified will be addressed immediately. All audit results will be submitted to QAPI Committee for review and recommendations. 5. Compliance Date: September 20, 2022

***************************************** OAR 411-086-0040 Admission of Residents (Advanced Directive Refer to F 578 ***************************************** OAR 411-086-0130 Nursing Services: Notification Refer to F 580 ***************************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F 656 ***************************************** OAR 411-086-0140 Nursing Services; Problem Resolution and Preventive Care Refer to F 692 and F 757 ***************************************** OAR 411-086-0330 Infection control and Universal Precautions Refer to F 880

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/13/2022 and 06/19/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.