Curry Village Health and Rehab of Cascadia

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.

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.

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.

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.




, 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.

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.

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.

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.

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OAR 411-086-0260 Pharmaceutical Services

Refer to F554
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F677 and F759
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411-086-0140 Nursing Services: Problem Resolution and Preventive Care

Refer to 688, F758
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OAR 411-086-0250 Dietary Services

Refer to F804 and F812
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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."

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.









, 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.

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.

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.

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.



, 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.

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.

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.

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.

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.

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.

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.

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.

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.

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OAR 411-085-0310 Residents' Rights: Generally
        
        
        

Refer to F550, F561, F583 and F585
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OAR 411-086-0040 Admission of Residents

Refer to F578
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OAR 411-088-0020 Basis for Involuntary Transfer

Refer to F622
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OAR 411-088-0080 Notice Requirements

Refer to F623
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OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F637, F656 and F657
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OAR 411-086-0230 Activity Services

Refer to F679
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care

Refer to F692, F758, F883 and F887
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OAR 411-086-0100 Nursing Services: Staffing

Refer to F727
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OAR 411-086-0260 Pharmaceutical Services

Refer to F756
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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880 and F881
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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.

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.

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.

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.

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.

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.

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.

*****************************************
OAR 411-086-0040 Admission of Residents (Advanced Directive

Refer to F 578

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OAR 411-086-0130 Nursing Services: Notification

Refer to F 580

*****************************************
OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F 656

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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.

Based on interview and record review it was determined the facility failed to resolve a grievance and accommodate residents' preferences for 1 of 1 sampled resident (#14) reviewed for grievances. This placed residents at risk for unresolved grievances. Findings include:

The 11/5/20 Facility Grievances, Suggestions or Concerns Policy & Procedure included the following information:
POLICY: Grievances, suggestions and concerns are to be deemed high priority customer satisfaction issues and thus will be followed up on in the quickest time frame possible.
PROCEDURE:
- 7. The grievance official will issue a written grievance decision to the individuals filing the concern and to the administrator. The written grievance decision must include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.
- 9. If the individual is not satisfied with the response and/or resolution to the grievance or concern, the grievance official will notify the administrator.

The undated Resident's Rights For Skilled Nursing Facilities Handbook included the following:
(e) The resident has a right to be treated with dignity including:
3. The right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.
(i) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents and other concerns regarding their stay.
(1) The resident has the right to and the facility must make prompt efforts to resolve grievances the resident may have.

Resident 14 was admitted to the facility in 6/2006 with diagnoses including quadriplegia.

Resident 14's 4/21/21 Quarterly MDS Section C: Cognitive Patterns indicated Resident 14 was cognitively intact with a BIMS of 15 and Section G: Function Status indicated Resident 14 was totally dependent on staff for bathing.

On 6/7/21 at 1:10 PM Resident 14 stated she/he preferred not to have a certain CNA provide her/his showers. Resident 14 stated the CNA smelled like smoke, the smell of smoke was "overpowering" and made her/him nauseous in the shower. Resident 14 stated she/he recently reported this issue to the administrative staff. Resident 14 stated administrative staff did not provide a satisfactory resolution and was told the CNA assignment on shower days would not be rearranged.

On 6/9/21 at 10:14 AM Staff 4 (SSD) stated the facility's grievance process included a multi-disciplinary review of the issue, collaborate to find a solution, talk to the resident and file the grievance form in a binder.

Review of the facility's Grievance Binder revealed no documentation of Resident 14's grievance, the steps taken to investigate the grievance, any corrective action to be taken by the facility, the resolution or the resident's satisfaction or dissatisfaction with the resolution.

On 6/10/21 at 11:29 AM Staff 3 (RNCM) stated Resident 14 verbalized she/he preferred to not have Staff 20 (CNA) provide her/his showers because the CNA smelled like smoke. Staff 3 stated she did not alter the CNA schedule, could not always change the schedule to accommodate Resident 14 and Resident 14 had the option to refuse any and all care. Staff 3 stated at times it was unavoidable for Resident 14 to be assigned staff she/he did not prefer on shower days, it was an unrealistic expectation and Resident 14 had the option to accept or decline the shower.

On 6/10/21 at 11:53 AM Staff 2 (DNS) stated Resident 14 told her she/he did not want Staff 20 to provide her/his shower because Staff 20 smelled like smoke. Staff 2 stated it was charge nurse's discretion to alter the CNA schedule based on staffing for a particular day. Staff 2 stated they tried not to assign Staff 20 to Resident 14, could not make promises and could not accommodate Resident 14's staff request at all times.

On 6/10/21 at 6:13 PM Staff 1 (Administrator) was provided information regarding this investigation. Staff 1 stated the facility had a process for grievances and it was a priority to resolve resident issues. Staff 1 stated in this case, it was not the facility protocol to have a different CNA provide Resident 14's shower who was not assigned to Resident 14.

Based on interview and record review it was determined the facility failed to document a thorough investigation to rule out abuse for 1 of 1 sampled resident (#11) reviewed for abuse. This placed residents at risk for abuse. Finding include:

Resident 11 was admitted to the facility in 4/2021 with diagnoses including venous insufficiency.

On 5/8/2021 at 10:00 AM Resident 11 was found to have pressure sores on the bottoms of both feet.

The investigation to rule out abuse or neglect was completed on 5/10/21 but did not include all required components, specifically interviews from staff on duty.

On 6/10/21 at 2:51 PM and 5:47 PM Staff 3 (RNCM) stated interviews with two on duty CNAs were performed to rule out abuse. From these interviews, the cause of the pressure ulcers was identified not as result of abuse or neglect. When asked to review the record of the investigation interviews, Staff 3 stated she did not feel the need to document the interviews of the investigation because she ruled out abuse and neglect.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing activities program to support 2 of 3 sampled residents (#s 13 and 27) and 11 of 23 non sampled residents (#s 3, 6, 11, 12, 15, 19, 20, 22, 24, 25 and 229) who required assistance to initiate activities of interest. This placed residents at risk of social isolation and decline in psychosocial wellbeing. Findings include:

1. Resident 13 was admitted in 4/2021 with diagnoses including dementia with behavioral disturbance and hearing loss.

The 4/25/21 Admission/5-day MDS coded the resident to have a BIMS of 3 indicating a severe cognitive deficit and identified activity preferences including reading books, newspapers or magazines; listening to music and participating in favorite activities. The resident was coded to need extensive assistance with many ADLs.

A 4/29/21 Activity Interest Data Collection Tool identified the resident was provided assistance to use the telephone to speak to her family and a plan was developed to offer music via compact discs in her/his room.

The 5/1/21 Activity CAA noted the resident was at risk of social isolation due to weakness and decreased attention. The resident's ability to participate was expected to improve with 1:1 visits initiated by the activity coordinator.

The 4/30/21 Activity Care Plan and the current Kardex Care Plan noted the resident was at risk for social isolation with approaches limited to: Weekly 1:1 visits, and offer food and beverages of choice.

In random observations from 6/8/21 through 6/10/21 from 8:47 AM to 5:25 PM, the resident was in her/his room. The television was frequently on, but the resident showed no awareness or interest in it. A small stuffed monkey was frequently held by the resident with no other activities offered by staff. On 6/9/21 at 11:42 AM, the resident was observed in bed while a music activity occurred in the Activity Room. There was no evidence there was a plan to assist the resident to group activities of interest or that the resident was offered the opportunity to participate in the music activity.

Activity Monitoring documented the resident received 1:1 activity support on 5/11, 5/31, 6/8 and 6/9/21. No other documentation of activity involvement was located in the medical record.

In a 6/10/21 interview at 10:27 AM, Staff 11 (CNA) stated Resident 13 enjoyed flowers, ice cream, family visits and coloring. Staff 11 stated activity supplies were available and staff accessed them if the resident showed interest and staff had the time.

When interviewed on 6/11/21 at 9:48 AM, Staff 12 (CNA) stated the resident liked to talk about her/his family and her/his job as a hand model, loved when music was offered in the Activity Room and enjoyed looking at pictures of animals on an electronic tablet. Staff 12 stated she gathered information about the resident's interests from other people who seemed to know her/him, but was unaware of any documentation regarding this.

In a 6/10/21 interview at 1:41 PM, Staff 1 (Administrator) stated the activity coordinator went on leave 5/18/21 and Staff 1 coordinated activities since then. There were three group activities offered per week. Staff 1 did not have expectations that staff would provide person-centered activities to the residents, but believed the staff was compassionate and gave much attention to the residents.
,
2. Resident 27 admitted to the facility in 5/2021 with diagnoses including dementia.

The 5/25/21 Admission MDS revealed Resident 27 had a BIMS score of 3, indicating a severe cognitive impairment. The corresponding Cognitive Loss/Dementia CAA indicated the resident was oriented to person only. The Activity CAA did not trigger for further assessment and no other assessment of the resident's activity interests was found.

The resident's Care Plan, dated 5/20/21 indicated the resident had potential for elopement due to cognitive impairment. Interventions included, offer to take resident for a walk outdoors and provide diversionary activity. No resident preferred activities were identified.

The resident's current Kardex for Activities identified the following approaches: Offer food, beverages of choice and provide diversionary activity. No resident preferred activities were identified.

The resident's Activities Monitoring for 5/2021 and 6/2021 identified four spiritual visits and two 1:1 visits only. No other activity documentation was found.

In random observations from 6/9/21 through 6/10/21 from 8:32 AM to 3:08 PM, Resident 27 was observed to wander throughout the facility and repeatedly called out for her/his dog. Resident 27 was confused and anxious, seeking attention from staff and repeatedly asked the same questions. The resident was observed to sit alone in several of the facility's common areas and was not engaged in any activities.

In a 6/9/21 interview at 12:59 PM, Staff 11 (CNA) stated, "It's complicated. It's hard to find ways to keep her/him busy."

In a 6/10/21 interview at 1:07 PM, Staff 10 (CNA) stated, "It's been difficult to find something that holds her/his attention, [resident] requires frequent redirection." Staff 10 stated activities offered
included puzzle books, going outside and writing note cards.

On 6/10/21 at 11:27 AM, Staff 11 was observed with Resident 27 in the TV room and provided her/him with an adult coloring book for activity. The resident showed interest in the coloring book. Staff 11 stated she would return with the colored pencils. Resident 27 sat with the coloring book in front of her/him for 30 minutes with no colored pencils.

In a 6/10/21 interview at 10:24 AM, Staff 12 (CNA) stated "There are no activities going on here."

In a 6/10/21 interview at 1:41 PM, Staff 1 (Administrator) stated the activity coordinator gradually transitioned to the position from another job in the facility. On 5/18/21 the coordinator went out on a leave and no replacement was put in place. The coordinator's projected return to the facility was 8/12/21. Staff 1 was coordinating activities in her absence and the facility was offering three group activities a week. There were no expectations of staff regarding provision of activities, but Staff 1 felt the staff was compassionate and knew the residents. Staff 1 acknowledged a lack of person-centered provision of activities.

On 6/11/21 at 10:23 AM, Resident 27 was observed to wander throughout the facility. The resident was confused and anxious, repeatedly called out for her/his dog and stated, "I want to go home."

3. The May Activity Calendar for 2021 revealed the following:
- Church in the dining room at 1 PM on 5/23/21 was the only identified activity offered in the month
- Nursing Home Week was identified, but no corresponding activities were scheduled

The June Activity Calendar for 2021 which was posted in the common area of the facility revealed the following:
- Church service was offered three of the four Sundays in the month
- A music program performed by a resident was scheduled every Wednesday
- Bingo was scheduled each Friday
- no other group or individual activities were reflected on the calendar

On 6/9/21 at 11:48 AM, six residents were observed listening to music in the Activity Room. According to staff, the person playing the piano was also a resident in the facility.

In a 6/10/21 interview at 10:24 AM, Staff 12 (CNA) reported there was a music activity the day before but activities was not regularly occurring in the facility.

In a 6/10/21 interview at 1:41 PM, Staff 1 (Administrator) stated the activity coordinator gradually transitioned to the position from another job in the facility. On 5/18/21 the coordinator went out on a leave and no replacement was put in place. The coordinator's projected return to the facility was 8/12/21. Staff 1 was coordinating activities in her absence and the facility was offering three group activities a week. There were no expectations of staff regarding provision of activities, but Staff 1 felt the staff was compassionate and knew the residents. Staff 1 acknowledged a lack of person-centered provision of activities. Staff 1 was asked to provide a list of residents who required assistance to initiate activities of interest. It was determined Residents 3, 6, 11, 12, 15, 19, 20, 22, 24, 25 and 229 required assistance to initiate activities of interest and were impacted by the lack of activities offered by the facility.

Based on observation and interview it was determined the facility failed to ensure food was served at palatable temperatures for 1 of 1 kitchen and 1 of 1 sampled resident (#8) reviewed for food. This placed residents at risk for food lacking in palatability. Findings include:

Resident 8 was admitted to the facility in 10/2020 with diagnoses including Type 2 Diabetes Mellitus (a chronic disease affecting the pancreas).

Resident 8's 4/21/21 Quarterly MDS Section C: Cognitive Function indicated Resident 8 was cognitively intact with a BIMS of 15.

On 6/7/21 at 9:38 AM Resident 8 stated her/his food was never hot.

Observations were conducted from 6/7/21 through 6/10/21 between the hours of 8:33 AM and 6:45 PM. During these observations, meal service was conducted and staff served breakfast, lunch and dinner to the 24-26 residents who resided in the facility during survey. Until served, the meal trays were held on a non-enclosed metal rack at the end of each hall. The delivery of each meal service took up to 45 minutes to complete.

Interviews on 6/7/21 at 1:00 PM and 6/9/21 at 10:38 AM and 6:06 PM with Resident 8 revealed her/his meals were not hot and she/he stated the temperature was not appetizing.

On 6/9/21 at 1:17 PM Staff 12 (CNA) stated it was common for residents to complain of cold food.

On 6/9/21 at 5:42 PM 10 dinner trays were observed leaving the kitchen and transported to the facility's hallways. One CNA was observed to serve eight trays in 24 minutes.

On 6/10/21 at 12:50 PM a lunch meal tray was obtained and consumed by four surveyors. The meal consisted of Beef Runza (a pastry enclosed with beef and covered with gravy), peas and orange wedges. All items were served on the same plate. The Beef Runza and peas, intended to be served hot, were lukewarm and determined to be an unappetizing temperature. The orange wedges, intended to be served cold, were warm and determined to be an unappetizing temperature.

On 6/10/21 at 1:22 PM and 2:17 PM Staff 5 (Dietary Manager) stated the dietary staff followed a multi-step process to ensure food was the appropriate temperature when plated. Staff 5 stated she was aware of food temperature complaints from multiple residents. Staff 5 stated the temperature of the food, once it reached the resident, was dependent on storage of the undelivered meal trays and on distribution time of the meal trays. Staff 5 stated the current meal delivery system did not work to keep food warm.

On 6/10/21 at 6:00 PM Staff 2 (DNS) stated she expected meal delivery time to finish in about 20 minutes to ensure appropriate food temperatures.

On 6/10/21 at 6:07 PM Staff 1 (Administrator) was notified of the findings of this investigation. Staff 1 stated she expected food to be served appropriately warm.

Based on interview and record review it was determined the facility failed to develop a comprehensive Facility Assessment utilizing current data which addressed the resources needed to provide resident care on a routine and emergency basis. This placed residents at risk for unmet needs. Findings include:

The Facility Assessment with a handwritten date of 12/18/2020 on the first page included the following information:
- Undated demographics and census data;
- a 7/7/2017 summary of hazards assessment which provided a general overview of risk by category;
- the 11/13/19 interior and exterior area inspection of the facility; and
- 2018 staff competencies data.

There was no evidence of a facility-wide assessment which identified the acuity or special needs of the residents, the resources needed to care for residents on a routine or emergency basis, required staff competencies and staffing levels, environmental requirements or ethnic/cultural/religious considerations. Specialized (e.g. therapy, pharmacy, etc.) and contract services utilized during normal operations and emergencies were not included in the assessment. The electronic health record system and how information was shared with other organizations was not considered. An all-hazards approach was not utilized to create a facility-based and community-based risk assessment.

In a 6/11/21 interview at 8:36 AM, Staff 2 (DNS) stated the facility had a small pool of workers to pull from in the community which was further impacted by the loss of a local CNA certification program. A plan was in place for current staff to cover shifts when needed and the facility was currently using temporary agency staffing which was unusual.

In a 6/11/21 interview at 11:49 AM, Staff 1 (Administrator) stated she was unaware of the requirement for a Facility Assessment and did not know what components were necessary to complete within the assessment.

Based on observation, interview and record review it was determined the facility failed to follow accepted standards of practice related to COVID-19 for personal protective equipment (PPE) use, signage, appropriate eye protection and storage, disinfection of reusable resident equipment and disinfection contact times (the time a product must stay wet on a surface to disinfect). This placed residents at risk for infections. Findings include:

1. According to CDC guidance: Hand hygiene should be performed prior to applying PPE. In addition to universal use of face masks and eye protection, gowns should fully cover torso and arms, wrap around the back and fasten at the neck and back. Gloves should be applied to extend over the wrist of the isolation gown. PPE should be removed before exiting a resident room, grasp the front of the gown and pull breaking the ties at neck and back and pull away from your body and either remove gloves in one motion, rolling the gown and gloves onto itself or after fully removing gown, remove gloves in a manner that avoids coming in contact with the contaminated areas of the gown and gloves. Wash hands or use alcohol hand sanitizer immediately after removing PPE.

On 6/7/21 at 1:14 PM Staff 10 (CNA) was observed to put on a gown and enter room 206 (a precautions room) without putting on gloves. A few minutes later Staff 10 exited the room, took off the gown, threw it away in a trash receptacle in the hall and walked to the resident shower room to wash her hands.

On 6/9/21 at 8:51 AM Staff 13 (LPN) was observed to put on gloves, touch and adjust her mask several times by pulling it up or down. Staff 13 then open six drawers in the cabinets on Hall two, obtained a gown and put it on leaving it untied and unsecured. she then entered room 208, disconnected a completed IV while the gown was falling forward onto the resident's bed and down her shoulders. Staff 13 exited the room, removed her gown and performed hand hygiene outside resident's room.

On 6/9/21 at 9:00 AM Staff 15 (CNA) was observed to respond to a call light in room 206 on hall two. Staff 15 placed an N95 mask over her surgical mask and applied hair and shoe coverings. Staff 15 then tied the neck ties of the gown and placed it over her head while wearing two masks and eye protection. Approximately 10 minutes later Staff 15 exited room 206 with both masks still on, removed the N95 mask while holding the surgical mask in place and proceeded to the staff lounge on Hall one to wash her hands. Staff 15 then exited the staff lounge without wearing any mask and walked back to the hand sanitizing station and obtained a new surgical mask.

There were no signs posted to indicate the correct use of PPE.

On 6/11/21 at 11:04 AM the findings related to posted instructions and proper use of PPE were discussed with Staff 3 (DNS) and she stated she was not aware of the guidance and had no additional information was provided.

2. According to CDC guidance: Transmission Based Precautions (TBP) signs should be posted outside a isolation room to describe the type of isolation precautions in place and to indicate what PPE should be used, the sequence of applying removing PPE, disposal and when to perform hand hygiene.

On 6/7/21 at 9:42 AM an observation of a dedicated isolation area (Hall two) contained two strips of green tape across the floor about midway down the hall, three small drawer cabinets containing PPE supplies and trash receptacles in the hall. Staff 10 (CNA) stated rooms 203 and 204 were in the green zone which indicated residents were no longer on isolation and could come out of their rooms. Staff 10 further indicated room 206 was an isolation room for a new admission. There were no signs posted to indicate the resident in room 206 was on special precautions or signage to indicate what PPE should be used to care for the resident. Staff 10 stated staff just knew that was the precautions hall.

On 6/10/21 at 11:45 AM Staff 10 (CNA) was asked how she would know if someone was on precautions and she stated they were on her hall (Hall two). Staff 10 added information was also shared in report. Staff 10 was then asked about signs and PPE use and stated the facility did not use signs, they were educated about PPE use and there was a picture on the wall in the staff break room.

There was no signage to indicate who was on precautions, the appropriate PPE required or how to put on and take off PPE to avoid contamination.

On 6/11/21 at 11:04 AM the findings related to informational signage for TBP and the use of PPE for residents in precautions was discussed with Staff 3 (DNS). Staff 3 stated she was not aware of the guidance for informational postings to be used for residents in TBP and no additional information.

3. According to CDC guidance: Eye protection should be a used to protect the eyes from potential contaminates. Face shields that extend from the forehead to the chin were preferred but the use of goggles was allowed. Goggles should touch areas of the face around the eyes and not vented on the top or sides. Eye protection should be disinfected when visibly soiled or at the end of the shift using an appropriate disinfectant and contact time. Eye protection should not be removed from the facility, should be labeled with the staff's name and stored in labeled clear plastic bag.

On 6/7/21 at 8:00 AM Staff 2 (DNS) was observed outside the facility wearing eye protection.

On 6/7/21 at 10:25 AM the eye protection storage area was observed at the front of the facility. The area had a string line on the wall with several paper bags labeled with staff names clipped to the line. A face shield was clipped to the line, unlabeled and not in a plastic bag. There was no place to disinfect the eye protection prior to storage.

On 6/10/21 at 11:37 AM Staff 19 (Medical Records) was observed to be wearing small oval lens glasses with vented flares attached to the stems. Staff 19 was asked about the care and stated she sanitized them daily and stored them in a paper bag next to her computer.

ON 6/10/21 at 11:45 AM Staff 10 (CNA) stated she could use bleach to clean her eye protection but felt like it scratched them and added she used alcohol. Staff 10 said they were stored up front in the paper bags after they were cleaned at the end of her shift. Staff 10 stated she had no idea what the contact time was for alcohol.

On 6/10/21 at 1:15 PM Staff 3 (RNCM) was observed to be wearing appropriate eye protection. Staff 3 indicated the facility used alcohol wipes to clean phones and other items but stated she knew the contact time depended on the product being used. When asked about disinfection of her eye protection, Staff 3 stated she washed them with soap and water in the bathroom. She then added she stored them in a open area in her car next to the radio. Staff 3 was then observed to pull out a large plastic bag which contained two different face shields and an N95 mask.

On 6/11/21 at 10:24 AM Staff 16 (Maintenance & Environmental Services) was asked about the disinfection and storage of eye protection and stated he used electronic screen cleaning wipes for his eye protection and stored them in a paper bag in his truck.

On 6/11/21 at 11:04 AM the findings related to the use of eye protection was discussed with Staff 3 (DNS). Staff 3 stated she was not aware of the guidance for the use of plastic bags, location and storage of eye protection and what constituted appropriate eye protection,

4. According to CDC guidance: Environmental and equipment disinfection should be completed using the appropriate disinfectant for the appropriate amount of contact time. The use of EPA's N list for COVID-19 was recommended to ensure adequate contact times were used.

On 6/9/21 at 8:33 AM Staff 18 (housekeeper) was asked about environmental disinfectants and stated the facility used a product that was dispensed in the utility rooms into a bucket and they used cloths to apply it. Staff 18 was asked about the contact time and stated it was five minutes. Review of the EPA number and product information indicated the contact time was 30 seconds.

On 6/10/21 at 11:45 AM Staff 10 (CNA) was asked about disinfection of eye protection and contact times for adequate disinfection and Staff 10 stated she had no idea.

On 6/10/21 at 2:23 PM Staff 17 (CNA) was asked about cleaning of reusable resident equipment and stated items were to be cleaned after each use and they used alcohol prep pads to wipe down the items and let them air dry.

On 6/11/21 at 10:24 AM Staff 16 (Maintenance & Environmental Services) stated the facility used a hydrogen peroxide product for environmental cleaning, the contact time was between five to 10 minutes and was their preferred disinfection product. Staff 16 added alcohol wipes were being used on the phones.

On 6/11/21 at 11:04 AM the findings related to environmental and reusable resident equipment was discussed with Staff 3 (DNS) and she did not provide any additional information.

Based on interview and record review it was determined the facility failed to obtain information related to pneumococcal immunization status and offer pneumococcal immunizations for 4 of 5 sampled residents (#s 3, 8, 11 and 17) reviewed for immunizations. This placed residents at risk for pneumonia. Findings include:

Residents 3, 8, 11 and 17 were reviewed for immunizations.

Records revealed none of the four residents had evidence documented regarding receiving pneumococcal immunizations or whether the facility offered the immunizations to them.

On 6/11/21 at 11:04 AM Staff 2 (DNS) was informed of the lack of pneumococcal immunizations. Staff 2 stated she could find no information related to pneumococcal immunization information for Residents 3, 8, 11 and 17.

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OAR 411-085-0310 Residents' Rights: Generally

Refer to F585

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OAR 411-085-0360 Abuse

Refer to F610

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OAR 411-086-0230 Activity Services

Refer to F679

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OAR 411-086-0250 Dietary Services

Refer to F804

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OAR 411-086-0010 Administrator

Refer to F838

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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880

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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventative Care

Refer to F883

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