Maryville

Resident 6 was admitted to the facility in 2025 with diagnosis including orthostatic hypotension and implantation of a prosthetic heart value. -á Resident 6GÇÖs 5/21/25 Care Plan indicated Resident 6 had impaired cardiovascular function and altered cardiovascular function due to the presence of a pacemaker.-á Resident 6GÇÖs MDS identified the resident with a BIMS score of 12 out 15 indicating mild to moderate cognitive impairment.-á A 6/5/25 Facility Risk Management Report identified Staff 16 (LPN) wrongly administered a combination of the following medications to Resident 6: Levothyroxine 50mcg, Tylenol 500mg, Gabapentin 300mg, Bactrim 800-160, Amidarone 200mg, Baclofen 5mg, Calcium Citrate 315mg-5mcg, Vit D3 125 mcg, Clopidogrel 75mg, CoQ10 75 mg, Entresto 300mg, Finasteride 5mg, Multivitamin 1 tab, Torsemide 100mg and Ezetimibe 10mg. Staff 16 was noted to have immediately discover the medication error and reported the incident to facility administration. Per Staff 16, she asked Resident 16 if she/he was the identified resident and resident responded yes and took the medication. Staff 16 confirmed during the report that she did not check to see if the medications administered were for the correct resident. Upon discovery of the medication error, Resident 6 was monitored and upon experiencing a change of condition including a low blood pressure of 99/49 was sent to the emergency room for evaluation. Resident 16 later returned to the facility after the hospital administered IV fluids to the resident to flush the medications from her/his system. Resident 16 was noted to have experienced no long-term effects from the medication administration error.-á A 6/5/25 Nursing Progress Note revealed Resident 6GÇÖs systolic pressure dropped below 100 reaching a total blood pressure range of 99/49 as a result of the medication administration error. Resident 6 was sent to the emergency room for evaluation.-á On 4/23/26 at 1:10 PM, Staff 4 (RCM) stated Resident 6 was sent to the hospital after Resident 6GÇÖs blood pressure dropped to 99/49. Staff 4 stated Resident 6 safely returned to the facility after being administered IV fluids to flush the medications from her/his system.-á On 4/23/26 at 1:21 PM, Staff 16 (LPN) confirmed she committed the medication error and confirmed Resident 6 was sent to the hospital after experiencing a change of condition from the medication error. Staff 16 stated the failure was due to an unstructured medication system and failing to confirm the identity of the resident before administration. Staff 16 reported during the incident, Staff 16 was assigned to administer medications managing three different treatment carts during her shift. Staff 16 indicated that upon preparing Resident 6GÇÖs medications, she failed to confirm if the medication she prepped and administered was for Resident 6.-á On 4/23/26 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the findings and indicated Staff 16 failed to administer the correct medication to Resident 6. -á

F  760    Residents are free of significant medication error 1.  Resident number 6 was discharged from the facility on 07/23/2025.  The resident did have an emergency room hospitalization related to a medication error and returned the same day with no further physician orders.  The facility continued to monitor and maintain 72- hour monitoring per the facilities alert monitoring protocol related to a change of condition. At the time of the error, a medication review and medication pass in-service were completed with the clinical staff member involved in the event. 2. The facilities medication pass protocol was reviewed and no changes to the facility medication pass procedures and protocols were noted to need revision.   However, a medication pass safety card has been added to each medication cart as a reminder to clinical staff to follow the six rights of medication pass which includes a two-step verification of a resident’s identity prior to medication pass. 3. All certified medication aides received medication pass procedure in-services on 04/20/26 and 4/21/26 during their routine previously scheduled training sessions. All licensed nurses received in-services regarding medication pass procedures and medication error prevention on their routinely scheduled license nurse meeting on 3/23/26 and 3/24/26.  Clinical staff will be in-serviced on the medication pass safety cards located on each medication cart as an additional medication pass safety check system. 4. The Director of Nurses, Director of Compliance and Director of Staff Development will complete root cause analysis on all medication errors should they occur.   Random audits will be completed weekly for four weeks and monthly for 90 days to verify the clinical staffs understanding of the two- step medication pass identification protocol to be completed.  The audits will be completed by the Director of Staff development, Director of Compliance and Director of Nursing. Any continued education will be completed with on- the- spot training and any trends will be reviewed through the facilities Quality Assurance and Assessment Committee

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 lack of personal hygiene. Findings include: Resident 36 was admitted to the facility in 8/2024 with diagnoses including cerebral atherosclerosis (hardening of arteries in the brain) and dementia. Resident 36's Significant Change MDS dated 1/23/25 indicated the resident was dependent on staff for personal hygiene and grooming. Resident 36 was observed on 4/8/25 at 10:24 AM, and on 4/9/25 at 8:24 AM with a significant amount of chin hair visible. On 4/8/25 at 10:24 AM, Resident 36 stated she/he did not want to have facial hair and would like for staff to take care of it for her/him. Resident 36 stated she/he relied on staff to shave unwanted facial hair. On 4/9/25 at 2:13 PM, Staff 6 (CNA) stated she obtained information to care for Resident 36 from the Kardex (bedside care plan) and acknowledged Resident 36 had long chin hairs. On 4/9/25 at 2:18 PM, Staff 2 (DNS) observed and acknowledged Resident 36's facial hair and stated the resident was in need of a shave.

F-677: ADL Care Provided for Dependent Residents: 1. Resident 36 received grooming on 04/09/2025 when the facility was notified of the issue. 2. On 04/09/2025, when the facility was notified of a grooming issue, all residents on all units were audited for grooming needs, whether independent to dependent for care needs. Any findings were resolved at the time of the audit and the survey team was notified that this was completed. 3. All clinical staff were in-serviced regarding ADL grooming needs for the dependent resident on 04/09/2025 and the survey team were notified that was completed and at the pre-scheduled mandatory CNA meetings on 04/22/2025 and 04/23/2025. The CNA staff and licensed nurses were also reminded to report any refusals or preferences for grooming to their supervisors for follow up care. 4. The RCM staff will randomly audit their residents weekly for four weeks, then monthly for 90 days and quarterly thereafter and report any trends or concerns to the Director of Nursing. Any trends or concerns will be reviewed in the facilities Quality Assurance and Assessment Committee meetings.

1.

Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was completed during meals for 1 of 6 halls reviewed for dining. This placed residents at risk for cross contamination. Findings include: The 8/2019 Handwashing/Hand Hygiene Policy indicated hand hygiene was the primary means to prevent the spread of infections. The policy indicated: 7. Use of an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. before and after direct contact with residents; l. after contact with objects in the immediate vicinity of the resident; o. before and after eating or handling food; p. before and after assisting a resident with meals; On 4/7/25 during the lunch meal in the west hall and dining room the following observations were made: -12:05 PM Staff 10 (NA) removed three dirty breakfast trays from a two-tier serving cart and loaded the cart with three lunch trays. Staff 10 did not sanitize the cart prior to loading the cart with the lunch trays. - 12:07 PM Staff 10 delivered lunch trays to three residents in the dining room, donned clothing protectors and set-up each tray for the three residents. Staff 10 did not sanitize her hands between each resident or after leaving the dining room. -12:10 PM Staff 10 loaded the two-tier cart with three lunch trays and delivered the lunch tray to Room 313 and exited the room without sanitizing her hands. Staff 10 delivered a lunch tray to Room 317.1, assisted the resident with repositioning, adjusted the head of the bed and moved the bedside table. Staff 10 delivered a lunch tray to Room 317.2, assisted the resident with repositioning in the bed, cleared and adjusted the bedside table. On 4/7/25 at 12:14 PM Staff 10 acknowledged she did not sanitize her hands in between delivering the lunch trays and touching each resident in the dining room and in the rooms. Staff 10 stated she should have sanitized the cart after removing the dirty breakfast trays and before using it for the lunch trays. On 4/7/25 at 12:20 PM Staff 2 (DNS) stated she expected all staff to complete hand hygiene after they passed out each resident tray and went in and out of resident rooms. Staff 2 stated she expected staff to sanitize the meal cart before each use. , 2. Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens. Findings include: The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, "Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water." A review of the facility's 9/2022 Legionella Water Management Policy revealed the following: -The water management program is reviewed annually by the facility water management team. -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. -The water management program includes a detailed description and diagram of the water system in the facility and areas identified in the water system that could encourage the growth and spread of Legionella or other water-borne bacteria. A review of the 2/2025 Facility Assessment revealed no evidence a risk assessment was completed to prevent the growth and spread of water-borne pathogens in the facility's main water system. On 4/11/25 at 10:05 AM Staff 1 (Administrator) stated the facility did not have a water management program and did not have a prevention plan or system in place for the prevention of the spread of water-borne pathogens, such as Legionella, in the facility's main water system.

F-880: Infection Control and Prevention: 1a. Staff member 10 was educated on 04/07/2025 hand hygiene and sanitation requirements during tray pass and meal assist when the facility was notified of the issue. The survey team was given a copy of this education. 2a. All dining rooms were monitored at dinner on 04/07/2025 and breakfast and lunch on 04/08/25 to determine education needs during meal tray pass and dining assistance with the CNA staff and to determine if any trends were occurring. 3a. All clinical staff were provided education on 04/07//2025 on hand hygiene and sanitation requirements as well as all CNAs during the pre-scheduled mandatory CNA meetings on 04/22/2025 and 04/23/2025. 4a. The facility will complete random dining room observation audits to determine compliance with hand hygiene and sanitation weekly for four weeks then monthly for 90 days and quarterly thereafter and report any trends or concerns to the Director of Nursing. Any trends will be reviewed in the facilities Quality Assurance and Assessment Committee meetings. Staff development and Director of Nursing responsible for completion. 1b. The facility has reviewed its Legionella Water Management Program and has completed the process of assuring that the program includes a detailed description and diagram of the water system in the facility and defined areas identified in the water system that could encourage the growth of legionella and other water borne bacteria. 2b. The facility receives water from the City of Beaverton in Washington County. A review of the City of Beaverton and Washington Counties water system risk management report for 2024 and 2023 showed that there were no issues related to legionella. The facility completed a risk assessment on 04/23/2025 as well as a diagram of the facilities water system. The facility assessment has been updated to reflect risk management related to the facilities Water management program. 3b. The water system has been tested for both bacteria on 05/05/2025 and found negative for bacteria and the water system will also be tested for the presence of legionella. The facilities management team and the safety committee have been updated on the facilities water management program, 4b. The Administrator and Maintenance Director will review the Water Management Program annually and test the facility water systems annually for the presence of bacteria and legionella risk. This will also include the review of the annual Washington County Water Safety Report. The outcome of the review and testing will be brought to the facilities Quality Assurance and Assessment Committee and the facilities safety committee when completed each year.

Based on interview and record review it was determined the facility failed to obtain reference checks for 1 of 3 newly hired facility staff members (#7) reviewed for reference checks. This placed residents at risk for lessened quality of care. Findings include: On 4/20/25 at 11:49 AM Staff 1 (Administrator) stated she completed reference checks for employment candidates. A review of the facility's new hires in the previous four months revealed the following: -Staff 7 (RN) was hired on 12/19/24. There was no evidence a reference check was completed for Staff 7. On 4/11/25 at 8:33 AM Staff 1 acknowledged there was no evidence to indicate a reference check was competed for Staff 7.

M-141: Employees Reference Checks and Verification: 1. The facility has a new hire checklist process in place that includes employee reference checks. 2. This check list and process for checking references was reviewed by the Administrator, Human Resources and the Director of Compliance to validate the reference check protocol and determine the audit process to maintain compliance. 3. The check list will be reviewed for completion by human resources upon the hire of all new employees. Human resources will complete a weekly audit for four weeks and then every two weeks ongoing for compliance. Results of the audits will be reviewed with the administrator. 4. The Administrator and Human resources will monitor and report any areas of concerns or trends to the facilities Quality Assurance and Assessment committee.

Based on interview and record review it was determined the facility failed to ensure criminal background rechecks were completed for staff employed two or more years for 1 of 3 sampled staff (#5) reviewed for background checks. This placed residents at risk for abuse. Findings include: The facility's undated Criminal History Background Check Policy indicated the following: -Each employee will have their criminal background check re-evaluated every two years from the last background check date. On 4/10/25 at 11:02 AM, during a review of background checks for three randomly selected staff employed two or more years, Staff 4 (Human Resources) stated Staff 5 (Laundry), hire date 6/27/18, required a criminal background recheck on 11/15/24 which was not completed. Staff 5 worked with residents and did not have a current criminal background check in place. On 4/10/25 at 11:49 AM, Staff 1 (Administrator) acknowledged Staff 5's criminal background check was not completed on 11/15/24 as required. Staff 1 stated she expected all staff to have current background checks in place.

M-143: Employee Criminal Record Checks: 1. The employee found to be missing a criminal history record 2 year recheck has had that completed. 2. An audit was completed of all employees who have been employed for 2 years or greater to ensure all had criminal history rechecks were completed. 3. The policy for criminal history background record check requirements was reviewed. In-servicing was provided to those that complete this process in the facility. Human resources will run an Orchards report every two weeks to determine all staff who are employed for 2 years or greater that are coming due for their criminal background record check. The staff members will be notified prior to their anniversary date to complete the criminal back ground check. Any staff members who do not comply will be removed from their work schedule until their updated background check is completed. 4. The Administrator and Human Resources will review the bi-monthly audit report for ongoing compliance and report results to the facilities Quality Assurance and Assessment committee.

OAR-411-086-0100: Nursing Services: Resident Care

Refer to F677 ************************** OAR-411-086-0330: Infection Control and Universal Precautions Refer to F880 **************************

Based on observation, interview and record review, it was determined the facility failed to follow care plan interventions related to aspiration risks for 1 of 3 sampled residents (#3) reviewed for accidents. Resident 3 admitted to the facility in 2024 with diagnoses including traumatic subdural hemorrhage (severe head injury) and dysphagia (difficulty with swallowing). Resident 3's 9/3/24 Care Plan indicated the resident required one on one eating assistance due to dysphagia. The care plan stated staff were not to deliver until staff was ready to assist the resident. The 9/2024 Admission MDS identified Resident 3 was cognitively intact. A 9/4/24 choking/aspiration investigation revealed Staff 5 (CNA) delivered Resident 3's lunch tray to the resident and informed Resident 3 that she would return to assist Resident 3 after delivering the last lunch tray. Resident 3 was noted to have begun eating without assistance and began to choke due to placing too much food in her/his mouth. Staff 4 (OT) was in the room at the time assisting Resident 3's roommate. Staff 4 was alerted by the resident's roommate that something was wrong with Resident 3. Staff 4 noted Resident 3 was choking and began to turn reddish purple. Staff 4 performed the Heimlich maneuver and was able to dislodge Resident 3's food from her/his throat. The facility's choking and aspiration investigation concluded Staff 5 did not follow Resident 3's care plan and residents who required one on one eating assistance were not to be left alone with a meal tray until staff were ready to immediately assist residents with eating. Observations conducted from 12/31/24 to 1/3/25 from, 9:30 AM to 3:40 PM, identified no additional issues or risks related to choking or aspiration for residents. On 12/31/24 at 10:00 AM, Staff 5 (CNA) could not be reached for interview. On 12/31/24 at 11:10 AM, Staff 4 confirmed Staff 5 had left Resident 3 with her/his meal tray before leaving the room and had conducted the Heimlich maneuver due to Resident 3 choking after she/he began to self-feed herself/himself. On 12/31/24 at 11:49 AM, Staff 6 (RNCM) indicated that staff were not to leave trays for residents who required meal assistance due to the risk of choking and aspiration occurring. On 1/3/25 at 11:52 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 3 choked as a result of Staff 5 not following the resident's care plan by leaving the resident's tray alone in her/his room.

F 689 Free of accident hazards/Supervision/Devices 1. Resident number 1 was discharged from the facility on 09/26/24 with no residual effects noted related to aspiration. 2. All residents have been audited for their level of dining assistance needed. Resident Care Managers have reviewed their residents for dining assistance need for accuracy and updated care plans and resident Kardex as applicable if any changes were needed. 3. All clinical staff were educated on 12/31/24 and 01/01/25 on types of dining assistance provided and when a meal tray is not to be left at resident’s bedside. All residents needing dining assistance were observed during meal times for appropriate level of support being provided on 01/01/25. 4. Resident Care Managers, Staff Development and Director of Nursing Services will monitor dining assistance provided every week for four weeks and then monthly for quality assurance and assessment review and report any trends to the facility Quality Assurance and Assessment committee for 90 days and as needed.

*************************** OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care Refer to F689 ***************************

Based on interview and record review it was determined the facility failed to ensure the plan of care was followed to provide care-planned assistance to prevent a fall for 1 of 3 sampled residents (#3) reviewed for falls. This resulted in Resident 3's hospitalization with leg fracture and surgical repair. Findings include: Resident 3 admitted to the facility in 2023 with diagnoses including a history of falls. The 11/16/23 Care Plan indicated Resident 3 was at risk for falls related to impaired mobility. Interventions included providing a safe environment, including personal items within reach. The Care Plan also indicated Resident 3 required one-person assistance with bathing. The 11/23/23 Admission MDS indicated Resident 3 was cognitively intact. A 12/30/23 fall investigation indicated Staff 3 (CNA) called Staff 4 (LPN) and Staff 5 (LPN) into Resident 3's room as the resident suffered a fall while in the shower. Upon entering the room, the resident was found lying on her/his right side. Resident 3 initially did not want to go to the hospital for evaluation. Resident 3 waited until family arrived and after speaking with staff, the resident agreed to go to the hospital. Resident 3 was found to have a right leg fracture requiring surgical repair. Witness statements indicated the following: - Resident 3 stated she/he was in the shower and was not able to recall what she/he was doing. Resident 3 thought she/he may have reached for water or the shampoo and then fell on her/his side. - Staff 3 stated she was providing Resident 3 with a shower in the resident's room. Staff 3 stated she transferred the resident to the shower chair and gave the resident a washcloth and shampoo. Staff 3 stated Resident 3 asked her to give her/him some time to wash her/his hair. Staff 3 stated she left the door open and closed the shower curtain halfway but was able to still see the resident. Staff 3 stated she went to make the resident's bed. Staff 3 stated Resident 3 fell out of the shower chair and onto the floor. Staff 3 stated she quicky called for the nurse. Staff 3 stated she read the Kardex (CNA Care Plan) and Resident 3 was to receive one-person assistance with bathing. Staff 3 stated she did not physically assist the resident with bathing before she left to make the resident's bed. Staff 3 stated she, "honestly didn't think anything would happen. I'm sorry." - Staff 4 stated Staff 3 called her and Staff 4 into Resident 3's room. Resident 3 was found laying on her/his right side with the shower chair tipped over. Resident 3 denied pain to the right thigh and indicated pain only when putting her/his leg down. Resident 3 was assisted to a wheelchair. - Staff 5 stated she assisted Staff 4 after Resident 3 fell. Staff 5 stated the resident was found wet on the floor inside the shower on her/his right side. Staff 5 stated Resident 3 indicated she/he may have been reaching for the shampoo or trying to get to the water, but could not recall for sure. The resident indicated she/he slipped and fell on her/his right side. Resident 3 was unable to extend her/his right leg completely out and an ice pack was applied to the right thigh. The resident was assisted to the wheelchair. The fall investigation concluded Staff 3 read Resident 3's Care Plan prior to the shower and if Staff 3 remained with Resident 3, and completed the shower, the fall could have been avoided. The Care Plan Indicated Resident 3 required one-person assistance with bathing and Staff 3 was not physically close to the resident at the time of the incident. On 3/15/24 at 9:58 AM Staff 5 (LPN) stated Resident 3 fell while in the shower. Staff 5 stated she recalled the resident was reaching for something when she/he fell. Staff 5 stated Resident 3 was able to move after the fall but was later sent out to the hospital. Staff 5 stated she believed Staff 3 was in the room with the resident but was unable to recall if Staff 3 was standing next to the resident or in the room doing "other things" when the fall occurred. On 3/15/24 at 2:43 PM Staff 4 (LPN) stated she assisted Resident 3 after the fall. Staff 4 stated Staff 3 came out of the room and indicated Resident 3 fell. Staff 4 stated she and Staff 5 went to assist and found the shower chair was tipped over and the resident was on her/his right side. Staff 4 stated Resident 3 did not complain of any pain and was able to transfer to the wheelchair. Staff 4 stated Resident 3 did not want to go to the hospital at first, but later complained of increased pain and was sent out. Staff 4 stated Staff 3 indicated she was making Resident 3's bed while the resident was in the shower. On 3/18/24 at 9:24 AM Staff 3 stated Resident 3's shower was connected to her/his room. Staff 3 stated she provided Resident 3 a shower on 12/30/23. Staff 3 stated she set up Resident 3 for the shower and the resident indicated she/he needed a minute to wash her/his hair. Staff 3 stated Resident 3 wanted to wash her/his own hair. Staff 3 stated she could see the resident in the shower from where she was standing at the bed. Staff 3 stated she didn't believe she was leaving the resident alone in the bathroom. Staff 3 stated she was next to the bed when she heard Resident 3 fall. Staff 3 stated the resident did not call out for help, and she was not sure how the resident fell as the resident was previously sitting on the shower chair. Staff 3 stated at the time of the incident, Resident 3's Care Plan indicated she/he required one-person assistance with bathing. Staff 3 stated she read Resident 3's Care Plan prior to the fall. On 3/15/24 at 11:53 AM Staff 6 (RNCM) stated Staff 3 was providing a shower to Resident 3 at the time of the fall on 12/30/23. Staff 6 stated Resident 3 required one-person assistance with bathing at the time. Staff 6 stated Resident 3 asked for privacy and Staff 3 stepped out of the shower and went to make the resident's bed while keeping an eye on the resident. Staff 6 stated she believed the resident reached out for something and fell. Staff 6 stated Staff 3 was supposed to be within reach of Resident 3 during the shower. Staff 6 stated Staff 3 was able to see the resident in the shower, but was not close enough reach the resident to prevent the fall. Staff 6 stated Staff 3 was aware that Resident 3 required one-person assistance with bathing and acknowledged Staff 3 did not provide assistance per the resident's Care Plan, which resulted in a fall with a leg fracture. On 3/18/24 at 12:39 PM Staff 17 (DNS) acknowledged Resident 3 suffered a fall with fracture due to Staff 3 not providing assistance per the resident's Care Plan for bathing. Staff 17 stated she asked Staff 3 to not return to the facility after the incident. On 3/20/24 at 6:59 PM the facility provided additional information to indicate education and an inservice was provided to nursing staff related to the identifed incident. The deficient practice was determined to be past non-compliance, corrected on 1/3/24.

*************************** OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care Refer to F689 ***************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/29/2024 and 02/04/2024, 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 a resident was treated in a dignified manner for 1 of 1 sampled resident (#324) reviewed for activities. This placed residents at risk for being treated in a dishonorable manner. Findings include: Resident 324 was admitted to the facility in 11/2023 with diagnoses including stroke and dysphagia (difficulty swallowing). A 11/28/23 care plan revealed Resident 324 required one staff person assistance with personal hygiene, dressing and needed one to one assistance with eating. On 12/13/23 at 8:30 AM Resident 324 was observed in bed asleep and two CNAs moved the resident up in bed and adjusted her/his pillows, the resident's eyes remained closed, and staff did not speak to the resident. Staff 32 (CNA) turned on the overhead light and said, "it's time to wake up." Staff 32 used the bed control to raise the head of the bed to approximately 90 degrees (in an upright position) and Resident 324's head slumped towards her/his left shoulder. Staff 32 placed a clothing protector on the resident's chest but did not speak to the resident and her/his eyes remained closed and Staff 32 left the room. At 8:34 AM Staff 32 came back to the room with a washcloth in her hand, wet the washcloth and wiped the resident's face without speaking to the resident. Resident 324 lifted both of her/his arms up in the air in attempt to stop Staff 32, who said "it's time to wake up." Resident 324 kept her/his eyes closed and Staff 32 stopped wiping the resident's face. Staff 32 proceeded to the right side of the resident's bed next to the bedside table that had Resident 324's breakfast. Staff 32 stood by the bed, took a spoon and scooped some thick liquid out of a cup and tried to feed the resident. Resident 324 did not open her/his mouth or eyes. Staff 32 removed the clothing protector from the resident and left the room. On 12/13/23 at 8:40 AM Staff 32 stated Resident 324 was difficult to wake up in the mornings. Staff 32 admitted she should have talked more to the resident in attempt to wake her/him before raising the head of the bed in an upright position. Staff 32 stated the resident required one staff to help her/him with eating because she/he was a "feeder." Staff 32 indicated she should have talked to the resident prior to washing her/his face and before placing the clothing protector on Resident 324. On 12/13/23 at 9:28 AM Staff 31 (Speech Language Pathologist) stated she worked with Resident 324 regularly due to her/his dysphagia. Staff 31 indicated the resident was hard to wake up in the mornings and staff should talk to her/him and not rush the resident when providing assistance. On 12/18/23 at 11:06 AM Staff 2 (DNS) and Staff 29 (LPN-Resident Care Manager) stated staff were expected to wake up Resident 324 gently and not rush her/his care. Staff 2 stated she expected staff to talk to Resident 324 the whole time or try to stimulate her/him by rubbing the resident's shoulder or feet and tell the resident what care they were going to give. Staff 2 stated staff were expected to ask permission before putting a clothing protector on for meals and to sit down when feeding any residents that needed help with eating.

F550: Resident Rights/Exercise of Rights 1. Resident number #324 has been observed during ADL care provided by the certified nursing assistants to monitor and provide on the spot education as applicable regarding the provision and maintenance of dignity and respect during care. 2. Charge nurses are to complete purposeful rounding on each shift to monitor for respect and dignity during care and services to determine if any areas of respect and dignity are not being maintained with all residents. 3. All nursing staff will be in-serviced on respect and dignity during ADL care focusing on resident notification and awareness of care to be provided. 4. DNS and Quality Assurance Nurse will monitor weekly purposeful rounding outcomes and do random resident care rounding every week for 90 days to assure respect and dignity during care is being maintained. Any trends will be reported to the Quality Assurance and Assessment Committee.

Based on interview and record review it was determined the facility failed to notify a resident's responsible party of a change in condition for 1 of 1 sampled resident (#372) reviewed for change of condition. This placed residents at risk for having uninformed responsible parties. Findings include: Resident 372 was admitted to the facility in 2018 with diagnoses including heart failure. On 3/1/23 a diagnosis of dementia with agitation was added. Resident 372's clinical record indicated Witness 2 (Family Member) was her/his responsible party, POA (Power of Attorney) for care, and "Emergency Contact #1." On 12/11/23 at 9:55 AM Witness 2 stated Resident 372 passed away in 8/2023 and when she went to the facility the day after to collect the resident's belongings, Staff 5 (RNCM) told her the resident had pressure ulcers. Witness 2 stated it was the first time she was notified of Resident 372's skin issues. The 8/18/23 Skin Investigation by Staff 3 (LPN) indicated on 8/17/23 Resident 372 had a partial thickness skin loss which measured 4.78 cm x 3.2 cm to the coccyx. The investigation indicated it was moisture associated dermatitis. The investigation further indicated Witness 2 was not notified of the skin issue until 8/21/23 at 12:49 PM (four days after the skin issue was discovered). On 12/13/23 at 2:31 PM Staff 3 stated he identified Resident 372's skin issue on 8/17/23 and acknowledged Witness 2 was not notified. On 12/15/23 at 1:03 PM Staff 2 (DNS) acknowledged Witness 2 was not notified of Resident 372's skin issue until 8/21/23 and the expectation was for staff to inform the responsible party within 24 hours.

F 580: Notification of Changes: 1. Resident #372 was discharged from the facility. 2. An audit of all resident profiles will be completed to determine the order and designation of the emergency contact information in each residents clinical record. Any resident that is not their own responsible party and does not have the responsible party and/or POA for healthcare noted to be the first contact will have the 1st emergency contact information determined and updated in the residents profile. 3. The Medical Records Director, Admission coordinator, Admission Nurse, Medical Records consultant and Nursing consultant were brought together on 1/12/24 to review the current profile emergency contact process and determine the appropriate process to validate the notification order for contacting the responsible parties or designees from the clinical profile. The admission coordinator will initiate the resident contact profile order, the admission nurse will validate with the resident on admission and if unable to determine with the resident, will notify the social services department to obtain the 1st emergency contact. The Medical Records Director will validate the resident contact profile within 48 hours of admission and the facility will re-evaluate quarterly through the resident care conference process. 4. The license nurses will be in-serviced on the emergency contact order in the residents profile and will understand who is to be contact first as applicable when notification of a change occurs. 5. The Administrator and The Director of Medical Records will monitor weekly for 90 days to validate accuracy and report any trends to the Quality Assurance and Assessment committee.

Based on interview and record review it was determined the facility failed to provide written notification to 2 of 3 sampled residents (#s 373 and 374) reviewed for Notice of Medicare of Non-Coverage (NOMNC). This placed residents at risk for unknown financial liabilities. Findings include: 1. Resident 373 was admitted to the facility on 6/12/23 and discharged from the facility on 6/27/23. The 6/27/23 Discharge MDS indicated Resident 373 had a planned discharge with a Medicare covered stay at the facility. A review of the resident's medical record revealed no indication a NOMNC was provided. On 12/14/23 at 10:17 AM Staff 16 (Assistant Administrator) acknowledged a NOMNC was not provided to Resident 373. 2. Resident 374 was admitted to the facility on 5/31/23 and discharged from the facility on 7/14/23. The 7/14/23 Discharge MDS indicated Resident 374 had a planned discharge with a Medicare covered stay at the facility. A review of the resident's medical record revealed no indication a NOMNC was provided. On 12/14/23 at 10:17 AM Staff 16 (Assistant Administrator) acknowledged a NOMNC was not provided to Resident 374.

F 582: Medicaid/Medicare Coverage/Liability Notice 1. Resident # 374 and resident # 373 have been discharged. 2. An audit of all residents who are being discharged from Medicare Services will be completed by the Assistant Administrator prior to the residents discharge to determine that a NOMNC and/or ABN have been provided as applicable. 3. The facility social workers will be in-serviced on the NOMNC and ABN requirement and process. 4. The Administrator, Assistant Administrator and Medical Record Director will audit weekly for 90 days for compliance and report any trends to the Quality Assurance and Assessment Committee

Based on interview and record review it was determined the facility failed to prevent the development of moisture associated skin damage (MASD) and follow physician orders for 2 of 3 sampled residents (#s 322 and 372) reviewed for skin conditions and pain management. This failure resulted in Resident 372 developing MASD and placed residents at risk for increased pain. Findings include: 1. Resident 372 was admitted to the facility in 2018 with diagnoses including heart failure. On 3/1/23 a diagnosis of dementia with agitation was added. Resident 372's 4/21/23 physician order indicated to apply barrier cream and cover with a foam dressing to the coccyx area two times a day for skin care protection. The 8/2023 TAR indicated Resident 372 received dressing changes twice daily from 8/13/23 through 8/17/23. The 8/18/23 Skin Incident Report indicated on 8/17/23 during a preventative dressing treatment it was noted Resident 372 had a partial-thickness skin loss that measured 4.78 cm in length x 3.2 cm wide moisture associated dermatitis to the coccyx. Resident 372 did not know how she/he got the skin injury. The 8/17/23 progress note by Staff 3 (LPN) indicated Resident 372 had an order to apply barrier cream and cover with foam dressing to the coccyx area BID for skin protection. The last time the dressing was changed was by Staff 3 on 8/13/23. On 8/13/23 her/his skin was not effected and the dressing was for ulcer prevention. On 8/17/23 when Staff 3 came to work Resident 372 had a bed bath completed by Staff 4 (CNA). Staff 4 reported the dressing had a date of 8/13/23 that was signed by Staff 3. The skin check was completed and pressure was noted on the coccyx area and her/his skin "came off." The area measured 4.8 cm x 3.2 cm. The skin was cleaned, barrier cream and dressing were applied. On 12/13/23 at 2:31 PM Staff 3 stated on 8/17/23 Staff 4 reported Resident 372's current dressing on the coccyx was dated 8/13/23 and signed by Staff 3. Staff 3 stated he observed the dressing with Staff 4 and it was "very wet." Staff 3 stated when he applied the dressing on 8/13/23 the skin was intact and when he removed the wet dressing on 8/17/23 the resident had a Stage 2 (partial thickness skin loss) pressure ulcer. On 12/13/23 at 2:47 PM Staff 4 stated on 8/17/23 she observed Resident 372's dressing to the coccyx dated 8/13/23 and signed by Staff 3. Staff 4 stated she reported the observation to Staff 3. On 12/15/23 at 12:23 PM Staff 5 (RNCM) acknowledged Resident 372 did not receive BID dressing changes as ordered from 8/14/23 through 8/17/23. Staff 5 further acknowledged Resident 372 did not have skin issues prior to the removal of the dressing on 8/17/23. Staff 5 acknowledged the skin assessment indicated it measured 3.11 cm x 2.03 cm on 8/18/23 and stated her/his open skin area was a combination of moisture related issues and a pressure ulcer. , 2. Resident 322 was admitted in 11/2023 with diagnoses including right leg fracture and stroke. Physician's orders dated 11/25/23 directed facility staff to place one lidocaine patch externally every 12 hours and to remove for 12 hours. Review of the 11/2023 and 12/2023 MAR revealed Resident 322 refused her/his lidocaine patch on the following days: -11/25/23, 11/26/23 and 11/27/23. -12/4/23, 12/5/23, 12/6/23, 12/7/23, 12/8/23, 12/9/23, 12/10/23 and 12/11/23. There was no documented evidence the resident's physician was notified of Resident 322's refusals. On 12/13/23 at 7:57 PM Staff 44 (LPN) stated the resident struggled with chronic pain but was not aware Resident 322 had an order for a lidocaine patch. On 12/14/23 at 6:57 PM Staff 36 (CMA) stated she was aware Resident 322 refused her/his lidocaine patch and documented as a refusal but did not notify the physician. On 12/18/23 at 10:30 AM Staff 2 (DNS) and Staff 29 (LPN-Resident Care Manager) confirmed, based on information on Resident 322's MARs, staff should have contacted the physician regarding her/his refusals.

F 684: Quality of Care 1. Resident #322 and resident # 372 have been discharged. 2. a. The Resident Care Managers will audit the residents current treatment orders and weekly skin assessments and skin risk management to determine if there are any changes in skin integrity that needs intervention as applicable. b. An audit will be completed on all residents receiving routine pain management to determine any residents that have refused any routine pain management two or more times in a 7- day period and to determine that the provider was notified of the refusal of pain medication. Any residents that are noted on the audit will have their pain management assessed by the Resident Care manager and the provider will be notified for interventions as applicable. 3. A. The charge nurses will be inserviced on following the residents skin and wound weekly skin assessment protocol including reporting to the Resident Care Manager any changes in skin integrity or refusals of wound and skin treatment. b. The Medication Aides and the Charge Nurses will be inserviced on notifying the provider when the resident refuses two or more routine pain medication. 4. The Director of Nurses, Resident Care Managers, and Quality assurance Nurse will audit weekly for 90 days any skin integrity changes and refusal of routine pain medications and will follow up as applicable and report any trends to the Quality Assurance and Assessment Committee

Based on observation, interview and record review it was determined the facility failed to assess elopement risk and provide supervision to prevent a severely cognitively impaired resident from eloping for 1 of 3 sampled residents (#272) reviewed for elopement. This failure resulted in an immediate jeopardy situation when Resident 272 eloped from the facility, was exposed to cold and rainy weather conditions, was without supervision at night in a high-traffic area, and was at risk for wandering into additional unsafe areas and getting lost. This placed the resident at risk for hypothermia, accidents, and a lack of access to support services. Findings include: Resident 272 admitted on 11/29/23 with diagnoses including dementia with self-neglect. A 11/15/23 Hospitalist History and Physical (H&P) indicated Resident 272 was hospitalized after she/he was found wandering in the streets and trying to get into various homes. Resident 272 was diagnosed with dementia in 2022 and had "slowly worsening cognition for some time." Resident 272 had a SLUMS (cognitive assessment) score of 10, indicating severe cognitive impairment. The H&P indicated Resident 272 needed placement in a Memory Care Unit (MCU) (secure locked unit attached to a skilled nursing facility). The document indicated Resident 272 was unable to care of her/himself and had poor insight into her/his disability. On 11/30/23 a provider progress note indicated Resident 272 was at high risk for elopement. A review of Resident 272's clinical record revealed no evidence of careplanned interventions put in place to prevent elopement subsequent to the provider's indication that Resident 272 was at high risk for elopement. A 12/3/23 facility investigation revealed the following: - On 12/3/23 at approximately 2:00 AM staff determined Resident 272 was not in her/his room. Facility staff began searching the facility as well as notifying local authorities. - Staff last made visual contact with Resident 272 at approximately 1:00 AM. - Resident 272 was located on the street at approximately 3:30 AM (two and a half hours after the resident was last seen by facility staff), a half mile from the facility, outside a local convenience store. The resident indicated she/he did not know why she/he was on the street and indicated she/he was, "Going to the jail." - Facility staff determined Resident 272 eloped from her/his room via the window after opening the window and removing the screen. - Facility staff reported earlier in the day Resident 272 asked staff, "How to get out", and expressed that he was not supposed to be in the facility. - On 12/5/23 Staff 23 (RN) stated she was aware an elopement assessment was required upon admission, but it was not completed, and stated, "I don't think I [passed] it to the next shift to assist. It's my fault." - On 12/5/23 Staff 57 (LPN) indicated she was aware of the resident's history of wandering prior to the 12/3/23 elopement and watched the resident closely. Staff 57 stated she previously asked Staff 58 (LPN Resident Care Manager) if Resident 272 needed a wanderguard (device used to prevent elopement) and was told, "We could always assess it." - On 12/5/23 Staff 59 (CNA) indicated Resident 272 was agitated in the evenings starting around 8:00 PM, paced the hallways, and asked how to get out of the unit. - On 12/5/23 Staff 13 (LPN) indicated Resident 272 was agitated upon admit to the facility, barricaded her/his room with furniture, and wanted to leave. The evening prior to the resident's elopement, Resident 272 was agitated, and verbalized she/he wanted to leave. - 1:1 supervision was put in place when the resident returned to the facility after her/his elopement, and window alarms were installed on 12/4/23. - On 12/6/23 Resident 272 was moved to a new room with a window that faced a courtyard instead of the street. Observations during the survey revealed the facility was located on the corner of two four-lane highways with a row of resident rooms facing the street. At the time of the elopement, Resident 272's room had a window with a view of the street. Local weather records from 12/3/23 at 3:53 AM indicate a temperature of 47 degrees F with light rain. Review of Resident 272's clinical record revealed no evidence of a completed elopement assessment until after the resident returned to the facility on 12/3/23. Review of Resident 272's care plan, initiated on 11/28/23, revealed no information regarding elopement risk or exit-seeking behaviors, and no associated careplanned interventions to prevent elopement were initiated until the resident returned to the facility on 12/3/23. On 12/14/23 at 4:32 PM Staff 49 (Activities Aide) stated Resident 272 exhibited exit-seeking behaviors. Staff 49 stated regularly around 4:00 PM Resident 272's behavior was to ask to leave the facility and stated staff couldn't hold her/him here. Staff 49 stated she witnessed Resident 272 go into other residents' rooms and open a window; she/he tried to exit from the doors and paced the halls. Staff 49 stated there was no redirecting her/him when she/he "was like that." On 12/14/23 at 4:40 PM Staff 50 (CNA) stated she was not familiar with Resident 272, but staff expressed concern regarding the position of her/his room [it faced a main road] because of Resident 272's history. On 12/14/23 at 4:43 PM Staff 51 (CNA) stated Resident 272 was confused about why she/he was in the MCU. Staff 51 stated the resident thought she/he was in jail. Staff 51 stated she cared for the resident the day prior to the incident and the resident wanted to call the police because of feeling trapped in the facility. On 12/14/23 at 4:45 PM Staff 52 (CNA) stated he helped Resident 272 a few days prior to the incident, and the resident thought she/he was in jail and talked about being trapped. On 12/14/23 at 10:09 AM Staff 53 (CNA) stated Resident 272 was far more active in the evenings. Staff 53 stated Resident 272 did not cause any "problems" in the morning, but she knew that was not the case on evening or night shift. Staff 53 stated she only knew if residents were an elopement risk if they had a wander guard on or if the resident asked her about getting out. On 12/14/23 at 10:49 AM Staff 55 (CNA) stated she did not know Resident 272 was an elopement risk. Staff 55 stated staff were told was Resident 272 was found by police breaking into houses. Staff 55 stated he was told Resident 272 was going to be very active. On 12/14/23 at 11:11 AM Staff 56 (LPN) stated when Resident 272 was admitted she was given report that Resident 272 was confused and paranoid, and Resident 272 stated she/he didn't need to be here for too long and didn't want to be t here. On 12/14/23 at 4:30 PM Staff 57 (LPN) stated Resident 272 walked the entire unit every evening shift before the elopement. Staff 57 stated she spoke to staff on night shift to figure out Resident 272's care needs and night shift staff didn't have any information either. Staff 57 stated she tried to redirect her/him and educate her/him about the risks [of elopement], but Resident 272 didn't care. Staff 57 stated an elopement assessment was supposed to be done on the first day. If the nurse didn't finish the assessments on the shift the resident admitted, then the next shift was supposed to continue working on it and finish the assessment. On 12/14/23 at 4:59 PM Staff 23 (RN) stated staff were not aware Resident 272 was an elopement risk when the resident admitted. Staff 23 stated she was not aware of a process to complete an elopement assessment upon admission. On 12/14/23 at 5:30 PM the facility was notified that the failure to assess Resident 272's elopement risk, combined with the failure to put interventions in place to prevent elopement of a severely cognitively impaired resident, and Resident 272's subsequent elopement which placed the resident at risk for hypothermia subsequent to exposure to cold and wet weather, and additionally placed the resident at risk for accidents, and a lack of access to support services, constituted an Immediate Jeopardy (IJ) situation. An immediacy removal plan was requested. On 12/14/23 at 8:17 PM The facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: 1. a. Resident 272 had an elopement risk assessment and elopement care plan initiated on 12/3/23. One on one monitoring and 15-minute checks were initiated immediately on return to secure unit. Her/his room and the adjacent room window alarms were installed on 12/4/23. A room change occurred when a room was available that did not have street access via window on 12/6/23. Physician adjusted residents' medication for behavior management and resident was placed on alert for medication changes and behavior monitoring. Resident will remain on every 15-minute checks until 12/26/23 when resident will be re-evaluated for medication effectiveness, continued elopement risk, determine if 15 minute checks are to continue or check time adjusted and elopement risk assessment re-evaluation will be completed. b. The facility will audit every 15 minutes visual checks every shift by Charge Nurse and continue to monitor visual checks ongoing per determined schedule based on elopement assessment. Elopement assessment will be re-evaluated every two weeks times 90 days, then quarterly or more often as needed. 2. Resident 85, Residents 101, and Resident 105 will have their elopement risk assessment re-evaluated and updated as applicable and care plan interventions for elopement risk will be updated as applicable by 12/15/23. 3. On admission to the facility secured memory care unit, an elopement risk assessment will be completed on the day of admission to determine risk and safety needs and an elopement care plan will be initiated on the day of admission. 4. The elopement admission criteria policy and procedure will be updated to reflect elopement assessment process change by 12/15/23. 5. All staff assigned to memory care unit and facility IDT will be in serviced on updated policy and procedure regarding elopement assessment, risk and care plan interventions for safety by 12/15/23 end of day and ongoing. 6. The administrator, DNS, Quality Assurance nurse will audit all new admissions to memory care unit for elopement assessment and care plan completion. 7. Environmental Service Department will monitor window alarm devices placement daily. The immediacy was removed on 12/15/23 based on onsite verification of the removal plan.

1. A.) Resident 272 has had an elopement risk assessment and elopement care plan initiated on 12/3/2023. One on one monitoring and 15-minute checks were initiated immediately on return to secure unit. His room and adjacent room window alarms were installed on 12/4/2023. A room change occurred when room was available that did not have street access via window on 12/6/2023. Physician has adjusted residents medication for behavior management and resident placed on alert for medication changes and behavior monitoring. Resident will remain on every 15 minutes checks until 12/26/2023 when resident will be re-evaluated for medication effectiveness, continued elopement risk, determine if 15minute checks are to continue or check time adjusted and elopement risk assessment re-evaluation will be completed. B.) The facility will audit every 15 minutes visual checks every shift by Charge Nurse and continue to monitor visual checks ongoing per determined schedule based on elopement assessment. Elopement assessment will be re-evaluated every two weeks times 90days, then quarterly or more often as needed. 2. Resident 101, 85, 105 will have their elopement risk assessment re-evaluated and updated as applicable and care plan interventions for elopement risk will be updated as applicable by 12/15/2023. 3. On admission to the facility secured memory care unit, an elopement risk assessment will be completed on the day of admission to determine risk and safety needs and an elopement care plan will be initiated on the day of admission. 4. The elopement admission criteria policy and procedure will be updated to reflect elopement assessment process change by 12/15/2023. 5. All staff assigned to memory care unit and facility IDT will be in-serviced on updated policy and procedure regarding elopement assessment, risk and care plan interventions for safety by 12/15/2023 end of day, and ongoing. 6. The Administrator, DNS, Quality Assurance nurse will audit all new admissions to memory care unit for elopement assessment and care plan completion. 7. Environmental Service Department will monitor window alarm devices placement daily.

Based on interview and record review it was determined the facility failed to provide adequate bowel and bladder care for 2 of 3 sampled residents (#s 48 and 118) reviewed for bowel and bladder. This placed residents at risk for skin breakdown. Findings include: 1. Resident 48 was admitted to the facility in 11/2023 with diagnoses including left leg/hip fracture and right foot drop (difficulty lifting the front part of the foot) . A 11/2/23 care plan revealed Resident 48 required one staff person assistance with toileting and personal hygiene needs. A review of a FRI dated 11/6/23 revealed Resident 48 was placed on a bedpan by Staff 41 (CNA). The resident was left on the bedpan for 30 minutes before Staff 43 (CNA) entered the room and removed the bedpan from under Resident 48. The resident was assessed by Staff 42 (RN) directly after the incident and was noted to have an indentation from the bedpan, she/he was not painful, not upset, or angry. Staff 2 (DNS) interviewed all parties involved and concluded Staff 41 did not abuse Resident 48 but could not rule out neglect. On 12/12/23 at 11:46 AM Resident 48 indicated she/he was left on a bedpan for about 30 minutes. Resident 48 stated she/he was a little uncomfortable but did not have skin breakdown from the incident. Resident 48 indicated it was a "one time" occurrence and was dealt with appropriately. On 12/13/23 at 12:28 PM Staff 43 indicated she arrived for her shift on 11/6/23 and was informed by Staff 42 that Resident 48 needed to be taken off a bedpan because she/he had been on the bedpan for roughly 40 minutes. Staff 43 stated when she entered the resident's room the resident did not appear upset but asked for the bedpan to be removed. Staff 43 indicated she removed the bedpan and could see marks on her/his buttocks from the bedpan. On 12/13/23 at 6:41 PM Staff 42 stated he worked on 11/6/23 when Resident 48 was placed on a bedpan and Staff 41 forgot to remove the bedpan prior to leaving his shift. Staff 42 stated Resident 48 used her/his call light and Staff 43 removed the bedpan from underneath the resident. Staff 42 indicated the resident was assessed, was not angry or painful but indicated she/he was left on the bedpan "too long." On 12/18/23 at 9:27 AM Staff 41 (CNA) stated he cared for Resident 48 on 11/6/23 and acknowledged he placed the resident on the bedpan and forgot to remove the bedpan before he left his shift. Staff 41 indicated he was educated and in-serviced regarding the incident and that it was not a "purposeful" act and apologized to Resident 48. On 12/18/23 at 11:14 AM Staff 2 (DNS) confirmed and acknowledged the incident occurred regarding Resident 48 on 11/6/23. 2. Resident 118 was admitted to the facility in 11/2023 with diagnoses including right arm fracture and a history of a hip fracture. A 11/16/23 care plan revealed Resident 118 required two staff person assistance with toileting and required one staff person for personal hygiene needs. A review of Resident 118's Urinary Incontinence and Indwelling Catheter CAA, dated 11/28/23 revealed the resident was frequently incontinent of bladder. Staff were to anticipate her/his needs, offer toileting frequently throughout the shift and provide incontinence care as needed. On 12/12/23 at 10:48 AM and 12/13/23 at 1:02 PM Resident 118 and Witness 6 (Family Member) stated on two different occasions, staff neglected her/his call light and left her/him in a soaked brief and saturated bed for an extended period. Resident 118 indicated on one occasion staff failed to change her/him after dinner and she/he was not provided assistance until evening shift. On 12/13/23 at 12:28 PM Staff 43 (CNA) stated Resident 118 required assistance with incontinence care because of bladder incontinence and she/he was a " heavy wetter. " Staff 43 indicated the resident was upset about sitting in a wet brief and bed several times. Staff 43 stated she provided incontinence care, changed the resident's bedding, and reported her concerns to the charge nurse. On 12/13/23 at 6:51 PM Staff 42 (RN) stated Resident 118 had bladder incontinence and had sat in wet brief and bed. On 10/18/23 at 10:52 AM Staff 2 (DNS) and Staff 40 (RNCM) denied knowing that Resident 118 received inadequate incontinence care and sat in a wet brief and bed. Staff 2 stated staff were expected to round every two hours and check on residents' dryness before the end of their shift.

F690: Bowel/Bladder Incontinence: 1. Resident #48 and # 118 have discharged. 2. The 24 hour report process will be reviewed daily to determine if there are any concerns and grievances regarding timely toileting, incontinence brief management and the timely completion of the toileting and brief management process, as well as an audit of the facility purposeful rounding to ensure that resident needs are being met. 3. The nursing staff will be inserviced regarding timely response and completion of bowel and bladder care. 4. The Director of Nursing Services, Resident Care Manager and Quality Assurance Nurse or designee will complete random audits weekly regarding bowel and bladder care to ensure compliance. Any trends will be reported to the Quality Assurance and Assessment Committee.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy and to ensure respiratory equipment was maintained for 1 of 1 sampled resident (#89) reviewed for respiratory care. This placed residents at risk for adverse respiratory complications and outcomes. Findings include: Resident 89 was admitted to the facility in 6/2022 with diagnosis including COPD (chronic obstructive pulmonary disease). a. Resident 89's Physician Order Summary Report as of 12/13/23 revealed the resident was to wear oxygen at one to three liters to keep her/his oxygen saturation between 88 to 92 percent. Staff were directed to document the saturation levels three times a day. Resident 89's oxygen saturation levels from 11/12/23 through 12/12/23 indicated the resident wore oxygen at night and while oxygen was in use the resident's oxygen saturation levels ranged from 93 to 96 percent. The amount of oxygen the resident used at night was not documented. On 12/13/23 at 1:21 PM Staff 22 (RN) stated the resident wore oxygen at night for COPD with parameters to keep the resident's oxygen saturation levels between 88 to 92 percent. Staff 22 stated they kept Resident 89's oxygen on all night per the resident's preference even when her/his oxygen saturation level exceeded 92 percent. Staff 22 verified Resident 89's oxygen saturation levels were above 92 percent when she/he was administered oxygen. On 12/18/23 at 11:40 AM Staff 2 (DNS) confirmed Resident 89's oxygen saturation levels were at levels that exceeded the physician ordered parameter for oxygen administration. Staff 2 stated her expectation was for staff to follow the physician's orders. b. Observations on 12/11/23 and 12/13/23 revealed Resident 89's oxygen tubing did not indicate when it was last changed. Resident 89's 12/2023 Physician Orders and 12/2023 TAR revealed no order for oxygen tubing changes. On 12/13/23 at 1:21 PM Staff 22 stated Resident 89's oxygen tubing was to be changed weekly, and labeled with a date and initials of staff to indicate when they were last changed. Staff 22 confirmed Resident 89's oxygen tubing was not labeled and there was no physician order for oxygen tubing changes. On 12/18/23 at 11:40 AM Staff 2 stated her expectation was for residents receiving oxygen therapy to have a physician's order for oxygen tubing changes to be completed weekly.

F 695: Respiratory/Tracheostomy Care and Suctioning: 1. Resident 89 will have her oxygen orders reviewed with her primary provider and re-evaluate her oxygen needs, and her preferences and complete any order changes as applicable. The resident treatment orders have been reviewed and orders obtained from the primary physician regarding the changing of oxygen tubing. 2. All residents with oxygen use orders will be audited to determine that their physician ordered oxygen use and parameters as well as tubing changes are present and being followed. 3. All charge nurses will be educated on following physician orders for oxygen use and to notify the primary physician should the residents preference for oxygen use not be in alignment with the residents current oxygen orders. The charge nurses will be in-serviced on assuring that oxygen tubing change orders are in place. 4. The Director of Nursing and Resident Care Managers will monitor weekly for 90 days and report any Trends to the Quality Assurance and Assessment Committee

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 2 of 7 sampled residents (#s 17 and 57) reviewed for medication administration. The facility's medication error rate was 10.71%. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 17 was admitted to the facility in 12/2017 with diagnoses including diabetes. Resident 17's 12/14/23 physician's orders included Humalog insulin 8 units to be administered to the resident subcutaneously (under the skin) two times a day. The Humalog manufacturer instructions indicated a priming dose of two units prior to each dose with the Humalog insulin pen was required to remove air and ensure an accurate dose. On 12/13/23 at 8:09 AM Staff 8 (LPN) was observed to dial 8 units on the Humalog insulin pen without first performing the two unit priming dose. On 12/13/23 at 8:09 AM the surveyor stopped Staff 8 and asked about the priming dose. Staff 8 stated she did not routinely use a priming dose. On 12/13/23 at 8:32 AM Staff 5 (RNCM) stated a priming dose for the Humalog insulin pen was completed when the pen was first accessed and not with every dose. On 12/18/23 at 11:26 AM Staff 2 (DNS) stated she expected each dose of an insulin pen to be primed first with 2 units and medications were administered according to manufacturer instructions. 2. Resident 57 was admitted to the facility in 8/2018 with diagnoses including gastroenteritis and colitis (inflammation of the stomach and colon). Resident 57's Physician Order Summary Report as of 12/12/23 indicated the following scheduled medication orders: - polyethylene glycol (laxative) daily. Hold for loose stools. - senna-docusate sodium (laxative) twice daily. Hold for loose stools. Resident 57's bowel movement (BM) records indicated on 12/12/23 the resident had two soft/loose BMs and one large diarrhea BM. On 12/13/23 at 9:00 AM Staff 8 (LPN) was observed to administer Resident 57 the scheduled polyethylene glycol and senna-docusate sodium medications. On 12/13/23 at 11:39 AM Staff 8 stated her process was to check resident's bowel records prior to the administration of scheduled bowel medications. Staff 8 stated she was not aware of Resident 57's loose stools and acknowledged the resident's bowel medications should have been held for loose stools as the physician ordered. On 12/18/23 at 11:26 AM Staff 2 (DNS) confirmed Resident 57 had loose/diarrhea stools on 12/12/23 and the resident's scheduled bowel medications were not held as the physician ordered. Staff 2 stated she expected medications to be administered as ordered.

F759: Free of Medication Error 1. Resident #17 and #57 will be reviewed for insulin pen management and bowel management. 2. All residents with insulin pens will be audited and staff will be observed for accurate insulin pen priming competency and residents with current bowel care will be audited to determine that appropriate bowel care management is present. 3. All nursing staff will be in serviced on the use of insulin pens and the priming process for use and on as needed bowel care and when to hold in the presence of loose stools per primary physician order. 4. The Director of Nurses and the Resident Care Managers will complete random audits weekly for 90 days for the accurate priming of insulin pens and the accurate use of bowel medications for bowel management. Any trends will be reported to the Quality Assurance and Assessment Committee.

Based on observation, interview, and record review it was determined the facility failed to ensure 2 of 9 medication carts were properly secured during random observation. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications. Findings include: 1. On 12/12/23 observations were made from 9:56 AM to 10:12 AM of a medication cart left unlocked and unattended near rooms 208 and 209. On 12/12/23 at 10:12 AM Staff 24 (CMA) acknowledged the cart was unlocked and was to be locked at all times when not in use. On 12/18/23 at 9:09 AM Staff 2 (DNS) stated she expected the medication carts to be locked when the CMA and nurse were not at the cart. 2. On 12/13/23 observations were made from 12:47 PM to 1:02 PM of a medication cart left unlocked and unattended near the Center Hall dining room. On 12/13/23 at 1:02 PM Staff 6 (RN) acknowledged the cart was unattended and unlocked. On 12/18/23 at 9:09 AM Staff 2 (DNS) stated she expected the medication carts to be locked when the CMA and nurse were not at the cart.

F 761: Storage of Drugs and Biologicals 1. The facility has completed full facility rounding on the utilization of medication carts to determine that they are locked when not in direct use per the facility protocol. 2. All units are affected in the facility where medication carts are utilized. 3. The nursing staff will be in serviced on the protocol to keep all medication carts locked for safety when not in direct use or in line of site. 4. The Director of Nursing and Quality Assurance Nurse or Designee will audit weekly that all medication carts are locked when not in use and will complete on the spot education if any medication carts are noted to be unlocked. Any trends will be reported to the Quality Assurance and Assessment Committee.

OAR-411-085-0310: Residents' Rights: Generally Civil Rights

Refer to F550 ***** OAR-411-086-0130: Nursing Services: Notfiication Refer to F580 ***** OAR-411-085-0320: Residents' Rights: Charges and Rates Refer to F582 ***** OAR-411-086-0110: Nursing Services: Resident Care Refer to F684, F695 and F759 ***** OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care Refer to F689 and F690 ***** OAR-411-086-0260: Pharmaceutical Services Refer to F761 *****

Based on observation and interview it was determined the facility failed to individually identify rooms for 9 of 20 resident rooms (Room 51, 55, 57, 58, 60, 62, 65, 67 and 70) reviewed for shadow boxes. This placed residents at risk for not being able to identify their rooms and increased wandering. Findings include: On 12/11/23 at 11:00 AM the shadow boxes (a specific display designed to be decorated and elicit an emotional response or trigger a memory in a specific resident) outside the following rooms were observed to either be empty or only one generic item in them: Room 51, Room 55, Room 57, Room 58, Room 60, Room 62, Room 65, Room 67 and Room 70 On 12/15/23 at 12:27 AM Staff 58 (Resident Care Manager/LPN) stated she was unaware of the requirement that each room be individually identified to assist residents with recognition. Staff 58 confirmed the identified shadow boxes were not individualized to each resident as required.

Z176: Resident Rooms 1. Resident rooms 52, 55,57,58,60,62,65,67 and room 70 have all been reviewed for being individually identified. 2. All rooms will be audited for individual identifying items such as shadow boxes that are resident specific. 3. The Activity Director and Resident Care Manager will be inserviced on the requirement to have resident specific/individualize identifying information at the residents room to assist the resident identifying their room and assist in the reduction of wandering. 4. The Administrator, Assistant Administrator and Activity Director will audit weekly for 90 days to determine that information is located at each room and that it is individualized to the resident needs. Any trends will be reported to the Quality Assurance and Assessment Committee.

The findings of the state licensure and memory care unit health survey conducted on 12/11/23 to 12/18/23 are documented in this report. The survey was conducted to determine compliance with OAR 411 Division 57. For additional information, refer to Form CMS 2567 dated 12/18/23. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day BIMS: Brief Interview for Mental Status CAA: Care Area Assessment CBG: capillary blood glucose or blood sugar cm: centimeter CMA: Certified Medication Aide CNA: Certified Nursing Assistant CPR: Cardiopulmonary Resuscitation DNS: Director of Nursing Services F: Fahrenheit FRI: Facility Reported Incident HS or hs: hour of sleep LPN: Licensed Practical Nurse MAR: Medication Administration Record mcg: microgram MDS: Minimum Data Set mg: milligram ml: milliliters O2 sats: oxygen saturation in the blood OT: Occupational Therapist PCP: Primary Care Physician PO: by mouth, orally PRN: as needed PT: Physical Therapist RA: Restorative Aide RAI: Resident Assessment Instrument RD: Registered Dietitian ROM: range of motion RN: Registered Nurse RNCM: Registered Nurse Care Manager SA: State Agency SLP: Speech Language Pathologist TAR: Treatment Administration Record tid: three times a day UA: Urinary Analysis UTI: Urinary Tract Infection

The findings of the licensure and complaint (Intake #s 44484, 44588, 45251, 46117, 46428, 46548 and 46767) health survey conducted from 2/20/24 through 2/20/24 are documented in this report. The facility was found to be in substantial compliance with requirements for the OARs 411 Division 85 through 89.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 2 of 11 sampled residents (#s 18 and 25) reviewed for abuse. This placed residents at risk for verbal and physical abuse and psychosocial harm. Findings include: 1. Resident 3 admitted to the facility in 2020 with diagnoses including dementia. Resident 25 admitted to the facility in 2020 with diagnoses including dementia and stroke. Resident 3's 6/6/23 Progress Note indicated Resident 3 had a physical altercation with Resident 25. Resident 3 scratched Resident 25's face when Resident 25 accidentally bumped Resident 3's wheelchair. Resident 25 sustained a skin tear to the forehead which measured 0.4 cm x 0.3 cm. The 6/6/23 Facility Investigation revealed Resident 3 scratched Resident 25 on the forehead when Resident 25 accidentally bumped her/his wheelchair into Resident 3's wheelchair, which resulted in a 0.4 cm x 0.3 cm skin tear. On 8/9/23 at 12:20 PM Staff 2 (Quality Assurance RN) and Staff 3 (LPN Resident Care Manager) confirmed Resident 2 physically abused Resident 25 on 6/6/23 when Resident 3 scratched Resident 25's forehead. , 2. Resident 18 was admitted to the facility in 2016 with diagnoses including dementia, hypertension, and hyperlipidemia. Resident 18's 7/20/23 Admission MDS included Resident 18 had a BIMS score of 2 out of 15 indicating significant cognitive impairment. Resident 18's Care Plan dated 11/27/19, and revised on 10/24/22, revealed Resident 18 had a history of behaviors related to verbal and physical altercations related to verbal abuse. A Facility Incident Report dated 10/19/22 revealed Staff 24 (CNA) stated to Resident 19 "you think you are special; you are not better than everyone else." The facility conducted interviews with Staff 24 and identified Staff 24 admitted to the altercation. On 8/8/23 at 11:50 AM Staff 24 could not be reached for comment. On 8/8/23 at 12:02 PM Staff 3 (LPN) confirmed the incident of verbal abuse as well as the words that were spoken from Staff 24 on the day of incident. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) the verbal abuse findings were confirmed with all parties and no additional information was provided.

F 600 1. a. Resident number 3 has had their care plan reviewed and updated as applicable for mood and behavior. Resident number 25s injury has resolved without incident. b. Resident number 18 has discharged from the facility. 2. a. A random audit of residents will be completed regarding dignity and staff communication every two weeks for 90 days to assure that appropriate communication between staff and residents is occurring. 3. a. An inservice regarding resident monitoring in the facilities behavioral unit will be conducted to review the interventions of residents that wander into other resident spaces and how to mitigate resident to resident negative interaction. b. All nursing staff will complete mandatory communication training 4. The Director of Nursing, Staff Development and Quality assurance nurse will assure compliance and review audit results and need for further training through the facilities quality assurance and process improvement committee

Based on interview and record review it was determined the facility failed to provide timely ADL assistance for 1 of 4 sampled resident (#13) reviewed for ADL Assistance. This placed residents at risk for untimely and unmet care needs. Findings include: Resident 13 was admitted to the facility in 2022 with diagnosis including Gullain-Barre Syndrome (a condition that causes rapid muscle weakness). Resident 13's Care Plan dated 8/3/22 identified Resident 13 required assistance with toileting. A Facility Investigation Report dated 9/27/22 stated Resident 13 reported she/he was left on the commode for nearly an hour by Staff 23 (CNA). Resident 13 indicated no staff came to assist her/him off the commode until they were notified by family. The investigation revealed Staff 23 witnessed Resident 13's call light activation but continued to complete his daily duties as he assumed other staff were going to answer the call light. On 8/11/23 at 3:10 PM Staff 23 confirmed he walked past the resident's activated call light, but did not respond and assist Resident 13. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed Resident 13 did not receive timely ADL assistance. No additional information was provided.

F 677 1. Resident number 13 has been discharged from the facility as planned at the end of their skilled needs. 2. A random resident satisfaction audit will be conducted every two weeks for 90 days regarding ADL care and call light response to determine timely resident care and follow up as applicable. 3. All clinical staff will be inserviced regarding the requirement to answer all call lights timely 4. Director of Nursing, Staff development and Quality assurance nurse will review and respond to the satisfaction audit and report to the facilities quality assurance and process improvement committee, any trends noted and resolutions completed.

Based on interview and record review it was determined the facility failed to respond timely to a change of condition for 1 of 3 sampled residents (#26) reviewed for change of condition. This placed residents at risk for a delay in treatment. Findings include: 1. Resident 26 admitted to the facility on 6/19/23 with diagnoses including left femur fracture with left artificial joint. The 6/16/23 Pain Care Plan instructed staff to monitor, record and report to the nurse any signs or symptoms of non-verbal pain or complaints of pain. The 6/26/23 at 10:50 AM Progress Note revealed Resident 26 had increased pain to the left hip, was unable to work with therapy and the left leg appeared to be turned in. The physician was notified. The 6/26/23 Physician Encounter note revealed the resident had significant pain and a deformity was noted upon exam. An urgent x-ray was ordered and a left leg dislocation was suspected. The 6/26/23 Facility Investigation revealed Staff 5 (CNA) noted the resident had pain both times incontinent care was performed during the night shift, but did not report the pain to the nurse. Staff 6 (CNA) assisted the resident to transfer to the commode on day shift, had to utilize the sit-to-stand machine and noted the resident had pain. Staff 6 did not report the deviation from Resident 26's baseline related to transferring or the complaints of pain to the nurse. Staff 4 (LPN) observed the resident in her/his wheelchair sitting "awkwardly." Staff 4 assisted Resident 26 back to bed and noted the resident was weak, in pain and "not helping much to stand." The nurse provided the resident with a narcotic pain medication and ice, but did not assess the resident for the change of condition. Staff 10 (PT Assistant) assessed the resident and notified Staff 4 (at 10:00 am) the left leg was turned inward. Staff 4 then notified the physician. The 6/27/23 Physician Encounter Note revealed Resident 26 was transferred to the Emergency Department on 6/26/23 due to worsening pain in the left leg with notable internal rotation. Resident 26 was diagnosed with a prosthetic dislocation, she/he underwent a closed reduction in the Emergency department and was transferred back to the facility the same day. Staff 5 and Staff 6 were unavailable for interview. On 8/14/23 at 11:14 AM Staff 4 verified she assisted Resident 26 back to bed, noted she/he was painful and weak and confirmed Staff 10 was the staff member who assessed Resident 26's change of condition. On 8/14/23 at 11:30 AM Staff 8 (RNCM) confirmed both Staff 5 and Staff 6 did not report Resident 26's pain or change of condition to the nurse and Staff 4 did not assess Resident 26's change of condition. ,

F 684 1. Resident number 26 has discharged from the facility. 2. An audit will be completed every week regarding pain management to determine if any residents have had any unusual increase in pain through the facilities 24 hour report process. The Resident Care Managers assess any changes in pain that have been reported to assure appropriate and timely assessment and interventions have been completed. 3. The clinical staff will be inserviced regarding change in condition including the certified nursing assistants responsibility to report any changes in condition immediately to the licensed staff. 4. The Director of Nursing, Staff development and the quality assurance nurse will assure compliance has occurred and report any trends and resolutions to the facility quality assurance and process improvement committee

Based on interview and record review it was determined the facility failed to follow resident care plans related to transfers for 3 of 7 sampled residents (#s 1, 2 and 24) reviewed for safety and transfers. Resident 1 fell and sustained a femur fracture. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses including hypertension, lymphedema, and reduced mobility. The Admission MDS dated 9/15/22 indicated Resident 1 required two-person extensive physical assistance for transfers. Resident 1's Care Plan dated 8/30/22 identified Resident 1 to be at risk for falls due to decreased mobility and weakness. Interventions on the care plan included two person mechanical lift assistance for transfers. A Facility Investigation Report dated 6/15/22 at 3:10 PM indicated Resident 1 fell to the floor from the commode and sustained an oblique fracture of the right distal femur. According to the investigation, Staff 18 (CNA) assisted Resident 1 from the commode back to bed when Resident 1 slid from the commode to floor. This caused Resident 1's right leg to point inwards while her/his left leg remained straight. Staff 18 grabbed Resident 1 by the upper body and called for help. Staff 19 (CNA) assisted Staff 18 to lower Resident 1 to the floor. The investigation revealed Resident 1 sustained a right distal femur fracture as a result of the fall. Staff 18 indicated she did not follow Resident 1's care plan that required 2-person extensive assistance for transfers. On 8/8/23 at 10:30 AM the surveyor attempted to contact Staff 18 but was unable to reach her. On 8/8/23 at 1:08 PM Staff 19 stated Staff 18 called for help during the 6/15/22 incident and witnessed Resident 1 with both legs twisted while she/he began to slide to the floor. Staff 19 confirmed Resident 1 was a two-person transfer and Resident 1 sustained an injury as a result of the fall. On 8/8/23 at 1:37 PM Staff 20 (RN) stated Staff 18 reported the incident. Staff 20 further stated Resident 1 complained of pain and an x-ray was conducted at the facility which confirmed Resident 1 sustained a fracture and was transferred to the hospital. Staff 20 confirmed Staff 18 did not follow the care plan. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 9 (Regional RN) and Staff 2 (Quality Assurance RN) acknowledged Staff 18 did not follow Resident 1's Care Plan which resulted in a right femur fracture. 2. Resident 2 was admitted to the facility in 2018 with diagnoses including stroke and paralysis. The Admission MDS dated 7/21/23 indicated Resident 2 required two-person extensive physical assistance for transfers. Resident 2's Care Plan dated 7/10/23, revised on 4/17/23 identified Resident 2 to be at high risk for falls related to paralysis. According to Nursing Notes dated 6/21/22 at 7:59 AM and 10:30 AM, Staff 3 (LPN) indicated Resident 2 experienced pain near her/his left breast. The note revealed Staff 19 "strapped" Resident 2 too tightly then transferred her/him into a shower chair which caused significant pain and resulted in a 15 cm x 14 cm bruise near the left breast. Resident 2 was identified as a two-person assistance for transfers. A Facility Investigation Report dated 6/25/22 revealed Staff 19 confirmed the strap used to transfer Resident 2 was tightened too tightly. Staff 19 further indicated when he attempted to transfer Resident 2 the strap became unsecured which caused Resident 2 significant pain. Staff 19 removed the strap and reported the incident. The facility revealed Resident 2 sustained a significant bruise on her/his left breast. On 8/7/23 at 11:47 AM Resident 2 stated she/he was being transferred using a sit to stand device. Resident 2 indicated Staff 19 strapped her/him too tightly which caused significant discomfort. Resident 2 stated she/he had to communicate several times to the CNA to stop the transfer due to the pain before the CNA stopped. Resident 2 stated once the strap was removed a large bruise had formed near her/his left breast. Resident 2 confirmed to the surveyor that she/he required two-person assistance for transfers. On 8/7/23 at 2:43 PM Staff 19 (CNA) confirmed he did not follow the care plan when transferring Resident 2 which led to the bruise. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed the findings above and no additional information was provided. 3. Resident 24 was admitted to the facility in 2023 with diagnosis including atrial fibrillation and heart failure. The Admission MDS dated 4/12/23 indicated Resident 24 required two-person extensive physical assistance for transfers. Resident 24's Care Plan dated 4/5/23 indicated Resident 24 was a two-person transfer and required non-skid footwear and use of a transfer pole for all transfers. Resident 24 was identified as a fall risk due to gait, balance, vision, and hearing problems. A Facility Investigation Report dated 5/10/23 at 11:40 AM indicated Staff 4 (LPN) was alerted by Staff 21 (PT Assistant/PTA) that Resident 24 reported significant pain in her/his great right toe during physical therapy. Resident 24 indicated her/his foot slipped and hit a wall during a shower performed by Staff 22 (CNA). An x-ray was ordered which revealed Resident 24 sustained a fracture in her/his great right toe. Staff 22 (CNA) reported that despite knowing Resident 24 was a two-person transfer with a transfer pole and required non-skid socks, he did not believe it to be necessary. The Facility Investigation revealed Staff 22 failed to follow Resident 24's Care Plan related to transfers. On 8/11/23 at 11:22 AM Staff 22 confirmed he did not follow Resident 24's care plan, Staff 22 indicated he believed Resident 24 was not injured after she/he hit her/his foot based on his assessment and therefore did not report the incident to the Charge Nurse. Staff 22 confirmed Resident 24 sustained a fracture on the right great toe as a result of the incident. On 8/11/23 at 11:28 AM Staff 4 stated the incident was reported to her the day after by the PTA. Staff 4 stated she requested an order for an x-ray to be conducted on Resident 24's right big toe. Staff 4 confirmed a fracture of Resident 24's right big toe was sustained as a result of Staff 22 not following Resident 24's care plan. On 8/11/23 at 11:45 AM Staff 21 confirmed she was alerted by Resident 24 regarding the residents reported toe pain. Staff 21 confirmed Resident 24 sustained a fracture. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed the above findings and no additional information was provided.

F 689 1. Resident number 1 has been discharged from the facility, Resident number 2s injury has resolved without complications and her care plan has been reviewed for appropriate transfer needs and updated as applicable, Resident 24 has been discharged from the facility. 2. All resident unusual occurrences will be monitored through the facilities 24 hour report process and will be evaluated for appropriate follow through in care and services from the facility clinical staff as determined by the residents care plan. The facility will complete random observation of staff providing ADL transfer care every two weeks for 90 days to assure that residents care plans are being followed as written. 3. All clinical staff will be inserviced regarding the requirement to follow care plan interventions including but not limited to transfer training and the assistance needed for transfer training. 4. The Director of Nursing, Staff Development and the Quality assurance nurse participate in facility staff monitoring and report trends and resolutions to the facility quality assurance and process improvement committee.

Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: Resident 15 admitted to the facility in 8/2022 with diagnoses including congestive heart failure and chronic kidney disease. Resident 15's most recent Quarterly MDS dated 2/17/23 revealed a BIMS score of 15, indicating no cognitive impairment. Resident 15 was assessed to be an extensive assist with bed mobility, transfers and toileting, was continent of bowel and bladder and used a bedpan. The facility submitted a report to the state agency on 10/3/22 which revealed Resident 15 told a staff member she/he was left on the bedpan for one and a half hours on 9/30/22. She/he stated the call light was activated around 6:00 PM and she/he waited a long time for a CNA to respond. The facility's investigation concluded the agency CNA who initially assisted Resident 15 on the bedpan left for her meal break and assumed the other CNA would assist the resident off the bedpan. The other CNA was unable to assist the resident and she/he was not assisted for approximately two hours. Resident 15 reported discomfort on her/his back and coccyx while on the bedpan but sustained no injuries. Resident 15 was not interviewed due to discharging from the facility. Resident 19 admitted to the facility in 4/2022 with diagnoses including stroke and heart disease. Resident 19's Quarterly MDS dated 10/21/22 revealed a BIMS score of 12, indicating moderate cognitive impairment. Resident 19 was assessed to be an extensive assist with bed mobility, transfers and toileting. She/he was incontinent of bowel and bladder and wore incontinent briefs. On 8/16/23 at 1:22 PM, Witness 1 (Family Member) stated she frequently visited Resident 19 from 4/2022 through 11/2022, recalled the resident had on a wet or soiled brief, and it took staff half an hour to an hour to respond. Witness 1 stated she had to find staff due to nobody answering the call light and upon responding staff told her they were short-staffed. Witness 1 recalled a few occasions when Staff 15 (CNA) was the only CNA on the hall and could not reposition or provide cares to Resident 19 alone. On 8/8/23 at 10:49 AM and 8/14/23 at 2:20 PM, Staff 13 (CNA) stated last fall and winter was "really bad" related to staffing levels and day shift was the least staffed. She/he recalled CNA's had up to 12 residents assigned to them on a shift, there were long call light response wait times, delayed care for residents, and "it was chaotic." Staff 13 stated the current resident assignent for CNA's was six to seven residents but there were times when showers were not given due to time constraints. On 8/14/23 at 12:12 PM Staff 15 recalled the facility was short-staffed 11/2022 and 12/2022 and the resident assignments were higher than usual. Staff 15 recalled she/he finished resident cares but was unsure if other staff were able to finish the care timely. On 8/14/23 at 2:41 PM, Staff 14 (CNA) stated the facility was short-staffed in the fall of 2022 and cares were provided late which included taking vital signs, bringing water and snacks to residents and completing incontinence care timely. Staff 14 recalled she/he was assigned up to 11 residents and the average ratio for evening shift was nine residents per CNA. Review of the Direct Care Staff Daily Reports from 9/1/22 through 9/30/22, 10/1/22 through 10/31/22, 11/1/22 through 11/30/22 and 12/1/22 through 12/31/22 revealed the facility did not meet state staffing requirements for CNAs for 16 out of 30 days in 9/2022, 14 out of 31 days in 10/2022, 21 out of 30 days in 11/2022 and 19 out of 31 days in 12/2022. The majority of the staffing shortages were for day shift. On 8/14/23 at 2:21 PM, Staff 11 (Staffing Coordinator) confirmed the facility was short staffed from 9/2022 through 12/2022 and it was challenging to find staff willing to work day shifts.

F 752 1. Resident 15 and resident 19 have both been discharged from the facility. 2. Resident rounds will be completed every two weeks for 90 days to monitor for call light response and ADL resident care completion. Any concerns or trends will be reported to the Director of Nursing Services and the facility Quality Assurance nurse for intervention. Clinical staff will be inserviced on call light and ADL completion responsibility at mandatory CNA and licensed Nursing meetings. . 3. The facility has added two additional licensed nurses to the day shift to assist in managing workflow and assure that care and services are being provided timely, including call light response and resident ADL care needs. The facility, to ensure that State staffing ratio mandates are met, will have the staffing coordinator report to the Director of Nursing and Administrator when the facility is at risk for or is not meeting mandated ratio. The Director of Nursing and Administrator will put an action plan in place to meet the staffing ratio needs, which includes ensuring that clinical staff are contacted to inquire regarding availability to cover the appropriate position that is vacant at the time, notifying all contracted agency of staffing needs for the current vacancy and determining their availability and assigning staff from existing roles into the vacant role as qualified, such as certified medication aid or restorative aid into the CNA position, Resident Care Manager, Quality Assurance Nurse, Staff development nurse, admission nurse, or resident care manager as available into vacant positions. The facility also has a bonus policy that is implemented to assist in filling in vacant positions for both facility staff and agency staff. The facility will audit all of the agencies regarding their staffing availability and add contracted agencies as available to increase the potential for available staff as needed. The facility continues to place and support individuals into community CNA classes as available and continues to advertise and hire and train clinical staff to meet the mandated facility staffing ratios. Staffing needs will be discussed at the facility stand up meeting daily to determine if any changes to internal staffing assignments needs to be completed. 4. Director of Nursing, Staffing Coordinator and Administrator will monitor through 24 hour report and review weekly for trends and resolutions needed and report to the facility quality assurance and assessment committee

Based on interview and record review it was determined the facility follow proper infection control techniques during bowel care for 1 of 1 sampled resident (#18) reviewed for bowel care. This placed residents at risk for cross contamination. Findings include: Resident 18 was admitted to the facility in 2016 with diagnoses including dementia, hypertension, and hyperlipidemia. Resident 18's 7/20/23 Admission MDS identified Resident 18 with a BIMS score of 2 out of 15 which indicated significant cognitive impairment and frequent bowel and bladder incontinence. A Facility Incident Report dated 10/19/22 revealed Staff 24 (CNA) performed improper infection control related to the use of gloves and handling of Resident 18's bowel care. Staff 24 stated she did not wear gloves when providing bowel care or when performing peri care. Staff 24 further stated she used the same wipes used to the clean the toilet on Resident 19's skin. On 8/8/23 at 11:50 AM Staff 24 could not be reached for comment. On 8/8/23 at 12:02 PM Staff 3 (LPN) confirmed Staff 24 performed improper infection control procedures and practices related to cleaning and hygiene. Staff 3 indicated Staff 24 used the same wipes to clean Resident 18's toilet on Resident 18's skin and confirmed Staff 24 handled Resident 18's bowel movement without gloves. On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed the above findings and no additional information was provided.

F 880 1. Resident 18 has been discharged from the facility. 2. Random resident ADL care observations will be completed every two weeks for 90 days to determine that ADL care, pericare, environmental surface cleaning and proper infection control practices are being carried out and maintained including handwashing and the use of gloves. 3. All Clinical staff will be inserviced on appropriate infection control practices which include handwashing, appropriate donning and doffing of gloves, and how to complete appropriate resident bowel care, pericare and environmental surface cleaning. 4. Director of Nursing, staff development and quality assurance nurse to review audits, observations and report any trends and resolutions to the facility quality assurance and process improvement committee

************************** 411-085-0360 Abuse Refer to F600 ************************** 411-086-0110 Nursing Services: Resident Care Refer to F684 ************************** 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689 ************************** 411-086-0100 Nursing Services: Staffing Refer to F725 ************************** 411-086-0330 Infection Control and Universal Precautions Refer to F880 **************************

Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 3 was admitted to the facility in 2021 with diagnoses including Alzheimer's disease. A 2/4/23 Progress Note (PN) revealed Resident 3 and Resident 2 were observed in an altercation in the common area, Resident 3's left arm was in the grip of Resident 2's hand. There was a small bruise and a skin tear noted to Resident 3's arm from the altercation. A 2/4/23 Incident report indicated staff were aware Resident 2 and 3 should not be near each other due to known behaviors. The incident report further indicated staff were in proximity to Residents 2 and 3 however were not paying close attention to the residents. On 3/29/23 Staff 3 (LN), Staff 4 (CNA), and Staff 5 (CNA) confirmed Resident 3 and Resident 2 were to be kept apart due to their behaviors. On 4/5/23 at 12:13 PM Staff 7 (Care Manager) confirmed the altercation occurred between Resident 3 and Resident 2.

F 600: 1. Resident 2 and Resident 3 will have their current care plan interventions re-evaluated with the nursing staff for appropriate preventative interventions regarding resident -to- resident interactions due to their behavior patterns and updated as appropriate 2. All residents in the Memory Care Unit will have their care plan re-evaluated by the nursing staff for appropriate preventative interventions regarding their behavior patterns and potential for resident-to-resident interactions that have the potential for physical altercation or psychosocial negative outcomes. 3. The nursing staff in the Memory Care Unit will be re-educated on resident behaviors patterns related to potential resident -to-resident interactions that can result in physical altercation or psychosocial negative outcomes . The nursing staff will be re-educated on the interventions available to be used to prevent resident- to- resident altercations as listed on the resident individualized care plans. The nursing staff will also be re-educated to report to their nursing supervisor and resident care manager when interventions need to be adjusted or are not preventing resident – to – resident events. 4. The Resident Care Manager, Director of Nursing and Social Services will review behavior patterns weekly for the next 90 days then through the facility psychotropic and behavior management meeting. Outcomes will be reported to the facility Quality Assurance and Process Improvement Committee 5. This will be completed by 5/25/2023

Based on interview and record review it was determined the facility failed to complete a thorough investigation for 1 of 3 sampled residents (#6) reviewed for abuse. This placed residents at risk for inaccurate investigations. Findings include: Resident 6 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease. Resident 6 had incident reports and summaries on the following dates: A 12/1/22 incident report Indicated Resident 6 had two new bruises. The facility suspected resident behaviors to be the cause. The resident stated, "I got beat up by someone." There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found. A 1/6/23 incident report indicated Resident 6 had a new bruise to the right lateral upper thigh. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found, and no new interventions initiated. A second 1/11/23 incident report indicated Resident 6 had a new bruise to the left lower outer leg. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found. A 1/19/23 incident report indicated Resident 6 had a new skin tear to her/his left arm. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A potential cause was identified but no new interventions were put in place. A 1/28/23 incident report indicated Resident 6 had a new bruise to the left upper chest measuring 4 cm by 3.4 cm. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found. A 2/2/23 incident report indicated Resident 6 had a new bruise to the anterior left upper arm. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found. A 2/7/23 incident report indicated Resident 6 had a new bruise to the right upper chest area measuring 3 cm by 5 cm, and a bruise to the back of her/his left thigh. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found, and no new interventions implemented. On 4/5/23 at 12:13 PM Staff 7 (LN Care manager) confirmed these investigations were not thorough.

F 610: 1. Resident number 6 expired on 02/11/23 2. The facility instituted a new weekly skin monitoring process in February of 2023. This process is monitored weekly by the facility Resident Care Managers and the Director of Nursing. All residents with bruising that are present on the weekly skin monitoring assessment review will be evaluated for a complete investigation of cause including staff witness statements by the Resident Care Managers and the Director of Nursing if the investigation has not already been completed. 3. The Resident Care Managers will be in-serviced on the investigative process for bruises or any injury of unknown origin including cause and effect and witness statements as well as prevention planning. 4. The Administrator and Director of Nursing will monitor weekly for 90 days then monthly and report any trends and outcomes to the Quality Assurance and Process Improvement Committee 5. This will be completed by 5/25/2023

Based on interview and record review it was determined the facility failed to provide adequate foot care for 1 of 3 sampled residents (#6) reviewed for diabetic foot care. This caused Resident 6 to develop a full thickness diabetic foot ulcer. This placed other residents at risk for increased foot problems. Findings include: Resident 6 was admitted to the facility in 2017 with diagnoses including diabetes with neurological complication. Review of Resident 6's clinical record revealed the following: A care plan intervention initiated 7/2017 revealed Resident 6 was to always wear her/his custom diabetic shoes when up and or mobilizing. According to the resident's record she/he was provided new diabetic shoes on an annual basis from 2019 through 2021. On 5/2/22 secure communication with the physician noted the top of all the toes on Resident 6's left foot were pink, possibly from the resident's shoes. Resident 6's clinical record indicated she/he was not reassessed, the care plan was not updated to address potential issues with the shoes not fitting, and monitoring of the resident's toes was not initiated. There was no documentation in Resident 6's clinical record indicating her/his toes were being monitored daily by a licensed nurse. According to the resident's record, in June of 2022 the resident did not receive new diabetic shoes due to a physician refusing to sign the authorization request. Progress notes dated 10/1/22 indicated Resident 6 had a full thickness wound to the top of her/his left great toe. A United Wound Healing (UWH) progress note dated 10/20/22 indicated not to use the diabetic shoes due to the shoes causing increased irritation to the left foot. A UWH progress note dated 10/25/22 indicated despite wound nurse recommendations, Resident 6 still wore her/his old diabetic shoe over the full thickness ulcer on her/his left great toe. Additionally, a blister to the same toe as the full thickness ulcer was noted to have formed since 10/20/22. On 3/29/23 at 3:37 PM Staff 9 (CNA) stated in the last six months Resident 6 stated she/he did not like her/his shoes, they made her/his feet hurt. Staff 9 also stated there were times when Resident 6 had non-skid socks and her/his shoes on and that caused a lot of pain to the resident as well. There was no documented evidence in Resident 6's clinical record this information was reported, and no changes were made to the resident's care as a result. On 4/5/23 at 12:13 PM Staff 7 (Care Manager) stated Resident 6's foot wound could have been caused by her/his old diabetic shoes not fitting properly. On 4/7/23 at 3:38 PM Witness 3 (Wound RN) indicated Resident 6 had a claw toe which raised the knuckle up; it put her/him at risk because the toe rubbed on any type of surface not designed to take that into consideration. She advised the facility to stop use of the resident's old shoe, however it was noted still on the left foot five days after she advised the shoe to no longer be used. Witness 3 indicated given the information available, Resident 6's shoes were the cause of irritation that led to the diabetic foot ulcer.

F 687 1. Resident number 6 expired on 2/11/23 2. The facility instituted a new weekly skin and wound care monitoring assessment in February 2023. This weekly skin monitoring has had the area of wound is not improving or getting worse included in the monitoring. The Resident Care Managers and the Director of Nursing review weekly for completion. The Resident Care Managers rounds with the outside wound care provider. The outside wound care provider will be required to exit with the Director of Nursing Services and/or the facility administrator to review any recommendations that have been made post resident rounds with each units Resident Care manager to assure that any follow up recommendations occur timely. The wound care reports from the outside provider will be reviewed by the Director of Nursing Services with a weekly update to the facility Administrator for completion of follow up. A review of all residents currently receiving wound care from the outside provide will be completed for timely follow up on recommendations. 3. The Resident Care Managers will be in-serviced on following up on all recommendations from outside wound care providers and will be required to notify the Director of Nurses when recommendations are completed. The Director of Nurses will follow up with the Resident Care Managers weekly for completion of wound care recommendations. 4. The Resident Care Managers, Director of Nurses and Administrator will monitor weekly for 90 days and then monthly thereafter for timely completion and follow up on all wound care recommendations and report any trends to the facility Quality Assurance and Process Improvement Committee for follow up. 5. This will be completed by 5/25/2023

Based on interview and record review it was determined the facility failed to ensure a resident received sufficient fluid intake for 1 of 3 sampled residents (#6) reviewed for hydration. This failure resulted in Resident 6 being hospitalized due to dehydration. This placed residents at risk for dehydration. Findings include: Resident 6 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease and difficulty swallowing. A 3/28/19 aspiration care plan indicated Resident 6 had a diet order of General/Puree/honey thick liquids; no straws, liquids via 2 handled cup. Resident 6 was to be close 1:1 supervision with full 1:1 cueing and 1:1 assistance as indicated for eating and drinking. The care plan provided no info on how resident 6 was to get drinks between meals, or how the resident was being monitored specifically for dehydration. A 6/29/21 and 4/19/22 medical nutritional therapy assessment indicated Resident 6 required an estimated 1700 milliliters of fluids per day. A review of Resident 6's meal and fluid intake record for 4/2022 revealed the following intakes: 4/1 - 940 mL 4/2 - 833 mL 4/3 - 640 mL 4/4 - 1000 mL 4/5 - 980 mL 4/6 - 400 mL 4/7 - 680 mL 4/8 - 720 mL 4/9 - 640 mL 4/10 - 720 mL 4/11 - 870 mL 4/12 - 710 mL 4/13 - 240 mL 4/14 - RNA 4/15 - RNA 4/16 - --- 4/17 - 240 mL 4/18 - 1030 mL 4/19 - 660 mL 4/20 - 820 mL 4/21 - 360 mL 4/22 - 720 mL 4/23 - 1000 mL 4/24 - 400 mL A progress note dated 4/24/22 indicated resident 6 was sent out to the emergency room for evaluation due to low blood pressure and increased respirations. A progress note dated 4/27/22 indicated Resident 6 was re-admitted from the hospital with diagnoses including dehydration and lethargy. Hospital Records dated 4/27/22 indicated Resident 6 was treated in the hospital for free water deficit and received three liters of fluids. On 4/7/23 at 10:58 AM Staff 11 (RN) indicated new interventions were put in place to monitor Resident 6's fluid status after returning from the hospital due to dehydration.

F 692: 1. Resent number 6 expired on 02/11/2023 2. The facility will review all residents who currently are care planned for 1:1 dining assistance, aspiration precautions and thickened liquid fluid consistency for adequate fluid consumption. This will include a review of the resident’s most current RD recommendations. If concerns are noted in fluid balance, then the primary provider will be notified and an RD evaluation will be requested. A review of resident’s with blood pressures that are below the physician parameters will also be completed to determine the cause of the low blood pressure and if any intervention is needed per the primary provider. Any changes in meal or fluid intake will be reported on the facilities 24 hour report and reviewed in the facilities interdisciplinary team stand up process. 3. The nursing staff will be in-serviced on the need to monitor fluid consumption in alert charting and through a fluid intake log that will be updated by the facility on those residents that are not meeting the recommended RD fluid requirements. The nursing staff will be in-serviced on notification to the primary provider of changes in meal and fluid intake timely. The Resident Care Managers will be in-serviced on changes in condition related to meal and fluid intake and interventions to be completed, primary provider notification, alert charting, fluid monitoring and Care plan revisions as applicable. 4. The Resident Care Managers, Director of Nursing and Administrator will monitor weekly for 90 days and then monthly. Any trends will be reported to the Quality Assurance and Process improvement Committee for interventions as applicable 5. This will be completed by 5/25/2023

Based on interview and record review it was determined the facility failed to process physician laboratory orders timely for 1 of 3 sampled residents (#8) reviewed for laboratory services. This placed residents at risk for untreated conditions. Findings include: Resident 8 admitted to the facility in 2020 with diagnoses including chronic kidney disease. A physician order dated 12/10/20 indicated staff were to obtain a UA with C & S (culture and sensitivity) for Resident 8. A physician progress note dated 12/14/20 indicated a C & S was not received. A physician progress note dated 12/16/20 indicated the physician ordered a second UA and C & S due to the results of the first C & S not being completed. Laboratory services results indicated the second UA was completed with no bacteria seen on 12/20/20. This was 10 days after the original order was given. A stat physician order dated 6/1/21 indicated the physician ordered a UA with C & S for Resident 8. Laboratory services results indicated an Automated UA was completed on 6/1/21, a C & S was not completed despite the facility sending the order correctly. A 6/7/21 physician progress note indicated the C & S result never returned despite facility request. The progress note further indicated a second UA and C & S was ordered. On 4/5/23 at 12:51 PM Staff 1 (Administrator) acknowledged the laboratory was not able to complete orders correctly. Staff 1 further stated the facility identified failures of that laboratory services company in early 2022. Staff 1 interviewed other laboratory services and switched companies in June of 2022. During survey, residents had laboratory services available to them. Lab requests were made, and results returned timely. On 5/15/22, the Past Noncompliance was corrected when the facility completed an investigation into new laboratory services and signed a new contract. The Plan of Correction included: 1. QA discussion of intermittent problems, 2. Conversations with old lab representatives, 3. Contact with other facilities for other possible laboratory options. 4. Negotiations and contract signing on 5/12/22 with new laboratory.

Based on interview and record review it was determined the facility failed to ensure hospice residents were routinely evaluated by physicians for PRN psychotropic use for 1 of 3 sampled residents (#4) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: Resident 4 was readmitted to the facility in 2023 for palliative care and ankle and foot infection. A faxed physician order dated 1/12/23 indicated Resident 5 was prescribed Haloperidol (Antipsychotic) as needed. There was no stop date indicated on the physician order. A faxed physician order dated 2/23/23 indicated Resident 5 was prescribed Quetiapine (Antipsychotic) one tab three times a day as needed. Thirty tabs in the initial order with three refills authorized which resulted in a 30 days' supply. There was no stop date indicated on the physician order. The 1/2023 through 2/2023 MAR indicated Resident 4 had orders for Haldol (antipsychotic) every four hours PRN for agitation or hallucinations. Order start date of 1/18/23 and a discontinue date of 2/23/23. There were no provider notes indicating Resident 4 was re-evaluated in person for the use of PRN Haldol for more than two weeks. The 2/2023 through 3/2023 MAR indicated Resident 4 had orders for Seroquel (Antipsychotic) every eight hours PRN for dangerous agitation or aggressive behaviors. Order start date of 2/23/23 and a discontinue date of 3/18/23. The Seroquel order description was changed by the facility multiple times however the dosage order remained the same. There were no provider notes indicating Resident 4 was re-evaluated in person for the use of PRN Seroquel. On 3/26/23 at 12:56 PM Staff 4 (Resident Care Manager) stated Resident 21 readmitted to the facility on hospice services. Staff 4 stated there was no evidence the hospice provider re-evaluated the PRN Haldol. Staff 4 added the provider gave an extension past the 14 days of the order. On 3/27/23 at 8:38 AM Staff 2 (DNS) was asked about PRN antipsychotic medications and stated the facility asked hospice to reassess and reorder the medication. Staff 2 added the facility needed to follow up with hospice. On 4/4/23 at 1:17 PM Staff 10 (RN) confirmed when hospice sent orders, they never put a stop date on the orders. Staff 10 further stated she could not recall ever seeing a hospice provider in the facility and knew hospice did not like being told a face-to-face visit was required or a medication stop date.

F 849: 1. Resident number 4 expired on 03/21/2023 2. The facility will review all Hospice resident’s with PRN psychotropic medications to determine if any resident’s have not been routinely evaluated by Physicians for PRN psychotropic use. The facility will contact the facilities contracted Hospice Providers regarding this regulatory requirement and that it must be met for the use of PRN psychotropic medications. The facility will contact the facility Medical Director for assistance with the Hospice providers in meeting this regulation and utilize the assistance of the primary provider if Hospice cannot meet the routine psychotropic review. 3. The Resident Care Managers will be in-serviced to report any residents that are on hospice that have PRN psychoactive medications to the Director of Nursing when the order is received for follow up on regulatory requirements. The Resident Care Managers will continue to report any orders for psychotropic medications in the facility stand up interdisciplinary team meeting. The facility will also review all PRN psychotropic medications for regulatory compliance through the facility psychotropic review meeting. 4. The Resident Care Manager, Quality Assurance Director and the Director of Nursing will monitor monthly for follow through and will report any trends to the Quality Assurance and Process Improvement Committee for intervention as applicable. 5. This will be completed by 5/25/2023

Based on interview and record review it was determined the facility failed to implement their Antibiotic Stewardship program to ensure antibiotics were used in accordance with current FDA (Food and drug administration) and CDC guidance for 2 of 3 sampled residents (#s 5 and 8) reviewed for infections. This placed residents at risk for proliferation of drug resistant organisms. Findings Include: 1. Resident 8 admitted to the facility in 2020 with diagnoses including chronic kidney disease. A. A physician progress note dated 12/10/20 indicated Resident 8 had increased weakness, fatigue, and poor appetite over the last 1-2 days. There were no reports of localized signs, symptoms, or fever. Resident 8's vitals were normal. A physician order dated 12/10/20 indicated staff were to obtain a UA with C & S (culture and sensitivity-determines appropriate antibiotic for the identified infection) for Resident 8. A physician order dated 12/10/20 indicated staff were to initiate treatment for urine infection with Cephalexin (antibiotic) for five days. Antibiotics were started without the C & S. A physician progress note dated 12/16/20 indicated the physician ordered a second UA and culture and sensitivity due to the results of the first not being completed A physician order dated 12/16/20 indicated Resident 8 was to be administered Ceftriaxone (antibiotic) for five days. Laboratory service results indicated the second UA was completed with no bacteria seen on 12/20/20. A review of Resident 8's clinical record indicated antibiotics were administered without indication for use. On 4/6/23 at 11:15 AM Staff 2 (DNS) confirmed the antibiotics were started early and the facility should have spoken with the physician regarding antibiotic stewardship (waiting for C & S) prior to starting the antibiotic. B. A physician progress note dated 6/1/21 indicated resident 8 was noted to have increased lethargy and reduced intake for the last two days. No other symptoms noted. A stat physician order dated 6/1/21 indicated a UA with culture and sensitivity (C & S) for Resident 8. A physician order dated 6/2/21 indicated Resident 8 was to be administered Cephalexin (antibiotic) for five days. A 6/7/21 physician progress note indicated the culture and sensitivity result never returned despite facility request. On 4/6/23 at 11:15 AM Staff 2 (DNS) confirmed the antibiotics were started early and the facility should have spoken with the physician regarding antibiotic stewardship (waiting for C & S) prior to starting the antibiotic. 2. Resident 5 admitted to the facility in 2021 with diagnoses including urinary incontinence. A progress note dated 1/9/23 indicated Resident 5 was shivering and walked around the unit. Resident 5's blood pressure was slightly elevated; all other vitals were within normal range. The progress notes also indicated the resident had a low-grade fever the night before. On 1/9/23 secure communication between the facility and Resident 5's physician revealed the physician ordered a UA with C & S (culture and sensitivity). Once the facility notified the physician the urine was collected for analysis the physician ordered Cipro (antibiotic) to be started immediately for a UTI. Resident 5's record indicated the C & S was reported to the facility on 1/12/23, three days after the antibiotic was started. On 4/6/23 at 11:15 AM Staff 2 (DNS) confirmed Resident 5's physician started antibiotics prior to the receipt of the C & S.

F881: 1. Resident number 5 has not had any further Urinalysis ordered since the 1/10/23 ordered Urinalysis collection date. Resident number 8 was discharged on 06/15/2021 2. All residents that have urinalysis or other laboratory testing to determine the potential or actual infection process and who are started on antibiotic therapy will be reviewed in the facility stand up process with the interdisciplinary team members. If any antibiotics are started without the results of the ordered laboratory testing, a review will be completed by the Resident Care Manger and the Director of Nursing to determine the reason for the initiation of the antibiotic prior to final laboratory results. This reasoning will be documented in the clinical record. The facility will contact the facilities Medical Director to review antibiotic initiation in relationship to antibiotic stewardship protocols for follow up with providers who are initiating antibiotics without laboratory results completed and without documented rationale. 3. The Resident Care Managers will be in-serviced to review all antibiotic orders and corresponding laboratory testing orders for compliance with the facilities antibiotic stewardship policies and procedures. 4. The Director of Nursing and the facilities Infection Preventionist will monitor weekly for 90 days then monthly thereafter and report findings to the facility Quality Assurance and Assessment Committee Quarterly. Any trends noted will be reported to the Quality Assurance and Improvement Committee monthly for intervention as applicable. 5. This will be completed by 5/25/2023

************************************************************* OAR 411-085-0360 Abuse Refer to F600 ************************************************************* OAR 411-085-0360 Abuse Refer to F610 ************************************************************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F687 ************************************************************* OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 ************************************************************* OAR 411-086-0010 Administrator Refer to F772 ************************************************************* OAR 411-086-0010 Administrator Refer to F849 ************************************************************* OAR 411-086-0330 Infection Control and Universal Precautions Refer to F881 *************************************************************

Based on interview and record review it was determined the facility failed to complete admission and annual MDSes, for 4 of 9 sampled residents (#s 1, 2, 3 and 9) reviewed for MDS. There were an additional 26 non-sampled residents with incomplete admission or annual MDSes. This failure was determined to be an immediate jeopardy situation because it put residents at risk for unmanaged medications, side effects from medications, skin conditions, and unknown needs that were never identified or addressed, which could have led to permanent injury, severe infection, and unknown potential harm due to the lack of comprehensive assessment. Findings include: 1. Resident 1 admitted in 2022 with diagnoses including dementia, depression, and neurocognitive disorder with Lewy body dementia (uncontrolled body movements and hallucinations). Review of Resident 1's record indicated the following was missing: - 11/7/2022 Admission MDS was incomplete. - Comprehensive care plan was incomplete. - Monitoring of symptoms and side effects for clonazepam (antianxiety medications). - Monitoring of symptoms and side effects for Olanzapine (antipsychotic medications). - Monitoring of symptoms and side effects for Paroxetine (antidepressant medications). Failure to assess for the appropriate use of these medications and failure to monitor for symptoms and side effects of these medications can lead to seizures, internal bleeding, difficulty breathing, uncontrolled body movements, loss of self-control, swelling, and thoughts of suicide. The incomplete admission assessment also resulted in a failure to assess the resident's functional capacity and needs, and an appropriate plan of care for, but not limited to, the following: -Infections, psychotropic medications, behavioral health, permanent side effects from medications, vision and dental needs, trauma informed care, appropriate activity and socialization, cultural and religious needs as well as other unassessed needs. This failure put Resident 1 at risk for unmonitored medications, behavioral health issues, psychotropic medication reactions, and any number of unknown treatable conditions due to a lack of assessment. This deficiency was likely to result in permanent injury, severe infection, mental anguish, and/or exposed other residents in the facility to potential behaviors. On 1/18/23 at 11:14 Staff 4 (RN) stated she believed all MDSes she was responsible for were completed and was unaware Resident 1's MDS was not completed. On 1/24/23 at 7:00 PM - Staff 3 (RN Consultant) confirmed the comprehensive care plans and monitoring of medications were not in place due to the Admission MDS not being completed. 2. Resident 3 admitted in 2022 with diagnoses including Parkinson's disease, depression, and osteoporosis. Review of Resident 3's record indicated the following was missing: - 8/29/22 Admission MDS. - Comprehensive care plan. - Assessment of and monitoring for symptoms and side effects for Paroxetine (antidepressant medications). - Assessment of and monitoring for symptoms and side effects for Carbidopa-Levodopa (Parkinson's medications). - A care plan for antipsychotic medications. Failure to monitor for symptoms and side effects of these medications can lead to internal bleeding, swelling of face, throat, thoughts of death, uncontrolled movement, seizures, and difficulty breathing. The incomplete admission assessment also resulted in failure to assess the resident's functional capacity and needs, and lack of an appropriate provide a plan of care for, but not limited to, the following: - Infections, psychotropic medications, behavioral health, permanent side effects from medications, pain, vision and dental needs, trauma informed care, cultural and religious needs, weight and fluid management and other unassessed needs. These failures put Resident 3 at risk for unmanaged medications and side effects, unmonitored behaviors, potential vision impairment, dental pain, and any number of unknown treatable conditions due to a lack of assessment. This deficiency was likely to result in permanent injury, severe infection, mental anguish, and/or potentially exposed other residents in the facility to behaviors. On 1/25/22 at 12:42 Staff 5 (RN) confirmed the monitoring, care plans, and MDS were missing or incomplete. 3. Resident 2 admitted in 2022 with diagnoses including mental and behavioral disorders, chronic obstructive pulmonary disorder, presence of cardiac pacemaker, and heart failure. Review of Resident 2's record indicated the following was missing: - 10/17/22 Admission MDS was incomplete. - Comprehensive care plan was incomplete. The incomplete admission assessment resulted in a failure to assess the resident's functional capacity and needs, and lack of an appropriate plan of care for, but not limited to, the following: -Infections, behavioral health, pain, vision and dental needs, trauma informed care, appropriate activity and socialization, respiratory problems, cultural and religious needs as well as other unassessed needs. This failure put Resident 2 at risk for behavioral health issues, vision issues, dental problems, pain, medication reactions, breathing issues, and any number of unknown treatable conditions due to a lack of assessment. This deficiency was likely to result in permanent injury, severe infection, mental anguish, and could have exposed other residents in the facility to behaviors. On 1/24/23 at 7:00 PM Staff 3 (RN Consultant) confirmed the comprehensive care plans were not in place due to the Admission MDS not being completed. 4. Resident 9 admitted in 2022 with diagnoses including gout, skin cancer, kidney disease, and atrial flutter. Review of Resident 9's record indicated the following was missing: - 9/3/22 Admission MDS - Comprehensive care plan. The incomplete admission assessment resulted in a failure to assess the resident's functional capacity and needs, and lack of an appropriate plan of care for, but not limited to, the following: - Psychotropic medications, behavioral health, permanent side effects from medications, safety, pain, vision and dental needs, trauma informed care, appropriate activity and socialization, cultural and religious needs, end of life care, other unassessed needs. This failure put Resident 9 at risk for unmanaged medications, unmanaged pain, incomplete knowledge of skin issues, potential heart problems, bleeding risk, and any number of unknown treatable conditions due to a lack of assessment. This failure was likely to result in permanent injury, significant physical pain, mental anguish, inadequate end of life services and potentially an early death. On 1/26/23 Staff 6 (RN) confirmed the admission MDS and care plans were missing or incomplete. 5. The 1/13/23 MDS Casper report (computer generated list of residents with missing MDS information) was compared to current medical records on 1/19/23 which revealed an additional 19 missing Admission MDSes, as well as seven Annual MDSes. On 1/24/23 at 7:00 PM staff 3 (RN consultant) confirmed the comprehensive care plans were not in place due to the admission MDS not being completed. On 1/24/23 at 6:20 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 1/24/23 at 7:53 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: - The facility will complete any Admission and/ or Annual assessments that are incomplete for Residents 1 and 3 and update the care plan and other appropriate monitoring and documentation as applicable by 1/27/2023 - The facility has audited all current in-house residents for MDS completion as of 1/24/23. Any current admission and annual missing assessments will be completed by 1/27/23 which includes care planning and other appropriate monitoring and documentation as applicable. - The facility will immediately begin reviewing all new admissions for timely completion of MDSes including care planning and other appropriate documentation as applicable within the 24-hour report process 1/25/2023 - The medical records coordinator will monitor all admission and annual assessment due dates and report all due dates to the interdisciplinary team members and daily stand up and report immediately to the director of nursing services and administrator any Admission and Annual MDSe that are out of compliance. The director of nurses will meet with the interdisciplinary team for an action plan of timely completion. - The facility has a skilled MDS Coordinator who will be utilized to assist with other facility units to maintain timely admission and annual MDS assessments. The facility will continue to retain outside MDS completion support as needed with a contracted RCM (Resident Care Manager) and Nurse Consultant. - The Quality Assurance nurse, administrator and director of nursing services will review weekly for ongoing compliance. On 1/30/23 at 1:45 PM record review was completed which verified the immediacy removal plan was fully implemented on 1/26/23.

F 636: Comprehensive Assessments and Timing: 1. The facility will complete any admission and/or annual assessments that are incomplete for residents 1 and 3 and update the care plans and other appropriate monitoring and documentation as applicable by 1/27/2023 a. Resident #1 has had a comprehensive assessment including care plan completed as of 1/26/23 and a quarterly assessment including care plan review as of 2/16/23. Monitoring as applicable was added to the care plan and resident administration records. b. Resident #2 was discharged from the facility on 10/21/22 c. Resident #3 has had a comprehensive assessment completed on 1/26/23 including care plan completion. Monitoring as applicable has been added to the care plan and resident administration record. d. Resident # 9 was discharged from the facility on 9/20/22 2. The facility has audited all current In-house residents for MDS completion as of 1/24/23. Any Current admission and annual missing assessments will be completed by 1/27/23 which includes care planning and other appropriate monitoring. a. All admission, annual and comprehensive assessments were completed by 1/26/23 including care plan updates and monitoring as applicable was added to the care plan and the residents administration record. 3. The facility will immediately begin reviewing all new admissions for timely completion of MDSs including care planning and other appropriate documentation as applicable within the 24 hour report process by 1/25/23. a. The 24- hour reporting tool was updated to include MDS and care plan review during the stand- up process. This includes looking at all admission residents for MDS timely completion of all required assessments. And interdisciplinary team members were in-serviced on its use on 01/25/23 b. Resident Care managers were given a copy of the chapter 2 algorithm of the Resident Assessment Instrument (RAI) manual that covers the required MDS completion dates from Assessment Reference Date to Submission to the QIES system at CMS (Center for Medicare and Medicaid Services) as part of their in-service for timely completion of the MDS process. The RCMs will lead the interdisciplinary team members on MDS completion for each individual MDS as the RCM is the individual to submit the MDS. 4. The Medical Records manager will monitor all admission and annual assessment due dates and report all due dates to the interdisciplinary team members and daily stand up and report immediately to the Director of Nurses and Administrator any Admission or Annual assessments that are out of compliance. The Director of Nurses will meet with the interdisciplinary team for an action plan of timely completion. a. The Medical records manager sends out a report to all of the interdisciplinary team members and facility administration that shows the MDS completion schedule of all required MDSs which includes the assessment reference date and the final date of completion to be timely. This is also reviewed with the interdisciplinary team and facility administration during the 24 hour report review process. 5. The facility has a skilled MDS coordinator as of 01/04/23 who has been completing skilled resident MDSs and who will be utilized to assist with other facility units to maintain timely admission and annual MDS assessments. The facility will continue to retain an outside MDS completion support as needed with a contracted RCM (Resident Care Manager) and Nurse Consultant. 6. The Quality Assurance Nurse, Administrator and Director of Nursing Services will review weekly for ongoing timely MDS completion. a. The Quality Assurance Nurse, Administrator and Director of Nursing Services all participate in the 24 hour report process where the Medical Records Manager reviews the full facility resident MDS schedule for assessment reference dates, MDS completion dates and timely completion to assure MDSs are completed timely and if not, that an action plan is put in place for timely completion. b. The MDS timely completion process will be reviewed in the facility Quality Assurance and Assessment meeting quarterly for process, trends and completion timelines.

Based on interview and record review it was determined the facility failed to complete Quarterly MDS assessments in the required timeframe for 4 of 9 sampled residents (#s 3, 4, 5 and 6) reviewed for MDS. This placed residents at risk for unassessed care needs. Findings include: The RAI Manual Chapter 2 instructed to complete a quarterly MDS assessment within 92 days of the previous assessment and within 14 days of the ARD (assessment reference date). 1. Resident 3 admitted to the facility in 2022 with diagnoses including depression. The 11/29/22 Quarterly MDS was completed on 1/25/23; 149 days from the previous assessment. On 1/25/23 at 12:42 PM staff 5 (RN) verified the 11/29/22 Quarterly MDS was not completed on time. 2. Resident 4 was admitted to the facility in 2021 with diagnoses including major depressive disorder. The 12/19/22 Quarterly MDS was completed on 1/19/23; 123 days from the previous assessment. On 1/25/23 at 12:27 PM staff 7 (RN) confirmed the 12/19/22 Quarterly MDS was not completed on time. 3. Resident 5 admitted to the facility in 2020 with diagnoses including Alzheimer's. The 9/26/22 Quarterly MDS was completed on 1/24/23; 212 days from the previous assessment. On 1/25/23 at 12:27 PM staff 7 (RCM) confirmed the 12/19/22 Quarterly MDS was not completed on time. 4. Resident 6 admitted to the facility in 2021 with diagnoses including Alzheimer's disease. The 11/16/22 Quarterly MDS was completed on 1/25/23; 162 days from the previous assessment. On 1/25/23 at 12:27 PM staff 7 (RCM) confirmed the 12/19/22 Quarterly MDS was not completed on time.

F 638: Quarterly Assessment at least every 3 months: 1. Resident #3, Resident #4, Resident # 5 and Resident #6 have all had their quarterly MDS completed by 1/26/23. 2. See above F 636: An audit of all current residents was completed on 1/24/23. Any quarterly assessments that were noted to need completion were completed by 1/26/23. 3. The 24- hour reporting tool was updated on 1/25/23 to include MDS completion and Care planning discussion. The interdisciplinary team were in-serviced on its use on 01/25/23 4. The Medical Records manager will monitor all quarterly MDS assessment due dates and report all due dates to the interdisciplinary team members at the daily 24-hour report stand up and report immediately to the Director of Nurses and Administrator any quarterly assessments that are not completed timely. The director of Nurses will meet with the interdisciplinary team for an action plan of timely completion as applicable. 5. The Quality Assurance Nurse, The Director of Nursing and Administrator will review this process daily. The facility Nurse Consultant also audits all residents weekly for compliance and reports to facility administration the outcome of that report. 6. The MDS quarterly assessment timely completion process will be reviewed in the facility Quality Assurance and Assessment meeting quarterly for process, trends and timely completion.

Based on interview and record review it was determined the facility failed to consistently assess, monitor, and accurately document skin related conditions for 4 of 9 sampled resident (#s 5, 6, 8 and 9) reviewed for MDS. This placed residents at risk for discomfort and worsening of wounds. Findings include: 1. Resident 5 admitted in 2020 with diagnoses including dementia. Resident 5 had an order for skin checks to be completed in a wound assessment every Sunday, this order started on 9/18/22. Skin and Wound - Total Body Skin Assessments were completed on: 9/25/22, 10/2/22, 10/5/22, 11/27/22, 1/8/23, 1/15/23. Wound and Skin Assessments were completed on: 3/23/22, 3/26/22, 3/30/22, 4/6/22, 4/23/22, 5/4/22, 5/11/22, 6/18/22, 6/22/22, 7/20/22, 7/30/22, 8/3/22, 9/21/22, 12/21/22, 12/28/22. Record review revealed there were no weekly skin assessments between 10/6/22 through 11/26/22 and between 11/28/22 through 12/20/22. On 1/25/23 at 12:27 PM Staff 7 (RN) confirmed staff should be completing assessments weekly and there was no other place the documentation would have been. 2. Resident 6 admitted in 2021 with diagnoses including dementia. Resident 6 had an order for skin checks to be completed in a skin and wound assessment weekly, this order started on 9/12/21. PCC Skin & Wound - Total Body Skin Assessments were completed on: 7/3/22, 7/10/22, 7/24/22, 8/7/22 Skin & Wound Evaluation were completed on: 10/31/22, 11/10/22, 11/23/22, 11/30/22, 1/27/22, 2/7/22, 2/10/22, 2/17/22, 2/23/22, 3/1/22, 3/2/22 Wound and Skin Assessment were completed on: 11/7/21, 11/14/21, 11/28/21, 12/5/21, 12/12/21, 12/26/21, 1/9/22, 2/13/22, 2/27/22, 3/6/22, 3/13/22, 3/20/22, 5/29/22, 6/5/22, 8/4/22 Record review revealed there were no weekly skin assessments between 1/10/22 through 1/26/22, between 3/21/22 through 5/28/22, and 6/6/22 through 8/3/22. On 1/25/23 at 12:27 PM Staff 7 (RN) confirmed staff should be completing assessments weekly and there was no other place the documentation would have been. 3. Resident 8 admitted in 2022 with diagnoses including diabetes. Resident 8 had an order for weekly skin audit on shower days and to document in the skin & wound assessment form, this order started 8/10/22. Skin & Wound evaluations were completed on: 8/29/22, 9/12/22, 9/19/22, 9/27/22, 10/4/22, 10/17/22, 11/9/22, 11/16/22, 11/22/22, 12/6/22 and 1/17/23. Wound and Skin Assessments were complete on: 8/30/22, 9/6/22, 9/13/22, 9/20/22, 9/27/22, 10/4/22, 1/26/23. Record review revealed there were no weekly skin assessments between 8/10/22 through 8/29/22, 10/17/22 through 11/9/22 and 1/4/23 through 1/17/23. On 1/25/22 at 12:42 PM Staff 5 (RN) confirmed skin assessments were supposed to be completed weekly. 4. Resident 9 admitted on 2022 with diagnoses including skin cancer. Resident 9 had the following orders: A. BUTTOCKS: cleanse with house wound cleanser, dry thoroughly, and apply bordered foam dressing in the morning for skin care, this order started on 8/28/2022. B. Licensed Nurse to do Weekly Skin Audit on Shower Day in the morning every Tuesday, document in skin and wound assessment weekly, this order started on 8/30/2022. C. Umbilicus and peri naval area. Cleanse with wound cleanser and pat dry. Apply ointment cover with foam dressing two times a day for discharge D/C when it resolved. This order started on 8/31/2022. D. Clean with wound cleanser, pat dry, skin perp the peri wound. Apply calcium alginate with silver in between the macerated areas between toes on both feet. Cleanse and change daily. Soak the right foot to get the gauze off and for future dressings to avoid disrupting healing tissue in the morning D/C when it resolved. This order started 8/31/2022. Three incomplete wound evaluations all dated 8/29/22 indicated the resident had right and left buttock wounds only. A 9/9/22 Wound and Skin Assessment indicated Resident 9 had: - Redness to coccyx without measurements or staging. - Right foot, 3rd, 4th, and 5th toe wounds without measurements or staging. - Umbilicus redness without measurements or staging. - Scrotum redness without measurements or staging. On 1/26/23 at 11:25 AM Staff 6 (RN) confirmed the 9/9/22 assessment was the only one that included all the skin conditions. Staff 6 confirmed the skin conditions were treated, but not well documented.

F 684: Quality of Care: 1. Resident #5, #6, and #8 have had skin and wound assessments completed. Resident # 9 was discharged on 9/20/22. 2. The facility has evaluated to types of wound and skin assessment tools available for use. The facility determined which wound and skin assessments- weekly will be utilized and redesigned the format to show if no skin issues present or if skin issues exist, that the progression of wound progress to resolution or interventions as needed are in place. 3. All Resident Care Managers were in-serviced on the new format and unit in-servicing with the licensed nurses took place. 4. An audit of the treatment administration record will be completed weekly as well as the review of the wound and skin assessment completion history report with a report sent to the Resident Care Managers, Quality Assurance, the Director of Nursing Services and the Administrator regrading compliance of weekly wound and skin assessment completion. Any areas not in compliance are given to the Resident Care Managers and Director of Nursing for follow up and action plan. 5. The Quality Assurance Nurse, Director of Nursing and Administrator will monitor the results of the compliance audits weekly for the next 90 days, then monthly thereafter and bring the audit summary to the Quarterly Quality Assurance and Assessment Committee to review progress, trends and compliance.

Based on the immediate jeopardy in the area of resident assessment it was determined the facility was not administered by the management team in an effective and efficient manner. Residents (#s 1, 2, 3 and 9) as well as others, had missing admission MDSs and were placed at risk for unassessed care needs and significant physical and mental injury. Findings include: 1. Resident 1 admitted in 2022 with diagnoses including dementia. Review of Resident 1's record indicated the 11/7/22 Admission MDS, comprehensive care plan, and monitoring of psychotropic medications were missing or incomplete. On 1/18/23 at 11:14 Staff 4 (RCM) stated she believed all MDSs she was responsible for were completed and was unaware Resident 1's MDS was not done. On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time. 2. Resident 2 admitted in 2022 with diagnoses including mental and behavioral disorders. Review of Resident 2's record indicated the 10/17/22 Admission MDS and comprehensive care plan were missing or incomplete. On 1/24/23 at 7:00 PM Staff 3 (RN consultant) confirmed the comprehensive care plans were not in place due to the Admission MDS not being completed. On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time. 3. Resident 3 admitted in 2022 with diagnoses including Parkinson's disease. Review of Resident 3's record indicated the 8/29/22 Admission MDS, comprehensive care plans, and monitoring of psychotropic medications were missing or incomplete. On 1/25/22 at 12:42 Staff 5 (RN) confirmed the monitoring, care plans, and MDS were missing or incomplete. On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time. 4. Resident 9 admitted in 2022 with diagnoses including gout. Review of Resident 9's record indicated the 9/3/22 Admission MDS and comprehensive care plan were missing or incomplete. On 1/24/23 at 7:00 PM Staff 5 (RN) confirmed the comprehensive care plans were not in place due to the Admission MDS not being completed. On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time. 5. As of 1/19/23 there were an additional 105 missing or incomplete Resident Assessments including Admission, Annual, Quarterly, Discharge, Entry, and Significant Change of Condition. On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time. Refer to F-636

F 835: Administration: 1. The facility will complete any admission and/or annual assessments that are incomplete for residents #1 and #3 and update the care plans and other appropriate monitoring and documentation as applicable by 01/27/23 a. Resident #1 has had a comprehensive assessment completed as of 1/26 and a quarterly assessment completed as of 02/16/23. Monitoring as applicable was added to the care plan and resident administration records b. Resident #2 was discharged from the facility on 10/21/23 c. Resident #3 has had a comprehensive assessment completed as of 01/26/23 including care plan completion. Monitoring as applicable has been added to the care plan and resident administration records d. Resident #9 was discharged from the facility on 09/20/22 2. All current in-house residents were audited on 01/24/23 for MDS completion. Any current resident admission and annual missing assessments will be completed by 01/27/23 and were completed by 01/26/23. Any current resident quarterly assessments that are missing will be completed by 01/27/23 and were completed by 01/26/23. The CMS CASPER (OR) OBRA MDS 3.0 Missing Assessment report for January 1, 2023 and February 1, 2023 was reviewed and all residents listed on this report will have their missing MDSs completed by 03/14/23. There are several residents on this report that have had MDS completed but are still showing on this report. Medical Records is running an error audit and any modifications that are needed to be completed to close the missing assessments will be completed by 03/14/23. a. The administrator will participate in the daily 24-hour report meeting and review all MDS completion timelines that are reported by the Medical Records Manager during the meeting and by the Medical Records written report review. The Administrator and the Director of Nurses will require an action plan from the interdisciplinary team on any resident MDS assessments that are not completed timely 3. The administrator will review the daily Medical Record MDS completion reports to validate that all MDSs are being completed timely. The administrator with the Director of Nursing and the Quality Assurance Nurse will review the CMS CASPER (OR) MDS 3.0 Missing OBRA assessment report at the beginning of each month to determine if there are any MDSs listed that are either not timely completed or if there are errors on the MDSs that needs correction and modification to complete the MDS process. An action plan for timely completion will be put in place as applicable based on the outcome of the review. 4. The Administrator, Director of Nurses and Quality Assurance Nurse will report the outcome of the MDS timely completion process to the Quality Assurance Committee quarterly and review the process, trends and timely completion of all MDS assessment types.

Based on interview and record review it was determined the facility failed to ensure residents' medical records were complete and accurate for 3 of 9 sampled residents (#s 2, 7 and 8) reviewed for MDS. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 2 admitted to the facility in 2022 with diagnoses including heart failure. Resident 2 discharged on 10/21/22. Resident 2's 10/21/22 Discharge MDS was not completed as of 1/27/23. On 1/26/23 at 11:25 AM staff 6 (RCM) verified the 10/21/22 Discharge MDS was not completed. 2. Resident 7 was admitted to the facility in 2022 with diagnoses including Alzheimer's. Resident 7 discharged on 4/10/22. Resident 7's 4/4/22 Discharge MDS was not completed as of 1/27/23. On 1/25/23 at 12:42 PM staff 5 (RN) verified the 10/21/22 Discharge MDS was not completed. 3. Resident 8 admitted to the facility in 2022 with diagnoses including diabetes. Resident 8 discharged on 12/26/22. Resident 8's 12/26/22 Discharge MDS was not completed until 1/26/22. On 1/25/23 at 12:42 PM staff 5 (RN) verified the 10/21/22 Discharge MDS was not completed.

F 842: Resident Records: 1. Resident # 2s discharge MDS has been completed, Resident # 7s discharge assessment has been completed, Resident #9s discharge assessment has been completed. 2. An audit of the CMS Casper (OR) MDS Missing Assessment Report was completed and all discharge assessments needing completion that were listed on this report were reviewed and will be completed by 03/14/23: a. The Medical Records manager reviews all resident MDSs to be completed daily as of 01/25/23. This includes Discharge MDSs as well as Death in the Facility MDSs. Any discharge or death in facility MDSs that are due and completion dates are reported in the facility 24- hour report process with the facility interdisciplinary team and facility administration. Any discharge or Death in Facility MDSs that are not completed timely are reported to the Director of Nursing Services and Administrator to have an immediate action plan put in place for completion of those residents that were identified not be timely. 3. The Resident Care Managers were inserviced an given an MDS completion timeline template from Chapter 2 of the Resident Assessment Instrument as a reference for the required Discharge MDS timelines. 4. The Quality Assurance Nurse, Director of Nursing and Administrator review this daily in the facility stand up process for compliance 5. The Quality Assurance Nurse, Director of Nursing Services and Administrator will review MDS compliance quarterly in the Quality Assurance and assessment meeting regarding the process, trends and timely completion.

Based on interview and record review it was determined the facility's QAA committee failed to correct deficiencies in the areas of MDS completion. This placed residents at risk for injury and adverse consequences. Findings include: The facility failed to complete Admission, Annual, Discharge and Quarterly MDS assessments in the required timeframe for 9 of 9 sampled residents reviewed for MDS. On 1/18/23 at 11:51 AM Staff 8 (Quality Assurance/Infection Prevention), Staff 6 (RN) and Staff 9 (RN) confirmed Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (RN consultant) were aware of the late MDSs in 2021 and timely MDS completion was still a problem as of 1/18/23. On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time. Refer to F636, F638, and F842.

F 867 QAA committee: 1. The facility has reviewed the requirements for Quality Assurance and Assessment quarterly meetings and who must participate at a minimum on the committee and what is to be covered within the agenda of that meeting. 2. The facility has determined the minimum committee members that must be in attendance which includes but is not limited to the Medical Director, Administrator, Director of Nursing Services, the Quality Assurance Nurse, the Infection Preventionist, the facility contracted pharmacist as well as an invited board member. Other members of the facility team members are invited to attend and may be required as determined by the QAPI program or Process Improvement programs that are in process or have been completed since the last Quality Assurance and Assessment Committee meeting. 3. The facility has an agenda outline and validation of who attended. 4. The facility has set up a calendar timeline for Quarterly Quality Assurance and Assessment Committee meetings going forward with the facility Quality Assurance Nurse maintaining the calendar, the agenda of the issues that will be discussed related evaluation of QAPI programs including current process improvement programs, the invitation of mandatory committee members and others as applicable, the validation of attendance report. 5. The infection preventionist will attend each Quality Assurance and Assessment meeting to report on infection control issues and outcomes, antibiotic stewardship in coordination with the consultant pharmacist and Director of Nursing Service. 6. The Administrator will review Quality Assurance and Process Improvement process in the facility monthly and will assure that the facility follows the Quarterly Quality Assurance and Assessment regulatory timelines and committee member attendance requirements.

Based on interview and record review it was determined the facility failed to meet at least quarterly and ensure an adequate number of staff attended for 2 of 2 QAA (Quality Assessment and Assurance) meetings reviewed for QAA. This placed residents at risk for lack of direct care staff insight and timely response to facility concerns brought to QAA. Findings Include: The facility records revealed QAPI (Quality Assurance Performance Improvement) meetings were conducted on 5/2022 and 10/2022, and one was scheduled for 2/2023. The 5/2022 meeting was held with Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (RN consultant) and was missing the medical director and two additional staff from the facility. On 1/18/23 at 11:51 AM Staff 8 (Quality Assurance/Infection Prevention) confirmed QAPI has not met for a significant period. Staff 8 could not recall specifically when the last meeting was. On 1/27/23 at 4:19 PM staff 8 (QA/IP) confirmed the facility had held QAPI meetings in 5/2022 and 10/2022 as well as one scheduled for 2/2023. Staff 8 indicated the 5/2022 QAPI meeting was held by Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (RN consultant).

F 868 QAA committee: 1. The facility has reviewed the requirements for Quality Assurance and Assessment quarterly meetings and who must participate at a minimum on the committee and what is to be covered within the agenda of that meeting. 2. The facility has determined the minimum committee members that must be in attendance which includes but is not limited to the Medical Director, Administrator, Director of Nursing Services, the Quality Assurance Nurse, the Infection Preventionist, the facility contracted pharmacist as well as an invited board member. Other members of the facility team members are invited to attend and may be required as determined by the QAPI program or Process Improvement programs that are in process or have been completed since the last Quality Assurance and Assessment Committee meeting. 3. The facility has an agenda outline and validation of who attended. 4. The facility has set up a calendar timeline for Quarterly Quality Assurance and Assessment Committee meetings going forward with the facility Quality Assurance Nurse maintaining the calendar, the agenda of the issues that will be discussed related evaluation of QAPI programs including current process improvement programs, the invitation of mandatory committee members and others as applicable, the validation of attendance report. 5. The infection preventionist will attend each Quality Assurance and Assessment meeting to report on infection control issues and outcomes, antibiotic stewardship in coordination with the consultant pharmacist and Director of Nursing Service. 6. The Administrator will review Quality Assurance and Process Improvement process in the facility monthly and will assure that the facility follows the Quarterly Quality Assurance and Assessment regulatory timelines and committee member attendance requirements.

****************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F636 ****************************** OAR 411-086-0060 Comprehensive Assessment and Care plan Refer to F638 ****************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ****************************** OAR 411-086-0010 Administrator Refer to F835 ****************************** OAR 411-085-0370 Confidentiality Refer to F842 ****************************** OAR 411-085-0220 Quality Assurance Refer to F867 ****************************** OAR 411-085-0220 Quality Assurance Refer to F868

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 10 of 17 sampled residents (#s 1, 2, 4, 5, 6, 7, 8, 18, 29 and 30) reviewed for abuse. This placed residents at risk for physical abuse and psychosocial harm. Findings include: 1. Resident 1 admitted to the facility in 2020 with diagnoses including dementia and anxiety. Resident 2 admitted to the facility in 2019 with diagnoses including dementia. A 3/17/22 FRI indicated Resident 2 walked past and made eye contact with Resident 1. Both residents got mad at each other, yelled and attempted to hit one another. Resident 1 successfully hit Resident 2. On 6/14/21 at 12:01 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Nurse Consultant) were interviewed. Staff 2 acknowledged Resident 2 was physically abused by Resident 1. 2. Resident 1 admitted to the facility in 2020 with diagnoses including dementia and anxiety. Resident 4 admitted to the facility in 2016 with diagnoses including dementia. Resident 1's 11/26/21 Progress Note indicated Resident 1 received aggression from Resident 4 and then returned the aggression. The 11/26/21 Facility Investigation revealed Resident 4 was in her/his wheelchair by the television organizing the books when Resident 1 approached Resident 4 to talk to her/him. Resident 4 got aggravated and hit Resident 1's right arm and hand. Resident 1 then hit back and would not let go of Resident 4's left hand. Staff intervened and separated the residents. On 6/14/21 at 12:01 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Nurse Consultant) were interviewed. Staff 3 acknowledged abuse occurred when Resident 4 hit Resident 1 and Resident 1 hit back. 3. Resident 1 was admitted to the facility in 2020 with diagnoses including dementia. Resident 6 admitted to the facility in 2019 with diagnoses including dementia. Resident 1's 11/3/21 Progress Note revealed Resident 1 was observed to be slapped on the left cheek by Resident 6. The 11/3/21 Facility Investigation revealed Resident 6 slapped Resident 1 on the left cheek. Redness was noted to Resident 1's left cheek and Resident 1 complained of pain. On 6/14/22 at 12:01 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Nurse Consultant) were interviewed. Staff 3 acknowledged abuse occurred when Resident 6 slapped Resident 1 on the cheek. 4. Resident 1 was admitted to the facility in 2020 with diagnoses including dementia. Resident 7 admitted to the facility in 2018 with diagnoses including dementia. The 11/15/21 FRI indicated Resident 1 got close to Resident 7 and pinched Resident 7 on the right forearm. The 11/12/21 Facility Investigation revealed Resident 1 grabbed Resident 7's right forearm because Resident 2 was too loud. Resident 1 made a pinching motion on Resident 1's right forearm. Resident 1's current Care Plan indicated Resident 1 pinched Resident 7 on the right forearm on 11/12/21. Resident 7's 11/13/22 Progress Noted revealed on 11/12/21 Resident 7 was pinched on the right forearm by Resident 1. Resident 1's undated care plan indicated on 11/12/21 Resident 1 pinched Resident 7 on the right forearm. Resident 7's undated Care Plan indicated on 11/12/21 Resident 7 was pinched on the right forearm by Resident 1. On 6/17/22 at 3:07 PM Staff 2 (DNS) acknowledged Resident 1 pinched Resident 7 on the right forearm which had the potential to cause pain or injury. On 6/21/22 at 4:20 PM Staff 3 (Nurse Consultant) verified physical abuse occurred when Resident 1 pinched Resident 7 on 11/12/21. 5. Resident 1 admitted to the facility in 2020 with diagnoses including dementia and anxiety. Resident 6 admitted to the facility in 2019 with diagnoses including dementia. The 10/9/21 Facility Investigation revealed the facility staff heard "get off me", looked over and saw Resident 6 holding Resident 1's wheelchair and left arm. Resident 1 shouted, grabbed onto Resident 6's left arm and tried to bite Resident 6. The residents were separated. Resident 6 was assessed for injury and found to have a "pink area" and "a little tooth mark" on the left forearm. The investigation determined abuse occurred. Resident 6's 10/9/21 Progress Note revealed Resident 6 had a "small teeth bite mark" on the left forearm. On 6/14/22 at 12:01 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Nurse Consultant) were interviewed. Staff 3 acknowledged abuse occurred when Resident 1 bit Resident 6. 6. Resident 1 admitted to the facility in 2020 with diagnoses including dementia and anxiety. Resident 18 admitted to the facility in 2019 with diagnoses including Alzheimer's Disease. On 6/14/22 at 12:01 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Nurse Consultant) were interviewed. Staff 3 acknowledged physical abuse occurred. 7. Resident 2 was admitted to the facility in 2019 with diagnoses including dementia. Resident 6 admitted to the unit in 2021 with diagnoses including Alzheimer's Disease. Resident 6's 10/2/21 Progress Note indicated Resident 2 adjusted Resident 6's blouse and Resident 6 slapped Resident 2 on the left upper arm and back area. The 10/2/21 Facility Investigation indicated Resident 2 adjusted Resident 6's blouse sleeve and Resident 6 perceived this action as a threat and slapped Resident 2 on the left upper arm and upper back. The investigation substantiated abuse. On 6/24/22 at 11:32 AM Staff 2 (DNS) acknowledged Resident 6 slapped Resident 2 and verified the facility identified this as abuse. 8. Resident 29 was admitted to the facility in 2018 with diagnoses including vascular dementia and bipolar disorder. Resident 30 admitted to the facility in 2018 with diagnoses including dementia. Resident 29's 10/4/21 Progress Note revealed Resident 29 got "irritated and agitated" with Resident 30 in the main dining room. Resident 30 attempted to sit in a chair next to the wall and was a few steps away from Resident 29. Resident 29 moved quickly in attempt to get in front of Resident 30 and when Resident 30 didn't move, Resident 29 "intentionally picked [her/his] walker off the ground and used it to whack [Resident 30] out of the way." Resident 30 was hit in the right hand and right forearm by Resident 29's walker and the items on Resident 30's walker fell to the ground. Resident 30's 10/4/21 Progress Note revealed she/he was hit by another resident on the right arm and right hand with the other resident's walker. Resident 30 attempted to sit in a chair next to Resident 29. Resident 29 picked her/his walker off the ground and hit Resident 30's right forearm and right hand. The 10/4/21 Facility Investigation indicated Resident 30 hit Resident 29 on the right arm and right hand with her/his walker. On 6/24/22 at 11:32 AM Staff 2 (DNS) verified Resident 29 physically abused Resident 30 when Resident 29 picked the walker off the ground, hit Resident 30 with the walker and pushed Resident 30 out of the way. , 9. Resident 8 admitted to the facility in 5/2020 with diagnoses including dementia. Resident 5 admitted to the facility in 1/2022 with diagnoses including dementia. The 11/5/21 Care Plan indicated staff were to keep Resident 8 away from other residents who could be physically aggressive towards her/him, including Resident 1, Resident 5, and Resident 6. A 10/31/21 Facility Incident Report indicated that day Resident 8 and Resident 5 were in their wheelchairs moving around the dining room. The two wheelchairs were close to one another and bumped. Staff 8 (CNA) witnessed Resident 8 telling Resident 5 "stop it" and then Resident 5 hit Resident 8 on her/his left forearm twice. Resident 8 then hit Resident 5 on her/his right forearm. The residents were separated immediately with no injury. On 6/16/22 2:46 PM Staff 8 (CNA) stated she recalled the incident between Resident 5 and Resident 8. Resident 5 was moving around in her/his wheelchair. Staff 8 was coming out of another resident's room and saw Resident 5 bump into Resident 8. Resident 8 became upset as she/he thought Resident 5 did it on purpose and yelled at the resident. Staff 8 stated she saw Resident 5 hit Resident 8 and then Resident 8 hit Resident 5 back. Staff 8 stated there were no outcomes to either resident and there were no further incidents between the two residents. On 6/16/22 at 12:02 PM Staff 2 (DNS) stated the incident between Resident 5 and Resident 8 on 10/31/21 constituted abuse. , 10. Resident 5 admitted to the facility on 1/2022 with diagnoses including dementia and diabetes. Resident 6 admitted to the facility on 8/2021 with diagnoses including bipolar disorder and anxiety. A 11/26/21 FRI indicated Resident 6 hit both hands of Resident 5 while they were playing ball during an activity. Resident 6 tried to stop Resident 5 from getting the ball from the activity aide. The 11/26/21 Facility Investigation revealed Resident 6 walked across the common area and struck Resident 5 on the back of both hands. A CNA and activity aide intervened; Resident 6 was incapable of explaining what occurred. On 6/28/22 at 5:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Nurse Consultant) acknowledged Resident 5 was physically abused by Resident 6. 11. Resident 4 admitted to the facility on 8/2018 with diagnoses including dementia and cognitive decline. Resident 27 admitted to the facility on 7/2019 with diagnoses including diabetes and dementia. The 11/27/19 FRI indicated Resident 27 was observed to call Resident 4 a "bitch". Resident 27 was removed from the immediate area. The 11/27/19 Facility Investigation revealed Resident 27 and Resident 4 sat in the dining room when Resident 27 called Resident 4 a "bitch". Both residents were separated and interviewed. On 6/28/22 at 5:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Nurse Consultant) confirmed verbal abuse occurred.

F 600: Free from Abuse and Neglect: 1. a. Resident number 2 was discharged on 04/10/22, resident number 7 was discharged on 03/02/22, Resident number 29 was discharged on 1/29/20, and resident number 30 was discharged on 05/21/22 b. Resident 1 has had multiple interventions since admission for behavioral issues. The facility will complete a full comprehensive behavioral focused assessment by the facility interdisciplinary team to determine any areas of preventative interventions that may be available. This assessment will include physical, behavioral, pain, medication and infection management and determination of trigger events. A 24- hour behavioral audit will be completed to determine if any specific times of day are a trigger and interventions that can be attempted to reduce behavioral outbursts towards others. The facility will request consideration for an updated PASSAR Level II review and a community hospital mental health evaluation. A care conference will be completed post comprehensive behavioral review with the IDT, Hospice, Provider, and family. A behavioral care plan will be updated as appropriate ongoing. The resident will remain in a private room at this time. The resident is currently on Hospice care. b. Resident numbers 4,5,6,8 and 18 will have their individual plan of care reviewed for types of existing behaviors both historic and current, types of triggers, and intervention appropriateness. Staff interviews with CNA staff, Licensed nursing, Resident Care Manager and Life enrichment will be completed and the residents plan of care will be updated as appropriate. 2. All residents residing in the facilities memory care unit will have their care plans reviewed for appropriate behavioral interventions. Staff will be interviewed for the appropriateness of behavioral interventions and a review of residents with known behavioral issues will be completed to determine that triggers and interventions have been identified and modified as applicable. a. The IDT staff will re-educated on abuse and neglect, root cause analysis, behavioral triggers and prevention intervention for residents presenting with agitated and aggressive behaviors and resident safety. b. All resident behavioral events that are defined as abuse will be reported immediately to the Director of Nursing and the Administrator for directed follow-up and investigation completion. c. behavioral events will be reviewed for investigation completion at morning staff review meeting for compliance with the IDT team. 3. A review of all resident behavioral events will be monitored by the Resident Care Managers and the Director of Nurses for completion of investigations, causative factors, triggers, preventative interventions and completed reporting as required every week for four weeks, then monthly thereafter as part of the facility Quality Assurance and Process Improvement process 4. The Director of Nursing and Administrator will complete random weekly audits to assure compliance for four weeks and then monthly ongoing with outcomes reported to the Quality Assurance and Process Improvement Committee.

Based on interview and record review it was determined the facility failed to implement care plan interventions for 1 of 17 sampled residents (#3) reviewed for abuse. This placed residents at increased risk for accidents and injury. Findings include: Resident 3 was admitted to the facility in 4/2021 with diagnoses including brain bleed and dyspnea. Resident 3's care plan intervention dated 9/3/21 revealed "2 person witnessed care with all contact-this means nurses, CMA's, CNA's, Social services, housekeeping, dietary, Restorative, therapies - in general all staff." A 12/24/21 FRI from indicated Resident 3 accused Staff 12 (CNA) of improperly provided care. The 12/24/21 Facility Investigation revealed Staff 12 did not follow Resident 3's care plan while providing care with two person cares. Staff 12 provided care alone. Attempts to contact Staff 12 were unsuccessful as his phone was disconnected. On 6/28/22 at 2:43 PM Staff 2 (DNS) confirmed Staff 12 did not follow the care plan.

F 656: Develop/Implement Comprehensive Care Plan 1. Resident number 3 was discharged on 03/28/22 2. A review of contract staffing orientation will be completed to determine if any additional training is needed at the beginning of an assigned shift prior to care being provided to a resident to prevent any further potential for failure to follow a residents plan of care. 3. The facility will create a staff to staff partner assignment for all new and/or contract clinical staff that includes reviewing the location and information present in the POC (Point of Care) system that is developed from the residents plan of care. A checklist of orientation areas will be utilized to verify that education is completed with signature verification. The staffing coordinator will assign the staff to staff partner on the daily assignment sheet. All clinical staff will be inserviced on the new staff to staff partnership program including staff development and staffing coordinator. 4. The Director of Nursing, Staff Development and Staffing Coordinator will audit the daily staffing assignments to assure that each new staff or agency staff member was partnered with a facility staff member for orientation/validation and will also audit for medication pass completion which include PCC competency. This will be done weekly for four weeks and monthly thereafter. Outcomes will be reported to the quality assurance and process improvement committee meeting. 5. Date of Completion: 08/14/22

Based on interview and record review it was determined the facility failed to follow physician's orders for medication administration and failed to monitor the residents for adverse outcomes in a timely manner for 18 of 18 sampled residents (#s 1, 2, 4, 5, 8, 9, 15, 16, 18, 31, 32, 33, 34, 35, 36, 37, 38, and 39) reviewed for missed medications. This placed residents at risk for not receiving prescribed medications and lack of monitoring of missed medications. Findings include: 1. Resident 31 was admitted to the facility in 2019 with diagnoses including pelvic fracture and dementia. Resident 31's MAR on 3/17/22 revealed the following medications were not administered: - acetaminophen tablet - pain medication - apixaban tablet - blood thinner medication - clonazepam tablet - anxiety medication - docusate sodium capsule - stool softener - donepezil HCL tablet - cognition enhancing medication - haloperidol tablet - mood disorder medication - memantine HCL tablet cognition enhancing medication - metoprolol tartrate tablet - blood pressure medication - quetiapine fumarate - mood disorder medication Resident 31's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 2. Resident 5 was admitted to the facility in 2017 with diagnoses including dementia and diabetes. Resident 5's MAR on 3/17/22 revealed the following medications were not administered: - metoprolol tartrate - blood pressure medication - doxycycline tablet - antibiotic - Tylenol tablet - pain medication Resident 5's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 3. Resident 32 was admitted to the facility in 2014 with diagnoses including Alzheimer's and osteoporosis. Resident 32's MAR on 3/17/22 revealed the following medications were not administered: - melatonin tablet - sleep aide - Tylenol extra strength tablet - pain medication Resident 32's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 4. Resident 33 was admitted to the facility in 2018 with diagnoses including failure to thrive and diabetes. Resident 33's MAR on 3/17/22 revealed the following medications were not administered: - atorvastatin calcium tablet - cholesterol medication - depakote sprinkles capsule - mood disorder stabilizing medication - ferrous sulfate tablet - supplement - hydroxychloroquine sulfate tablet - Rheumatoid arthritis medication - Miralax powder - laxative - norco tablet - pain medication - sulfasalazine tablet - anti-inflammatory - vitamin C tablet - supplement Resident 33's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 5. Resident 18 was admitted to the facility in 2019 with diagnoses including dementia and diabetes. Resident 18's MAR on 3/17/22 revealed the following medications were not administered: - Tylenol - pain medication - atorvastatin calcium tablet - cholesterol medication - Eliquis tablet - blood thinner medication - memantine HCL tablet - cognition enhancing medication - metoprolol tartrate tablet - blood pressure medication Resident 18's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 6. Resident 34 was admitted to the facility in 2014 with diagnoses including dementia and diabetes. Resident 34's MAR on 3/17/22 revealed the following medications were not administered: - atorvastatin calcium tablet - cholesterol medication - docusate sodium tablet - stool softener - senna tablet - stool softener - Tylenol - pain medication Resident 34's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 7. Resident 1 was admitted to the facility in 2017 with diagnoses including osteoporosis and dementia. Resident 1's MAR on 3/17/22 revealed the following medications were not administered: - Tylenol - pain medication - depakote sprinkles capsule - mood disorder stabilizer - donepazil HCL tablet - cognition enhancing medication - melatonin tablet - sleep aide Resident 1's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 8. Resident 2 was admitted to the facility in 2019 with diagnoses including stroke and dementia. Resident 2's MAR on 3/17/22 revealed the following medications were not administered: - docusate sodium tablet - stool softener - donepezil HCL tablet - cognition enhancing medication - lorvastatin tablet - cholesterol medication - melatonin tablet - sleep aide Resident 2's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 9. Resident 35 was admitted to the facility in 2014 with diagnoses including dementia and diabetes. Resident 35's MAR on 3/17/22 revealed the following medications were not administered: - Tylenol tablet - pain medication - calcium-vitamin D tablet - supplement - gabapentin capsule - nerve pain medication - tramadol HCL tablet - pain medication Resident 35's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 10. Resident 8 was admitted to the facility in 2020 with diagnoses including Alzheimer's Disease and dementia. Resident 8's MAR on 3/17/22 revealed the following medications were not administered: - Tylenol tablet - pain medication - atorvastatin calcium tablet - cholesterol medication - donepezil HCL tablet - cognition enhancing medication - melatonin tablet - sleep aide - quetiapine fumarate tablet - mood disorder medication Resident 8's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 11. Resident 36 was admitted to the facility in 2021 with diagnoses including dementia and restlessness. Resident 36's MAR on 3/17/22 revealed the following medications were not administered: - melatonin tablet - sleep aide - quetiapine fumarate tablet - mood disorder medication Resident 36's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 12. Resident 37 was admitted to the facility in 2020 with diagnoses including chronic kidney disease and dementia. Resident 37's MAR on 3/17/22 revealed the Tylenol tablet (pain medication) weas not administered. Resident 37's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 13. Resident 38 was admitted to the facility in 2021with diagnoses including Alzheimer's Disease and prostate cancer. Resident 38's MAR on 3/17/22 revealed the following medications were not administered: - donepezil HCL tablet - cognition enhancing medication - Tylenol tablet - pain medication Resident 38's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 14. Resident 4 was admitted to the facility in 2016 with diagnoses including dementia and edema. Resident 4's MAR on 3/17/22 revealed the following medications were not administered: - lipitor tablet - cholesterol reducing medication - melatonin tablet - sleep aide - senna plus tablet - stool softener - tramadol HCL tablet - pain medication - Tylenol tablet - pain medication Resident 4's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 15. Resident 39 was admitted to the facility in 2015 with diagnoses including hypertension and dementia. Resident 39's MAR record on 3/17/22 revealed the following medications were not administered: - metoprolol tartrate tablet - blood pressure medication - namenda tablet - cognition enhancing medication - sennosides-docusate - stool softener - Tylenol tablet - pain medication Resident 39's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 16. Resident 9 was admitted to the facility in 2019 with diagnoses including dementia and anxiety. Resident 9's medication administration record on 3/17/22 revealed the following medications were not administered: - Lorvastatin tablet - cholesterol reducing medication - Tylenol tablet - pain medication Resident 9's progress notes indicated there was no alert charting from 3/17/22, date of incident, through 3/22/22. On 6/13/22 at 12:51 PM Staff 9 (Agency LPN) confirmed she failed to administer the listed medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 17. Resident 15 was admitted to the facility on 6/2021 with diagnoses including heart failure and diabetes. A Facility Incident report dated 7/1/21 indicated Resident 15 received the following medications which were prescribed for Resident 16: - Tylenol - pain medication - asorbic acid - supplement - aspirin - pain medication - calcium polycarbophil - supplement - Centrum silver 50+ for women - multivitamin - Citracel Petites/VitD - supplement - CoQ10 - supplement - vyanocobalamin - supplement - ditiazem CD extended release - blood pressure medication - duloxetine HCL delayed release - depression medication - ferrous sulfate tablet - supplement - gabapentin - nerve pain medication - metoprolol extended release - blood pressure medication - mirabegron extended release - over active bladder medication - Ocuvite-Lutein - (multivitamin-minerals) - omeprazol capsule - acid reflux medication - Wixela inhub aerosol powder - asthma medication On 6/10/22 at 2:10 PM Staff 10 (CMA) stated she had inadvertently administered Resident 15, Resident 16's medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred. 18. Resident 16 was admitted to the facility on 11/2019 with diagnoses including heart failure and Parkinson's disease. A Facility Incident report dated 7/1/21 indicated Resident 16 received the following medications which were prescribed for Resident 15: - aspirin EC tablet - pain medication - cholecalciferol tablet - supplement - fluticasone proplonate -allergy nasal spray - hydralazine HCL - blood pressure medication - metoprolol succinate ER - blood pressure medication - generic multivitamin - Nifedlpine ER - blood pressure medication - omeprazole - acid reflux medication - senna-docusate - stool softener - torsemide - diuretic - Welbutrin XL - depression medication. On 6/10/22 at 2:10 PM Staff 10 (CMA) stated she had inadvertently administered Resident 16, resident 15's medications. On 6/28/22 at 5:40 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the medication error occurred.

F 684: Quality of Care: 1. Resident number 2 was discharged on 04/10/22, Resident number 15 discharged on 08/27/22 and Resident number 16 was discharged on 07/9/22. Residents number 1,4,5,8,9,18,31,32,33,34,35,36,37,38 and 39 were all assessed by the nursing clinical staff, as well as the residents providers to determined that there was no adverse response to the omission of medications to each individual resident listed here as well as the resident that received the wrong medication pass. 2. The facility is completing medication pass competency audits on clinical staff by the facility Staff Development and Clinical Nurse Consultant ongoing. The facility will create a staff to staff partnership with all new or contracted clinical staff on their first day of service with resident medication pass process to assure that the staff member is familiar with the medication administration system in the electronic health record (EHR) Point Click Care(PCC). This includes how to determine which medications are due for distribution to the resident by shift as well as those as needed medications (PRN) and how to determine which medications are due per the residents individual schedule. An orientation checklist will be created that will have a validation signature of medication administration training on the electronic health record system. The facility created a room configuration guide that is attached to each medication and treatment cart to show staff any room configuration changes as to bed location in individual rooms that is utilized to assist staff in determining resident placement in a room. This was created in July of 2021 post medication error that is listed in this report. The guides have been verified that they are in place and staff have validated knowledge of the guides. 3. All new clinical staff will have a medication pass competency completed by the facility staff development. Medication pass competency includes observation of practice that includes medication pass rights such as right resident, medication, dose, time, and . All clinical staff will be inserviced on the requirement for alert charting for any resident that has had a medication error. This inservice will include the type of charting to be completed, what to monitor for and the duration of monitoring, including notifying primary provider if any adverse response is noted from the monitoring. This inservice will be completed by staff development. 4. Director of Nursing Services and Staff Development will monitor weekly for four weeks, then monthly ongoing. Outcomes will be reported to the facility Quality Assurance and process improvement committee meeting. 5. Date of Completion: 08/14/22

Based on interview and record review it was determined the facility failed to ensure care plans were followed to prevent accidents for 5 of 6 sampled residents (#s 7, 17, 25, 26 and 28) reviewed for accidents and falls. This placed residents at risk for injury. Findings include: 1. Resident 7 admitted to the facility in 10/2018 with diagnoses including dementia. Resident 7 passed away on 3/2/22. The 10/21/21 Annual MDS indicated the resident was rarely/never understood and required extensive, two-person assistance with transfers during the look-back period. The 9/18/19 Care Plan indicated Resident 7 required two-staff participation with transfers using a sit-to-stand (mechanical lift). A 10/18/21 Fall Investigation indicated Resident 7 was transferred using a sit-to-stand by one Staff 5 (CNA) when the resident let go of the bars on the mechanical lift and slid out onto the floor. The investigation indicated the resident would let go of the mechanical lift bars due to her/his diagnosis of dementia and required staff cues to hold onto the bars. The resident sustained a skin tear to her/his right upper extremity. The investigation summary indicated Resident 7's care plan was for two-person staff assistance for transfers and the resident was transferred with only one staff present and Staff 5 did not review the care plan prior to transferring Resident 7. Attempts were made to contact Staff 5 on 6/9/22 and 6/10/22 but there was no response to calls. On 6/14/22 at 11:34 AM Staff 2 (DNS) confirmed the care plan for Resident 7 was not followed resulting in a fall and the expectation was for every mechanical lift transfer there must be two staff present. The witness statements completed by Staff 5 were true and accurate to her knowledge. 2. Resident 28 re-admitted to the facility in 10/2019 with diagnoses including a hip fracture. The resident discharged on 12/6/19. The 10/22/19 Care Plan indicated Resident 28 required two-person assistance with transfers and toileting and required a sit-to-stand (mechanical lift) for transfers. The 10/29/19 Admission MDS indicated the resident had moderately impaired cognition and required extensive, two-person assistance with transfers. A 11/19/20 incident investigation indicated Resident 28 sustained an assisted fall while being transferred to the restroom resulting in a right knee abrasion. The resident required two-person assistance with transfers and toileting. Witness 1 (Agency CNA) acknowledged he transferred Resident 28 independently without reviewing the resident's care plan. Witness 1 was unable to be contacted due to no longer working at the facility or the Agency. On 6/14/22 at 11:34 AM Staff 2 (DNS) confirmed the care plan for Resident 28 was not followed resulting in a fall and the expectation was for every mechanical lift transfer there must be two staff present. The witness statements completed by Witness 1 were true and accurate to her knowledge. , 3. Resident 17 was admitted to the facility in 9/2019 with diagnoses including dementia and heart failure. Resident 17's Fall Care Plan included the intervention "Dycem (non-stick) pad on the seat of [her/his] chair to prevent sliding out of [her/his wheelchair]." this intervention was created on 2/12/21. A 5/12/21 Facility Fall Investigation indicated Resident 17 was found sitting on the floor in the hallway. The investigation stated Resident 17 had on socks, shoes, hat, hip protectors, and the lights were on. The investigation concluded that Resident 17 either slid out of their chair or attempted to rise unassisted. The facility stated the care plan would be updated with a new intervention; the implementation of a Dycem non-stick pad to be placed in the resident's chair to prevent sliding. On 6/29/22 at 2:30 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Nurse Consultant) confirmed the Facility Investigaiton was accurate and no additional information was provided. 4. Resident 25 was admitted to the facility in 2/2019 with diagnoses including heart failure and diabetes. Resident 25's care plan intervention dated 11/14/19 indicated Resident 25 was allowed to transfer when wearing shoes. The intervention stated "NO AMBULATION". A 12/4/19 FRI indicated Resident 25 fell while being ambulated to shower room by the nursing staff. The 12/4/19 Facility Fall Investigation concluded the nursing staff confused an order written by a provider when Staff 13 (CNA) attempted to ambulate Resident 25 to the shower. On 6/27/22 at 1:56 PM Staff 15 (RNCM) confirmed Resident 25 should not have been ambulated by clinical staff and the care plan was not followed. 5. Resident 26 was admitted to the facility in 9/2016 with diagnoses including dementia, high blood pressure, and arthritis. Resident 26's care plan intervention dated 11/20/17 indicated two person assist using a sit-to-stand lift with transfers and to not use a shower bench for her/his shower. A 11/27/19 FRI form indicated Resident 26 was transferred by a single CNA from a shower bench to her/his wheelchair in the shower room. The 11/29/19 Facility Investigation revealed Staff 5 (CNA) transferred Resident 26 from a shower bench back to her/his wheelchair after completing a shower. The investigation indicated Staff 5 was advised by Staff 15 (LPN) to use a shower chair. The investigation concluded staff 5 had one person transferred Resident 26, used the shower bench not chair, and Resident 26 had received a laceration that required stitches. All attempts to contact Staff 5 failed, their phone was disconnected. 6/28/22 at 4:48 PM Staff 3 (Corporate RN) reviewed this investigation and confirmed the care plan was not followed.

F 689: Free of accident hazards/Supervision/Devices 1. Resident number 7 expired on 03/02/22, resident 17 discharged on 06/15/21, resident number 25 discharged on 12/24/19, resident number 26 discharged on 10/13/20, resident number 30 discharged on 05/21/22, 2. All residents can be affected by failure to follow an individuals plan of care. The facility will complete random audits to assure that care plans in the area of transfer and safety devices are in place each week for four weeks and monthly on going by the facility staff development, Resident Care Managers and Director of Nursing Services. 3. All clinical staff, and Interdisciplinary team members will be inserviced by staff development on the Point of Care ( POC) care plan tasks system. This includes tasks for transfer training, safety equipment, mobility and other specific individualize care plan interventions for safety. The facility will develop a staff to staff partnership program with all new and contract staff to assure that education and training has been completed on the POC/Task program and plan of care follow up with resident care. There will be a signed validation from the staff to staff partnership that this has taken place. 4. Staff Development, Resident Care Managers will randomly audit weekly for four weeks and then monthly ongoing and report outcomes to the Quality Assurance and Process Improvement Committee. 5. Completed by: 08/14/22

Based on interview and record review it was determined the facility failed to effectively manage pain for 1 of 3 sampled residents (#17) reviewed for pain control. This placed residents at risk for increased pain and agitation. Findings include: Resident 17 admitted to the facility in 2015 with diagnoses including chronic kidney disease, major depressive disorder, and dementia. Resident 17 discharged from the facility the morning of 6/15/21. A 4/22/21 Quarterly MDS revealed Resident 17 had cognition problems, was rarely understood, and had pain daily per staff assessment. An active nursing order stated "if resident is still restless, use the PAINAD scale and attempt to contact the [Power of Attorney]. If no response, give the PRN morphine and document the effectiveness". A 6/10/21 Physician Order for morphine indicated to administer 0.25 ml every two hours for pain, restlessness, or shortness of breath and to call the guardian before the medication was administered. Resident 17's 6/2021 MAR indicated Resident 17 was able to receive morphine every two hours starting at 10:45 PM on 6/10/21. Resident 17 received morphine at the following times: -1:07 PM on 6/11/21 pain = 6 -3:33 AM on 6/12/21 pain = 8 -9:40 AM on 6/13/21 pain = 5 -12:31 PM on 6/13/21 pain = 4 -4:45 PM on 6/13/21 pain = 0 -5:40 AM on 6/14/21 pain = 6 -8:18 AM on 6/14/21 pain = 6 -10:39 AM on 6/14/21 pain = 6 -4:15 PM on 6/14/21 pain = N/A -6:15 PM on 6/14/21 pain = 0 -9:30 PM on 6/14/21 pain = 0 -12:07 AM on 6/15/21 pain = 4 -2:45 AM on 6/15/21 pain = 5 Resident 17's 6/2021 MAR had an as needed acetaminophen suppository (pain medication) order which could have been administered up to every four hours. This order started 6/10/21. According to the 6/2021 MAR this medication was administered once a day. Three of the four days the medication was given it was marked ineffective. Resident 17's 6/2021 MAR had an order for acetaminophen to be administered orally every evening. This medication was not administered on 6/10/21 and marked not given on 6/13/21 or any evening after. Resident 17's 6/2021 MAR had an order for acetaminophen to be administered up to every four hours orally, this order was used one to two times a day, and not at all after 6/11/21. Resident 17's progress notes indicated the following: -6/6/2021 at 3:50 AM: Resident awake all night, restless trying to get out of bed. -6/7/21 at 3:49 AM: Resident was awake all night and restless, trying to get out of bed. -6/8/21 at 5:48 AM: Resident was awake all night, restless and agitated, trying to get out of bed. -6/9/21 at 5:17 AM: Resident noted to be very restless and confused all shift. -6/10/21 at 5:22 AM: Resident was agitated, restless and awake all night. -6/11/21 at 7:04 AM: Resident was awake all night restless, agitated, aggressive. Guardian was called around 2:50AM (for permission to give morphine) no response. -6/12/21 at 6:42 AM: Resident wasrestless, agitated, and aggressive all night. Called guardian twice, administered a single dose of morphine. -6/13/21 at 6:43 AM: Resident appeared restless all shift. -6/14/21 at 3:54 AM: Resident noted calmly resting, no signs of discomfort or agitation noted. -6/15/21 at 5:21 AM resident was noted to be comfortable in bed. On 6/29/22 at 2:30 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed the above records and provided no further information regarding Resident 17's pain control not being managed effectively.

F 697: Pain Management 1. Resident 17 was discharged on 06/15/21. 2. Residents are potentially at risk for need of pain management. An audit of resident Medication Administration Records (MARs) will be completed and residents identified with pain management issues such as utilization of as needed pain medication (PRN) and or signs and symptoms of pain will be reassessed for appropriateness and effectiveness of the pain management program. Any areas of concern will be directed to the residents primary provider for intervention. 3. All Licensed nurses and Medication Aides will be educated on pain management including signs and symptoms of pain such as discomfort, restlessness, agitation, aggression, insomnia, and anxiety. The facility will determine if all pain medications available are utilized as necessary and that ineffective pain control is reported to the residents Resident Care Manager and primary provider as applicable. 4. Resident Care Managers, Staff Development, and Director of Nurses will complete random pain management audits weekly for four weeks and monthly ongoing until compliance is sustained. Outcomes will be reported to the Quality Assurance and Process Improvement Committee. 5. Completion date: 08/14/22

****************************** OAR 411-085-0360 Abuse Refer to F600 ****************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 ****************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 and F697 ****************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 ***************************

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 09/06/2021 and 09/12/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.