Avamere Rehabilitation of Lebanon

A review of the Resident Council Meeting Minutes from 6/28/25, 7/25/25, and 8/27/25 revealed resident rights were not reviewed during any of the meetings.On 9/4/25 at 2:08 PM, Staff 27 (Activity Director) stated he did not review resident rights during Resident Council meetings.On 9/5/25 at 10:51 AM, members of the Resident Council confirmed resident rights were not reviewed during the meetings.On 9/8/25 at 11:38 AM, Staff 1 (Administrator) stated the expected resident rights to be reviewed with residents during Resident Council meetings.-á

4. Resident 11 was admitted to facility in 8/2023 with diagnoses including chronic kidney disease.A review of ResidentGÇÖs clinical record revealed she/he was hospitalized on 6/30/25, 7/29/25, 8/13/25 and 8/18/25. No evidence was found in the clinical record to indicate written notice of transfer or the facilityGÇÖs bed-hold policy was provided to the resident or her/his representative.On 9/5/25 at 2:50 PM, Staff 14 (Social Services Director/AIT) stated she did not have or send copies of notice of transfers to the Ombudsman.On 9/8/25 at 12:40 PM, Staff 1 (Administrator) stated Resident 11 did not receive a notice of transfer or have a signed acknowledgement of the bed-hold policy for her/his hospitalizations.A review of the facility's Transfer or Discharge, Emergency Acute Care and Bed-Holds and Return policy dated 10/2022 revealed the following:-When a resident is transferred to an acute care facility a notice of transfer is provided to the resident and resident representative.-A Copy of the transfer was also sent to the LTC Ombudsman.GÇ¥-á-All resident/representatives were provided written information regarding the facility and state bed-hold policies, which address holding or reserving a residentGÇÖs bed during periods of absence.GÇ¥-á1.Resident 10 was admitted to the facility in 6/2025 with diagnoses including heart failure and kidney disease.A review of Resident 10GÇÖs clinical record revealed she/he was transferred to the hospital on 8/16/25. No evidence was found in the clinical record to indicate written notice of the facilityGÇÖs bed-hold policy was provided to the resident or her/his representative. No documentation was found indicating the LTC Ombudsman was notified of the transfer.On 9/8/25 at 12:01 PM, Staff 1 (Administrator) stated a written bed-hold notification was not provided to Resident 10 or her/his representative at the time of transfer to the hospital. Staff 1 stated the LTC Ombudsman was not notified of the transfer.2.Resident 67 was admitted to the facility in 7/2025 with diagnoses including weakness and stroke.A review of Resident 67GÇÖs clinical record revealed she/he was discharged home on 8/1/25. No documentation was found in the clinical record indicating the LTC Ombudsman was notified of the discharge.On 9/8/25 at 12:01 PM, Staff 1 (Administrator) stated his expectation was the LTC Ombudsman should have been notified of Resident 67GÇÖs discharge home.3.Resident 69 was admitted to the facility in 7/2025 with diagnoses including alcohol abuse.A review of Resident 69GÇÖs clinical record revealed she/he was discharged home on 8/14/25. No documentation was found in the clinical record indicating the LTC Ombudsman was notified of the discharge.On 9/8/25 at 12:01 PM, Staff 1 (Administrator) stated his expectation was the LTC Ombudsman should have been notified of Resident 69GÇÖs discharge home.-á-á

Resident 11 was admitted to facility in 8/2023 with diagnoses including chronic kidney disease.On 9/2/25 at 2:19 PM, Resident 11 stated she/he was not certain of what her/his care needs consisted of, as she/he had recently experienced multiple hospitalizations.A review of Resident 11GÇÖs clinical record revealed her/his Annual MDS completion deadline date was 8/2/25 and was incomplete as of 9/7/25. -á-áA review of ResidentGÇÖs clinical record revealed she/he was hospitalized on 6/30/25, 7/29/25, 8/13/25 and 8/18/25 and her/his most recent entry back to facility was on 8/22/25. No evidence was found in the clinical record to indicate a significant change assessment, or an admissions assessment was completed as of 9/7/25.On 9/8/25 at 8:58 AM, Staff 15 (Regional Reimbursement Analyst) acknowledged a comprehensive assessment had not been completed timely for Resident 11. He stated although Resident 11 had multiple hospitalizations, the expectation was for a comprehensive assessment to be completed timely.On 9/8/25 at 12:40 PM, Staff 1 (Administrator) acknowledged Resident 11GÇÖs MDS assessment was not completed timely. He stated the expectation was for MDS Assessments to be completed timely and accurately for each resident.

Resident 6 was admitted to the facility in 4/2025 with diagnoses including persistent vegetative state (awake with no environmental awareness) and traumatic brain injury.The 4/24/25 Admission MDS indicated Resident 6's ability to understand others was not assessed.A 5/26/25 physician order indicated PT, OT, SLP per family request.-áA 7/21/25 facility Care Conference Information form indicated Witness 2 (Family Member) requested Staff 6 (Resident Care Manager-LPN) coordinate referrals for OT. PT, SLP and a neurologist (brain disorder specialist).A 7/23/25 revised care plan indicated Resident 6 was not able to make her/his needs known and used non-verbal techniques to supplement her/his communication.On 9/2/25 at 12:59 PM, Witness 2 stated Resident 6 previously communicated using flash cards and wanted her/him assessed for improved communication technology.On 9/4/25 at 9:08 AM, Resident 6 was observed lying in bed and grunting while the television was on.On 9/4/25 at 2:08 PM, Staff 27 (Activities Director) stated he observed Resident 6's eyes respond and noted increased grunting when she/he was engaged in an activity of interest.On 9/5/25 at 4:00 PM, Staff 23 (CNA) stated Resident 6 made her/his needs known by swatting Staff 23's hand when undesired care was attempted.On 9/8/25 at 9:44 AM, Staff 6 acknowledged Resident 6 communicated using her/his eyes, but Staff 6 was unsure how an SLP could assist. Staff 6 stated a referral to a neurologist was ordered within the last few days and did not know if SLP had been contacted following the care conference.On 9/8/25 at 11:20 AM, Staff 3 (Regional Director of Quality Assurance) stated staff were expected to initiate referrals for communication services and specialists as soon as the request was made. Staff 3 acknowledged communication services for Resident 6 were delayed.

Resident 16 was admitted to facility on 7/5/25 with diagnoses including chronic obstructive pulmonary disease and metabolic encephalopathy (temporary or permanent brain dysfunction caused by a problem with the body's metabolism).Resident 16GÇÖs 7/5/25 Care Plan indicated she/he required two staff to assist with bathing.Resident 7/13/25 Admission MDS indicated the resident was dependent on assistance with bathing/showering.Resident 16GÇÖs 7/2025 Bath/Shower task logs indicated the resident received showers on 7/8/25, 7/15/25 and 7/22/25. There was no documentation for 7/11/25, 7/18/25, and 7/29/25, which were Resident 16GÇÖs scheduled shower days, as those entries were left blank.A review of Resident 16GÇÖs Progress Notes from 7/5/25 through 7/30/25 revealed no evidence the resident was offered additional a showering opportunity when a shower was refused or not provided.-áOn 09/04/2025 7:35 AM Staff 8 (CNA) stated there were times when staff would get too busy to chart tasks performed on residents. She stated after performing a shower task on residents, she would chart the shower task as completed.On 9/8/25 at 10:14 AM, Staff 6 (Resident Care Manager - LPN) stated if the Bath/Shower task logs were blank, it would indicate the task was not given. She stated residents were typically given baths/showers two times per week, and the expectation was for staff to complete resident showers and documenting they were done. At 11:53 AM, Staff 6 provided documentation stating on 7/11/25, Resident 16's bath/shower was not completed due to being short-staffed.-á

Resident 49 was admitted to the facility in 8/2025 with diagnoses including a leg fracture.An 8/8/25 Orthopedic Physician Order directed staff to remove Resident 49GÇÖs dressing one week after 8/8/25. Staff were instructed to gently cleanse the incision using warm water and soap, pat dry, apply a nonadhesive pad or gauze dressing secured with tape, and change the dressing every one to two days until the follow-up appointment. Staff were to contact Trauma/Orthopedics if signs or symptoms of redness, drainage, onset of pain, chills, fever, sweats, or infection were observed.The 8/25 TAR did not contain the Orthopedic PhysicianGÇÖs order for wound care. There was no evidence the wound care was completed.On 8/25/25, a Progress Note indicated Resident 49GÇÖs middle incision on her/his left thigh was red, swollen, and warm to the touch. Resident 49 reported a burning sensation and tenderness.On 9/2/25 at 10:01 AM, Resident 49 stated staff did not remove her/his wound dressing for nearly two weeks after she/he was admitted to the facility, and her/his incision became infected and painful. Resident 49 stated she/he reported the pain to staff multiple times but staff did not check the incision until the incision was infected.On 9/8/25 at 9:29 AM, Staff 29 (LPN) stated when residents were admitted, Staff 30 (Medical Records) placed the orders in the residentGÇÖs electronic record. Staff 6 stated two nurses verified the orders were correct and placed them on the MAR and TAR. Staff 6 verified the Orthopedic PhysicianGÇÖs order was not on the TAR, dressing changes were not initiated, and Resident 49 developed an incision infection.On 9/8/25 at 9:45 AM, Staff 30 stated upon a new admission she reviewed the orders and uploaded the orders into the electronic record. Staff 30 stated two nurses reviewed the orders, confirmed they were correct, and placed them on the MAR and TAR. Staff 30 verified the Orthopedic PhysicianGÇÖs order was not on the TAR and acknowledged the order was missed.On 9/8/25 at 12:28 PM, Staff 6 (Resident Care ManagerGÇôLPN) stated upon admission, the residentGÇÖs new orders were placed in the electronic record by Staff 30 and reviewed by two nurses to verify accuracy. Staff 6 verified the Orthopedic PhysicianGÇÖs order was not on the 8/2025 TAR. Staff 6 acknowledged dressing changes were not initiated for Resident 49 and she/he developed an incision infection.On 9/8/25 at 12:38 PM, Staff 3 (Regional Director of Quality Assurance) stated the process for new admissions was for Staff 30 to upload the new orders into the electronic record. Staff 3 stated two nurses were to verify the orders were uploaded correctly and placed on the MAR and TAR. Staff 3 verified the Orthopedic PhysicianGÇÖs order was not on the 8/2025 TAR and acknowledged Resident 49 developed an incision infection.

The facility provided the following schedule for smoking:3:00 AM9:30 AM1:30 PM4:00 PM7:45 PM11:00 PMResident 37 was admitted to the facility in 9/2019 with diagnoses including inhalant dependence with inhalant-induced dementia (a condition where an individual has developed a physical or psychological reliance on substances which are inhaled to induce psychoactive effects).Resident 37GÇÖs 8/8/25 Annual MDS assessment indicated she/he was cognitively intact.Resident 37GÇÖs comprehensive Care Plan related to smoking safety last revised 8/26/25 indicated although she/he was assessed to be independent with smoking, she/he was to smoke in the smoking areas and to follow the smoking schedule. The care plan also indicated Resident 37GÇÖs clothing and hands were to be checked for burns and for the facility to store her/his tobacco and fire materials in a lock box at the nurseGÇÖs station.On 9/2/25 at 1:59 PM, Resident 37 stated she/he did not smoke where the others gathered in the designated courtyard of the facility. Resident 37 was observed entering a code into a keypad, exiting out the North exit door, and using a vape box.The following observations were made on 9/3/25:At 6:59 AM, Resident 37 was observed vaping/smoking outside of the North exit door.At 7:08 AM, Resident 37 was observed placing a box of cigarettes, lighter, and vape box on the counter of the nurseGÇÖs station before entering her/his room. -áAt 7:16 AM, Resident 37 came out of her/his room, picked up the box of cigarettes, lighter, and vape box off the counter of the nurseGÇÖs station and exited through the North exit door.The following observations were made on 9/4/25:At 7:20 AM, Resident 37 was observed entering the facility from the North exit door, placed a box of cigarettes, lighter, and vape box on the nurseGÇÖs station counter and entered her/his room.At 7:29 AM, Resident 37 was observed exiting her/his room, picked up the box of cigarettes, lighter, and vape box and exited through the North exit door.At 7:38 AM, Resident 37 was observed placing a box of cigarettes, lighter, and vape box on the nurseGÇÖs station counter.At 7:47 AM, Resident 37 took a vape box and exited through the North door. The box of cigarettes and lighter were still on the counter.On 9/4/25 at 2:59 PM, Staff 9 (CNA) stated Resident 37 was able to smoke without supervision, but the smoking items were to be kept in a lock box. Staff 9 stated the items were given to Resident 37 when she/he asked. Staff 9 stated Resident 37 could smoke whenever she/he wanted to and did not need to go during designated times with the other residents who smoked in the designated courtyard. She stated Resident 37 could go through the North exit door independently.On 9/4/25 at 3:06 PM Staff 2 (DNS) stated the only designated smoking area on the premises was the courtyard, not where Resident 37 was going outside of the North exit doors. She stated Resident 37 had a lockbox kept in a cupboard for staff to keep the smoking materials. She stated her expectations were for staff to immediately take the smoking materials and lock the items in the lock box. Staff 2 stated she expected for staff to check Resident 37 for burns, but was not sure of the frequency.

A review of personnel profile records revealed the following.-Staff 24 (hired on 5/14/20): The last performance review was dated 6/12/24.-Staff 25 (hired on 8/1/18): The last performance review was dated 8/15/24.On 9/8/25 at 11:36 AM, Staff 1 (Administrator) stated he expected the timely completion of annual staff evaluations. -á-á

Resident 2 was admitted to the facility in 7/2025 with diagnoses including anxiety and heart failure.-á-áThe 2/2025 Facility Assessment revealed behavior health staffing was insufficient.-á-áThe 7/23/25 Admission MDS revealed Resident 2 had a BIMS score of 15 which revealed she/he was cognitively intact, was depressed two to six days during the previous two weeks and received no antidepressant medications.-á-áThe 8/2025 Behavior Monitoring Record revealed Resident 2 exhibited inappropriate behaviors on nine of 31 days which included refusal of care, confabulation (fabrication of false memories), and verbal aggression. On eight out of nine days, behavior interventions did not alter the outcome.-á-áThe 8/1/25 through 9/5/25 Progress Notes revealed Resident 2 exhibited no additional behaviors.-áAn 8/12/25 physician order revealed Resident 2 started melatonin (a supplement used to regulate sleep) for insomnia and anxiety.-áThe 8/24/25 revised care plan indicated staff were to addressed Resident 2's behaviors through interventions which included: redirection, assessment of her/his pain, one on one interactions, toileting, snacks, to leave the room and then return, and repositioning. Resident 2's triggers included pain, feeling the loss of independence, and being upset.-áOn 9/3/25 at 9:26 AM, Resident 2 stated she/he banged her/his walker against the wall a few days earlier because staff did not respond to her/his needs. Resident 2 was observed wringing her/his hands while speaking and stated she/he wanted to ensure the correct person was ""blamed"" for her lack of care.-á-áOn 9/4/25 at 1:18 PM, Staff 17 (CMA) stated Resident 2's behaviors were challenging to address. Staff 17 stated she witnessed Resident 2 bang her/his walker against the wall in her/his room over ten days ago. Staff 17 stated she said did not report the incident because she believed other staff were aware.-á-áOn 9/4/25 at 7:10 PM, Staff 28 (LPN) stated Resident 2 accused Staff 28 of providing inadequate care, which was dismissed following an investigation. Staff 28 acknowledged Resident 2's mood and behaviors impacted her/his care.-áOn 9/5/25 at 12:38 PM, Staff 14 (Social Services Director) stated she was aware of Resident 2's verbal aggression towards staff, refusal of care, and confabulation related to staff. Staff 14 stated she witnessed Resident 2 bang her/his walker against the wall a few days earlier, which Staff 14 identified as a change in behavior. Staff 14 was unaware of Resident 2's prior physically aggressive behavior and expected documentation of behavioral changes to ensure timely interventions. Staff 14 stated behavioral services should be considered due to change in Resident 2's behaviors. Staff 14 stated she needed to complete a new behavioral assessment for Resident 2 to obtain additional behavioral services.-áOn 9/5/25 at 1:03 PM, Staff 2 (DNS) stated she was unaware of Resident 2's physical aggressive behavior and expected documentation of the incident to support the management team in addressing the behavioral change.

1. On 9/4/25 at 7:15 AM, the North Hall treatment cart was unlocked. Staff and residents were observed to be walking by the treatment cart.On 9/4/25 at 7:17 AM, Staff 17 (CMA) walked by the cart, walked back, and locked the cart. Staff 17 stated she was not in charge of the treatment cart, but noticed it was unlocked and locked it on behalf of Staff 19. She stated Staff 19 was with a resident. -áOn 9/4/25 at 7:19 AM, Staff 19 (RN GÇô Charge Nurse) stated she usually locked the treatment cart before walking away, but was unsure why she did not lock the treatment cart. The treatment cart contained insulin, needles, glucometers, and IV supplies.On 9/8/25 at 12:40 AM, Staff 1 (Administrator) and Staff 3 (Regional Director of QA) stated they expected treatment carts to be locked at all times when staff walked away from the cart.2. On 9/4/25 at 8:03 AM, the South Hall treatment cart was unlocked. There were no staff members observed to be near the treatment cart.On 9/4/25 at 8:05 AM, Staff 20 (LPN GÇô Charge Nurse) stated she was supposed to lock the treatment cart before walking away from it. Inside of the cart were insulin, syringes and prep pads. Staff 20 stated the small vials of liquid were anticoagulant and antibiotic medications.On 9/8/25 at 12:40 AM, Staff 1 (Administrator) and Staff 3 (Regional Director of QA) stated they expected treatment carts to be locked at all times when staff walked away from the cart.

The facilityGÇÖs Dental Services policy dated 12/2016 included the following:Social services representatives will assist residents with appointments, transportation arrangements, and reimbursement of dental services. All dental services provided are recorded in the residentGÇÖs medical record.The facilityGÇÖs Referrals to Social Service Director dated 11/2024 included the following:Any referrals for the following areas will be made to the social services department: dental.Social services is responsible for the follow up and communication with outside providers for any of the above referrals.The Social Services Director will document any referrals made to ancillary services, mental health services, or additional community services/supports and will also document the outcomes following these referrals.Resident 11 was admitted to facility in 8/2023 with diagnoses including chronic kidney disease.Resident 11GÇÖs Care Plan related to dental revised on 7/11/25 revealed staff were to coordinate arrangements for dental care and transportation as needed.A review of Resident 11GÇÖs clinical record revealed no evidence of dental services referred from 6/2025 through 9/2025.On 9/18/25 at 8:15 AM, Staff 14 (Social Services Director) provided documentation which showed a dental referral for Resident 11 was provided on 7/3/25, when the provider was at the facility. Staff 14 stated she was unsure of what occurred afterward and found no notes or documentation indicating a follow-up dental appointment was-áscheduled for Resident 11.

On 9/2/25 at 10:04 AM, an uncovered exterior refuse container was observed outside a North Hall exit. The container held food containers and other trash. -á-áOn 9/4/25 at 10:03 AM, uncovered exterior refuse containers were observed outside a second North Hall exit and a rear exit. The containers held food debris and other trash. -á-áOn 9/5/25 at 10:00 AM, Staff 4 (Maintenance Lead) observed the uncovered refuse containers and stated there were no lids available for the containers.-á-áOn 9/8/25 at 12:38 PM, Staff 1 (Administrator) and Staff 3 (Regional Director of Quality Assurance) acknowledged exterior refuse containers needed to be covered and there were refuse containers without covers at 3 exterior doors.-á

The 2025 Facility Assessment indicated the facility had areas of insufficiencies in staffing, training, services and personnel.On 9/4/25 at 4:59 PM, Staff 23 (CNA) stated staff were not asked to provide input regarding staffing needs based on the acuity (severity of condition) of residents. -áOn 9/5/25 at 11:07 AM, members of the Resident Council stated concerns about staffing had been discussed during previous meetings, but no resolution had been reached. The Resident Council reported the facility utilized agency staff and felt the staff members required additional training.-áOn 9/7/25 at 2:42 PM, Staff 7 (Resident Care Manager-LPN) stated staff were not fully trained which resulted in some staff resignations. Staff 7 stated there was no formal process to provide feedback to management related to staffing needs. -áOn 9/8/25 at 1:08 PM, documentation was requested to demonstrate how staffing hours, as well as resident and staff feedback, were incorporated into the facility assessment. Staff 1 (Administrator) stated no such documentation was available

3. Resident 26 was admitted to the facility in 6/2025 with a diagnosis of chronic obstructive pulmonary disease (chronic respiratory illness). Resident 26 resided in Room 408.A 9/2/25 revised care plan revealed Resident 26 had COVID-19 (respiratory illness) and was on Special Droplet Precautions.On 9/2/25 at 12:10 PM, a sign was observed outside the door of Room 408 which indicated Resident 26 was on Special Droplet Precautions. Staff 26 (CNA) was observed to exit the room, disposed of her respirator facemask, and placed a new respirator facemask on as she exited the room. Staff 26 did not perform hand hygiene before donning her clean mask and acknowledged she neglected to perform hand hygiene as needed.-áOn 9/4/25 at 12:20 PM, Staff 11 (IP) stated she expected staff to perform hand hygiene before donning a clean facemask.-á-á2.An observation on 9/4/25 at 9:08 AM revealed used COVID-19 tests on top of the North Nurses Station. Staff 11 (LPN-Infection Preventionist) retrieved a paper towel, picked up the used tests, discarded them in the trash, then donned a glove to pick up the paperwork the tests had been placed on. Staff 11 stated the COVID-19 tests should not have been left in the open. Staff 11 stated testing was to be completed in the locked medication storage room to prevent the spread of COVID-19. The nurse was to read the test results within 15 minutes and discard the used tests. Staff 11 stated the night nurse had performed the COVID-19 tests and acknowledged the tests had remained on the North Nurses Station for an extended period and stated the tests should have been secured in the locked medication storage room. Staff 11 stated her expectation was for staff to place used Covid-19 tests in a closed locked room, not on top of the nurse's station counter to avoid the spreading of Covid-19.The facilityGÇÖs COVID-19 Testing Program Guidelines dated 6/7/24 included the following:Facility testing programs for both the residents as well as the facility staff are implemented at the facility in addition to other infection prevention and control activities and interventions aimed at preventing the spread, detecting cases quickly and stopping transmission. These infection control activities including the testing programs are coordinated and overseen by the facility Infection Preventionist who is in contact with the local health department as needed.The facilityGÇÖs COVID-19 Identification and Management of Ill Residents policy dated 7/2020 included the following:Staff caring for residents with suspected or confirmed COVID-19 must strictly adhere to infection prevention and control practices. Residents with known or suspected COVID-19 are cared for using all recommended PPE, including an N95 or higher-level respirator (or facemask if respirators are not available), eye protection, gloves and gown.1. The following observations were made while in the facility:On 9/3/25 at 7:06 AM, a bedside table was stationed inside of the facility next to the North exit door. There were used COVID rapid tests lined up on the bedside table. Staff 21 (Housekeeping Manager) stated all staff were required to take a COVID rapid test prior to the start of their shift. Staff and residents were observed going in and out of the North door where the bedside table was located.On 9/3/25 at 3:01 PM, Staff 31 (CNA) was observed entering room 408, which was identified to be on Droplet Precautions wearing an N95, gloves, and a gown. When she exited the room, she acknowledged forgetting to don a face shield. She stated she also forgot to doff the N95 respirator on her face before leaving the room.On 9/4/25 at 12:18 PM, Staff 11 (LPN GÇô Infection Preventionist) acknowledged staff were testing at the North and South exit doors for COVID-19. Staff 11 stated staff were expected to take COVID tests inside of the medication rooms and a nurse was to administer the COVID-19 test. The used COVID-19 tests were to remain in the medication room. The nurse was to check the test after 15 minutes and throw it away. Staff 11 also stated she expected all staff to follow PPE guidelines provided on the signs posted by resident doors, which included doffing PPE before leaving the room. She acknowledged the GÇ£Droplet PrecautionsGÇ¥ were incorrect, as they had additional instructions posted on the back of the sign, which staff could not see. She stated the appropriate sign read, GÇ£Special Droplet/Contact Precautions,GÇ¥ as it did not have additional instructions on the back.On 9/8/25 at 12:40 PM, Staff 1 (Administrator) and Staff 3 (Regional Director of QA) stated they expected staff to follow appropriate PPE guidelines posted outside of resident doors.

A review of Direct Care Daily Staffing Reports (DCDSR) from 7/29/25 through 9/7/25 revealed the facility failed to maintain CNA staffing ratios for the following dates: 7/29/25, 7/30/25, 7/31/25, 8/4/25, 8/6/25, 8/8/24, 8/9/25, 8/13/25, 8/14/25, 8/15/25, 8/16/25, 8/17/25, 8/18/25, 8/20/25, 8/24/25, 8/26/25, 8/30/25, 9/1/25, 9/3/25, and 9/6/25.On 9/4/25 at 4:59 PM, Staff 23 (CNA) stated the lack of sufficient CNA staffing was ongoing.-áOn 9/8/25 at 7:59 AM, Staff 18 (LPN) stated it was difficult for nursing staff to fill vacant CNA positions due to CNA absenteeism.-áOn 9/8/2025 at 11:38 AM Staff 1 (Administrator) acknowledged the facility struggled to meet the minimum CNA staffing requirements on the dates indicated.-á

A Grievance Policy last revised 1/2017 revealed the facility would promptly address grievances. The grievance would be addressed within five days of its receipt. The Grievance official, administrator, or department head would contact the concerned party to inform them of the resolution of their concern.-áResident 8 was admitted to the facility in 4/2021 with a diagnosis of diabetes. Resident 8GÇÖs 5/14/25 quarterly MDS revealed she/he was cognitively intact. Resident 8GÇÖs Missing Property investigation initiated on 7/11/25 revealed when she/he went to take money out of her/his wallet, there was only 20 dollars instead of 65 dollars in her his wallet. Resident 8 reported there should have been three 20-dollar bills and five one-dollar bills. With the residentGÇÖs permission, staff looked in Resident 8GÇÖs wallet and observed one 20-dollar bill and some loose change. On 7/14/25 Staff 3 (LPN Resident Care Manager) indicated theft was ruled out because Resident 8 made GÇ£multipleGÇ¥ statements, Resident 8 was offered to lock her/his remaining money in a safe, and Staff 4 (Social Services) was notified.-áOn 7/21/25 at 12:30 PM Resident 8 stated she/he reported her/his money was missing and no one told her/him if the money would be reimbursed.-áOn 7/21/25 at 12:44 PM Staff 3 stated she spoke to Resident 8 multiple times and the amount of money she/he reported missing kept changing. Staff 3 stated after she completed her/his investigation she notified Staff 4. Staff 3 indicated she was not sure if Resident 8 was going to be reimbursed her/his money or not.On 7/22/25 at 9:48 AM Staff 4 stated last week she was told Resident 8 was going to be reimbursed her/his lost money, so she/he did not communicate the findings with Resident 8.-áOn 7/22/25 at 2:19 PM Staff 1 (Administrator) acknowledged the Grievance policy revealed staff were to resolve a residentGÇÖs concerns within five days of receipt of the issue and staff did not notify Resident 8 of the resolution of her/his reported missing money timely.

Resident 3 was admitted to the facility in 8/2023 with a diagnosis of a stroke. Resident 3GÇÖs 2/19/25 quarterly MDS revealed she/he was cognitively intact.-áResident 3GÇÖs 4/7/25 Theft investigation revealed Resident 3 reported her/his cell phone was missing. Resident 3 reported on the evening of 4/6/25 she/he used the phone to call her/his spouse and after the call was completed placed the phone on her/his bedside table. The investigation included staff interviews verifying Resident 3 had her/his phone the evening of 4/6/25. Resident 3's spouse filed a police report the following day. Resident 3GÇÖs spouse was able to use a phone locator and Resident 3GÇÖs phone was a few blocks from the facility.-áA 5/10/25 letter from Witness 1 revealed a request for reimbursement for the lost phone and for the purchase of a new phone.A 5/16/25 bank check Pay to the Order to Witness 1 revealed the dollar amount requested by Witness 1 on 5/10/25.On 7/21/25 at 11:19 AM Resident 3 stated she/he always kept her/his phone in her/his room when she/he was in the room or on a lanyard around her/his neck. Resident 3 stated on 4/6/25 she/he called her/his spouse and placed her/his phone on the bedside table and then went to sleep. Resident 3 stated no one came in her/his room except staff and at times her/his roommate's visitors. Resident 3 stated Witness 1 was able to find the approximate location of the phone the next day, and it was about eight blocks from the facility. Witness 1 (via phone) stated the facility investigated the incident and reimbursed her/him in a timely manner.-áOn 7/21/25 at 2:54 PM Staff 17 (CNA) stated Resident 3 always had her/his phone either around her/his neck with a lanyard or on her/his bedside table. Resident 3 did not leave the facility unless she/he had an appointment and when she/he left the facility, she/he always took her/his phone. Staff 17 stated he recalled Resident 3 had her/his phone the evening of 4/6/25 and it was missing the next day. -áThe deficient practice was identified as Past Noncompliance based on the following:-á-4/7/25 Resident 3 reported a missing cell phone.-4/7/25 A FRI was submitted, and an investigation was initiated-A facility wide search for Resident 3GÇÖs phone was unsuccessful-4/8/25 a police report was filed.-4/9/25 Resident 3GÇÖs spouse was notified of the reimbursement procedure-5/10/25 a request for reimbursement was submitted by Witness 1.-5/16/25 reimbursement was provided to Witness 1.

2. A public complaint received on 2/4/25 alleged the facility did not provide adequate staffing on 2/1/25.A review of the 2/1/25 Daily Nursing Assignment revealed there were five CNAs scheduled to work from 2:00 PM to 10:00 PM, one CNA to float between 2:00 PM and 4 PM, and two CNAs scheduled to work 6:00 PM to 10:00 PM.On 7/21/25 at 11:21 AM, Resident 4 stated she/he preferred to go to bed between 7:00 PM and 8:00 PM. Resident 4 stated there were frequently not enough CNAs scheduled and management did not help the CNAs when there were not enough CNAs. Resident 4 stated the CNAs would give up their lunch and breaks to provide care to the residents when they were short staffed.On 7/21/25 at 10:09 AM Witness 7 (Complainant/Former CNA) stated on 2/1/25 there were not enough CNAs scheduled for evening shift causing residents to get to bed late, missed showers, and residents were unable to get oral care due to staffing. Witness 7 stated she was Resident 4GÇÖs CNA on 2/1/25 and she did not put Resident 4 to bed until approximately 9:30 PM on 2/1/25.On 7/21/25 at 12:03 PM Staff 16 (CNA) stated the facility was short CNAs every day in 2/2025 and when they were short CNAs, he would have to prioritize care and sometimes showers would not get completed. Staff 16 stated he was Resident 5GÇÖs CNA on 2/1/25. Staff 16 stated if he did not chart a shower was completed, the shower was not completed.A review Resident 5GÇÖs 2/2025 Documentation Survey Report revealed no documentation Resident 5 received her/his scheduled shower on 2/1/25.On 7/21/25 at 12:23 PM, Staff 12 (Former Staff Coordinator/CNA) stated she was unable to remember if the facility was short CNAs on 2/1/25 but stated the facility was short on CNAs a lot. Staff 12 stated the facility continued to admit new residents even though there were not enough CNAs.On 7/21/25 at 1:20 PM, Staff 3 (LPN Resident Care Manager) stated she was sure the facility was short CNAs in 2/2025, but she could not remember specific dates. Staff 3 acknowledged when the CNAs worked short, they were unable to complete all required tasks.On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residentsGÇÖ needs on 2/1/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering.3. A review of the 7/19/25 Direct Care Staff Daily report revealed the following:-On 7/19/25 day shift the census was 65 and there were eight CNAs scheduled.-On 7/19/25 evening shift the census was 64 and there were five and one half CNAs scheduled.A review of Oregon CNA ratios revealed the following:-Dayshift with a census of 65 required 10 CNAs.-Dayshift with a census of 63 required nine CNAs.-Evening shift with a census of 64 required seven CNAs.-Evening shift with a census of 63 required seven CNAs.On 7/21/25 at 11:21 AM, Resident 4 stated there were frequently not enough CNAs scheduled and management would not help the CNAs when there were not enough CNAs. Resident 4 stated the CNAs would give up their lunch and breaks to provide care to the residents when they were short staffed.On 7/21/25 at 12:23 PM, Staff 12 (Former Staffing Coordinator/CNA) stated the facility had a ton of CNA shortages, but the facility kept admitting new residents even though there were not enough staff.-áOn 7/21/25 at 12:32 PM, Staff 15 (LPN) stated the staffing was getting better, but the last week was the worst. Staff 15 stated they were short CNAs a lot but especially on 7/19/25. Staff 15 stated the census was going up and the facility did not have the staff to care for the residents.On 7/21/25 at 1:20 PM Staff 3 (LPN Resident Care Manager) stated the facility was short CNAs off and on throughout the year. Staff 3 stated she was on call on 7/19/25 and there were not enough CNAs for day and evening shifts. Staff 3 stated the CNA staff informed her they needed help, and she attempted to find coverage but was unable to. On 7/21/25 at 4:35 PM, Staff 7 (CNA) stated they frequently worked without enough CNAs on day shift and evening shift. Staff 7 stated she could complete all required tasks but frequently stayed late to finish.On 7/22/25 at 11:15 AM Staff 8 (RN) stated they were short CNAs on 7/19/25. Staff 8 stated another nurse called the on-call nurse, Staff 3, and Staff 2 (DNS) to request help. Staff 8 stated, GÇ£no managers came in to help us, they just left us short staffed.GÇ¥On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residentsGÇÖ needs on 7/19/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering.a. Resident 9 was admitted to the facility in 1/2024 with a diagnosis of a stroke.Resident 9GÇÖs Care Plan Report revealed she/he required one person assistance for bathing.Resident 9GÇÖs 4/17/25 quarterly MDS revealed she/he was moderately cognitively impaired, was able to participate in the mood interview, and was able to express her/his needs.Resident 9GÇÖs 7/2025 ADL report revealed she/he was to be bathed on Wednesdays and Saturdays. There was no documentation for 7/19/25, Saturday, to indicate if bathing was provided.On 7/21/25 at 1:14 PM Staff 18 (CNA) stated Resident 9 did not receive a shower on 7/19/25 due to short staffing.-á On 7/22/25 at 1:21 PM Resident 9 indicated she/he did not receive a shower on 7/19/25, and she/he did not decline a shower. Resident 9 also indicated she/he was not happy she/he did not receive a shower.On 7/22/25 at 9:53 AM Staff 3 (LPN Resident Care Manager) stated on 7/19/25 she was aware showers were not provided due to staffing, including Resident 9GÇÖs shower, and GÇ£make-upGÇ¥ showers were provided on 7/21/25.On 7/22/25 at 10:09 AM Staff 2 (DNS) stated she was aware there were concerns related to short staffing, staff were not able to complete charting, but she was not aware bathing was not being completed. On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residentsGÇÖ needs on 7/19/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering.b. Resident 10 was admitted to the facility in 7/2018 with a diagnosis of a stroke.Resident 10GÇÖs 5/16/25 annual MDS revealed she/he was cognitively impaired and required extensive assistance with bathing. Resident 10GÇÖs 7/2025 ADL report revealed she/he was to be bathed on Wednesdays and Saturdays. On 7/19/25, Saturday, it was documented Resident 10 refused bathing.On 7/22/25 at 9:45 AM Staff 5 (CNA) stated Resident 10 did not refuse to bathe on 7/19/25 but there were no options to document staff did not have time to provide bathing. Staff 5 stated they did not have enough staff, and she did not have time to provide Resident 10 her/his bath. Staff 5 stated Resident 5 was provided a make-up bath on 7/21/25. On 7/22/25 at 9:53 AM Staff 3 (LPN Resident Care Manager) stated on 7/19/25 she was aware showers were not provided due to staffing, including Resident 10GÇÖs shower, and GÇ£make-upGÇ¥ showers were provided on 7/21/25.On 7/22/25 at 10:09 AM Staff 2 (DNS) stated she was aware there were concerns related to short staffing, staff were not able to complete charting, but she was not aware bathing was not being done.-áOn 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residentsGÇÖ needs on 7/19/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering.c. Resident 11 was admitted to the facility in 2/2017 with a diagnosis of cancer.Resident 11GÇÖs 11/26/24 annual MDS revealed she/he had limited mobility and required the assistance of one staff for bathing.-áResident 11GÇÖs 5/24/25 quarterly MDS revealed she/he was cognitively intact. Resident 11GÇÖs ADL report revealed she/he was to be bathed on Wednesdays and Saturdays. It was documented Resident 11 refused to shower on 7/19/25.On 7/21/25 at 2:05 PM Resident 11 stated on Saturday, 7/19/25 the staff were short staffed and very busy, and she/he did not refuse to take a shower. Resident 11 stated she/he received a GÇ£make-upGÇ¥ shower today.-áOn 7/21/25 at 7:40 PM Staff 19 (CNA) stated the facility worked short staffed on 7/19/25 and Resident 11 was not provided a shower. Resident 11 did not refuse to take a shower, but there were no additional code options to document indicating a shower was not provided due to low staffing.-áOn 7/22/25 at 9:53 AM Staff 3 (LPN Resident Care Manager) stated she was aware showers were not provided due to staffing on 7/19/25 and GÇ£make-upGÇ¥ showers were provided on 7/21/25, including Resident 11.On 7/22/25 at 10:09 AM Staff 2 (DNS) stated she was aware there were concerns related to short staffing, staff were not able to complete charting, but she was not aware bathing was not being done. On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residentsGÇÖ needs on 7/19/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering.-á4. A review of 7/20/25 Direct Care Staff Daily report revealed the following:-On 7/20/25 day shift the census was 63 and there were seven CNAs scheduled.-On 7/20/25 evening shift the census was 63 and there were five CNAs scheduledA review of Oregon CNA ratios revealed the following:-Dayshift with a census of 63 required nine CNAs.-Evening shift with a census of 63 required seven CNAs.On 7/21/25 at 11:21 AM, Resident 4 stated there were frequently not enough CNAs scheduled and management would not help the CNAs when there were not enough CNAs. Resident 4 stated the CNAs would give up their lunch and breaks to provide care to the residents when they were short staffed.On 7/21/25 at 12:23 PM, Staff 12 (Former Staffing Coordinator/CNA) stated the facility had a ton of CNA shortages, but the facility kept admitting new residents even though there were not enough staff. Staff 12 stated on 7/20/25 they had seven CNAs on day shift and five CNAs on evening shift.On 7/21/25 at 12:32 PM, Staff 15 (LPN) stated the staffing was getting better, but the last week was the worst. Staff 15 stated they were short CNAs a lot but especially on 7/20/25. Staff 15 stated the census was going up and the facility did not have the staff to care for the residents.On 7/21/25 at 1:20 PM Staff 3 (LPN Resident Care Manager) stated the facility was short CNAs off and on throughout the year. Staff 3 stated she was on call on 7/20/25 and there were not enough CNAs for day and evening shifts. Staff 3 stated the CNA staff informed her they needed help, and she attempted to find coverage but was unable to.-áOn 7/21/25 at 2:49 PM, Staff 14 (CNA) stated they worked short a lot, especially on 7/20/25. Staff 14 stated when there was enough CNAs, she would prioritize care and was unable to complete showers, oral care, and personal hygiene. Staff 14 stated there were some days when they were short CNAs and she was only able to change residents, get them up for their meal, and lay them back down in bed after dinner.On 7/21/25 at 4:35 PM, Staff 7 (CNA) stated they frequently worked without enough CNAs on day shift and evening shift. Staff 7 stated she could complete all required tasks but frequently stayed late to finish.On 7/21/25 at 4:45, Staff 5 (CNA) stated they were short CNAs a lot, for the last week they were short one to two CNAs every day. Staff 5 stated the management knew there was not enough staff, and they kept admitting new residents. Staff 5 stated on 7/20/25 they did not have enough CNAs, and she was unable to complete one of two showers she was assigned.On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility did not provide adequate CNA staff to provide for residentsGÇÖ needs on 7/20/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering.1. Resident 3 was admitted to the facility in 3/2025 with diagnoses including dementia and stroke.A 5/2025 Documentation Survey Report revealed Resident 3GÇÖs showers were typically provided during the evening shifts. The resident was scheduled to receive a shower on 5/27/25, and there was no documentation Resident 3GÇÖs shower was completed.The 5/27/25 Direct Care Staff Daily Report indicated five CNAs worked during the evening shift with a facility census of 56 residents.A 6/2/25 public complaint was received which alleged, on 5/27/25, each CNA had 12 residents during the evening shift due to call outs, and it was possible resident showers were not provided.A 6/12/25 revised care plan indicated Resident 3 required one person to assist with bathing.On 7/21/25 at 12:14 PM, Staff 13 (LPN) stated she recalled 5/27/25 as a GÇ£terribleGÇ¥ day. Staff 13 stated the facility was understaffed, she answered numerous call lights, and there was a lack of assistance from management to help on the floor. Staff 13 stated she often skipped breaks and stayed after hours to complete her charting when there was a lack of CNA staffing.On 7/21/25 at 2:20 PM, Staff 6 (CNA) stated on 5/27/25 the staff were unable to complete Resident 3GÇÖs shower due to insufficient staff. Staff 6 stated showers were frequently missed for residents due to unresolved facility staffing issues.On 7/21/25 at 3:54 PM, Staff 4 (Social Service Director) confirmed on 5/27/25 efforts were made to contact agency staff resources, and no staff responded to the request for assistance. Staff 4 acknowledged staff not working when scheduled remained an issue.On 7/22/25 at 2:20 PM, Staff 1 (Administrator) stated the facilityGÇÖs issues related to staffing and meeting the needs of residents remained a concern and a focus since 12/2024. Staff 1 confirmed resident needs were not met on 5/27/25 since the facility was short-staffed. Staff 1 acknowledged additional staffing resources were necessary to meet resident needs.-á-á

Based on interview and record review it was determined the facility failed to follow resident rights for 1 of 3 sampled residents (# 2) reviewed for resident rights. This placed residents at risk for lack of dignity. Findings include:

Resident 2 admitted to facility in 7/2024, with diagnoses including dementia.

A 1/2025 Quarterly MDS Assessment indicated Resident 2 was moderately cognitively impaired.

The facility's abuse investigation dated 10/3/24 indicated the following:

-Staff 4 (CNA) changed Resident 2's soiled shirt. Resident 2 had told Staff 4 to leave her/him alone and not change her/his shirt.

-On 10/3/24 Resident 2 stated "the lady" took her/him to the room and ripped Resident 2's shirt off. Resident 2 stated they refused to have their shirt removed.

-On 10/3/24 Staff 4 (CNA) stated she went into Resident 2's room to change her/his shirt. The shirt was a lot dirtier than just "wiping it off." Staff 4 stated she explained this to Resident 2, but the resident fought and cussed at her while she changed the resident's shirt. Staff 4 notified Staff 5 (LPN) that Resident 2 was very upset about their shirt being changed.

-On 10/4/24 Staff 5 (LPN) stated Staff 4 (CNA) told her that Resident 2 was mad because she made Resident 2 change their shirt.

On 5/2/25 at 6:05 AM, Staff 3 (CNA) stated she heard about the incident and recalled the education received by all staff afterward. Staff 3 stated Staff 4 should have gotten a second CNA or the nurse and not complete the task on her own.

On 5/2/25 at 7:06 AM, Staff 6 (CNA/RA) stated she remembered Resident 2 crying. Resident 2 told her something about a girl and her/his shirt. Staff 6 indicated she was unsure what occurred but knew something wrong had happened. Staff 6 stated she informed the nurse of the situation.

On 5/2/25 at 9:12 AM, Staff 8 (LPN/RCM Assistant) stated at the time of the incident Resident 2 appeared in distress. Staff 8 stated Resident 2 never used the words abuse, and when asked only repeated the details of the incident, but it was clear Resident 2 was forced to do something she/he did not want to do. Staff 8 recalled two days later Resident 2 no longer had any recollection of the incident.

Attempts to contact Staff 4 (CNA) were unsuccessful and Staff 4 did not return the surveyor's calls.

On 5/5/25 at 11:00 AM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed the information of the incident was accurate and the failure to maintain resident rights had occurred.

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411-085-0310 - Residents' Rights: Generally

Refer to F550
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Based on interview and record review it was determined the facility failed to provide risk and benefit information related to the use of antipsychotic medications to residents/responsible parties prior to administration for 1 of 5 sampled residents (#10) reviewed for medications. This placed resident responsible parties at risk for lack of informed consent. Findings include:

Resident 10 admitted to the facility in 5/2024 with diagnosis including dementia.

A review of the 5/2024 MAR revealed instruction staff to administer Haloperidol (an antipsychotic used to treat mental and mood disorders) four times a day for anxiety and agitation with a start date of 5/9/24.

The Admission MDS dated 5/14/24 revealed Resident 10 had a BIMS score of 10, which indicated the resident was moderately impaired cognitively.

A review of Resident 10's clinical record revealed Witness 2 (Family Member) was Resident 10's responsible party.

A review of a Consent for use of Psychotropic Medication Therapy dated 5/16/24 revealed Resident 10 was prescribed haloperidol for anxiety. Resident 10 was informed about the risk and benefits of the medication.

In an interview on 7/19/24 at 12:42 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) confirmed staff were expected to have medication consent forms signed before the medications were administered.

Based on interview and record review it was determined the facility failed to ensure care conferences were completed for 1 of 5 sampled residents (#15) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include:

Resident 15 admitted to the facility in 11/2021 with diagnoses including dementia.

On 7/18/24 at 1:30 PM Witness 6 (family member) stated the facility scheduled a care conference on 5/27/24. Witness 6 stated the care conference did not occur and no one contacted her to reschedule.

On 7/18/24 at 3:01 PM Staff 15 (LPN Assistant RCM) confirmed Resident 15 had a care conference scheduled on 5/27/24. Staff 15 stated on 5/27/24 Witness 6 came down to the social services office to inquire about the scheduled care conference. Staff 15 stated she spoke with Witness 6 and Witness 6 had no concerns. Staff 15 confirmed Resident 15 was not in attendance.

On 7/18/24 at 3:09 PM Staff 33 (Social Service Coordinator) stated on 5/27/24 Witness 6 came to her office to inquire about the scheduled care conference. Staff 33 stated she spoke with Witness 6 and Witness 6 had no concerns. Staff 33 confirmed Resident 15 was not in attendance.

On 7/19/24 at 7:55 AM Staff 32 (LPN RCM) stated the care conferences should include the resident, family and the interdisplinary team (IDT) which included nursing, social services, therapy (if applicable), dietary and activities.

On 7/19/24 at 8:24 AM Staff 31 (SSD) stated care conference should include the resident, family and IDT. Staff 31 confirmed Resident 15 did not have a care conference and stated she was working on rescheduling the care conference.

Based on observation, interview and record review it was determined the facility failed to include a resident in shower schedule decisions for 1 of 4 sampled residents (#36) reviewed for choices. This placed residents at risk for lack of independent choices. Findings include:

Resident 36 admitted to the facility in 2024 with diagnoses including diabetes and a foot ulcer.

A 5/22/24 revised care plan indicated Resident 36 required two staff to assist with transfers and was dependent on staff with dressing.

A 6/25/24 Census for Resident 36 indicated a room move.

On 7/16/24 at 9:09 AM a communication board in Resident 36's room indicated her/his shower days were Monday and Thursday. Resident 36 stated the schedule for her/his showers were recently changed without a conversation with the resident. Resident 36 stated the current shower schedule interferred with her/his weekly medical appointment which was not acceptable.

On 7/18/24 at 5:11 PM Staff 28 (LPN-Resident Care Manager) stated when Resident 36 moved to a new room her/his shower scheduled automatically changed. Staff 28 acknowledged Resident 36's shower schedule should have been discussed with Resident 36 prior to any changes.

Based on interview and record review it was determined the facility failed to notify provider of CBG check and orthostatic blood pressure refusals for 1 of 5 sampled residents (# 17) reviewed for medications. This placed residents at risk for unmet needs. Findings include:

Resident 17 admitted to the facility in 9/2019 with diagnoses including diabetes.

A review of Resident 17's Physician Orders revealed a 9/26/23 order to check her/his CBG every Tuesday morning and a 5/11/22 order to check her/his orthostatic blood pressure (blood pressure check when laying down, sitting and standing) every month.

A review of Resident 17's 5/2024 MAR revealed she/he refused CBG checks on 5/21/24 and 5/28/24 and she/he refused orthostatic blood pressures on 5/12/24.

A review of Resident 17's 6/2024 MAR revealed she/he refused CBG checks on 6/4/24, 6/11/24, 6/18/24 and 6/25/24 and she/he refused orthostatic blood pressures on 6/12/24.

A review of Resident 17's MAR from 7/1/24 through 7/18/24 revealed she/he refused CBG checks on 7/2/24, 7/9/24 and 7/16/24 and there was no evidence of documentation for orthostatic blood pressures on 7/12/24.

A 7/18/24 review of Resident 17's medical record revealed no evidence the provider was notified of Resident 17's refusals for CBG checks and orthostatic blood pressures.

On 7/19/24 at 10:23 AM Staff 23 (RN Regional Nurse Consultant) confirmed Resident 17's provider was not notified of Resident 17's refusals for CBG checks and orthostatic blood pressures.

4. Resident 6 admitted to the facility in 2024 with diagnosis including heart disease.

On 7/16/24 at 10:01 AM missing flooring was observed by the resident's nightstand.

On 7/19/24 at 8:00 AM Staff 19 (Maintenance Lead) acknowledged the flooring damage.

5. Resident 27 admitted to the facility in 6/2023 with diagnosis including stroke.

On 7/16/24 at 10:25 AM a gray putty or cement rectangular area was observed on the floor by Resident 27's transfer pole. Resident 27 stated staff used putty to fix holes in the floor.

On 7/19/24 at 8:00 AM Staff 19 (Maintenance Lead) acknowledged the flooring damage.

6. Resident 29 admitted to the facility in 2024 with diagnosis including stroke.

On 7/16/24 at 11:10 AM the ceiling by Resident 29's TV appeared to have leakage damage and was coming apart in areas. There was also dark brown dried debris on the wall where the roof leaked.

On 7/19/24 at 12:59 PM AM Staff 19 (Maintenance Lead) confirmed the ceiling damage.

7. Resident 37 was admitted to the facility in 2024 with diagnoses including weakness.

On 7/16/24 at 10:48 AM Resident 37's bathroom flooring was observed chipped and missing pieces. Resident 37's toilet had dark brownish black debris around the base of the toilet.

On 7/19/24 at 8:00 AM Staff 19 (Maintenance Lead) confirmed the dark brownish black debris around the base of the toilet and acknowledged the flooring damage.

8. Resident 46 admitted to the facility in 2024 with diagnosis including anxiety disorder.

On 7/16/24 at 11:46 AM approximately 10-15 dents with black marks were observed on the floor at the foot of Resident 46's bed. Resident 46 stated the floors were bad and needed to be fixed.

On 7/19/24 at 8:00 AM Staff 19 (Maintenance Lead) confirmed the flooring damage.




, Based on observation and interview it was determined the facility failed to provide a clean homelike environment for 7 of 10 sampled residents (#s 6, 19, 27, 29, 37, 46 and 58) and 1 of 2 halls (North) reviewed for environment. This placed residents at risk for an unclean and unhomelike environment. Findings include:

1. Resident 19 admitted to the facility in 6/2023 with diagnosis including reduced mobility.

On 7/15/24 at 10:41 AM approximately 50 dents with black marks were observed on the floor at the foot of Resident 19's bed. Resident 19's roommate mentioned ongoing cleaning efforts by housekeeping that did not remove the marks. Additionally, in the bathroom, there were two gray substance lines, each approximately four inches by 12 inches on an aged and dingy floor.

On 7/19/24 at 8:00 AM Staff 19 (Maintenance Lead) confirmed completion of some work was needed near the toilet and acknowledged flooring damage.

2. Resident 58 admitted to the facility in 4/2024 with diagnosis including end-of-life care.

On 7/15/24 at 10:32 AM multiple square dents with black marks were observed under the foot of Resident 58's bed. There was gray substance around the toilet in the bathroom with cracking, and an unclean base with black substance in several areas. The flooring appeared aged and dingy.

On 7/19/24 at 8:00 AM Staff 19 (Maintenance Lead) confirmed the flooring damage.

3. On 7/15/24 at 10:14 AM and 12:12 PM two strips of white tape, approximately two inches wide and six inches long, were observed outside Room 401 on the carpeted floor. In the hallway between rooms 405 and 406 a large dark stain was observed. The carpet outside Room 405 showed a black coloration extending approximately four to six inches from the door threshold and spanning the door's full width.

On 7/19/24 at 8:00 AM Staff 19 (Maintenance Lead) confirmed the flooring damage.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 1 resident (#46) reviewed for abuse. This placed residents at risk for abuse. Findings include

Resident 46 admitted to the facility in 2024 with diagnoses including PTSD (post traumatic stress disorder) and anxiety disorder.

The 4/5/24 Admission MDS indicated Resident 46 had a BIMS of 15 which indicated she/he was cognitively intact.

The 4/1/24 care plan indicated Resident 46 was on behavior monitoring related to a history of PTSD, depression, and anxiety. Resident 46's triggers for PTSD included:
-overwhelmed
-feeling loss of control
-upset with situation

On 6/13/24 a public complaint was received which indicated Resident 46 was being harassed and intimidated by Resident 29. The facility was not doing enough to keep her/him safe and it was an ongoing issue. Witness 8 (Complainant) stated on 6/2/24 Resident 29 came into the dining room and was disruptive. Resident 46 politely asked her/him to to not be disruptive while they were having their meal. Resident 29 became angry and began yelling and cursing, and ever since then Resident 29 continued to come in the dining room on her/his electric scooter, ride around Resident 46 and stare at her/him. Resident 46 told Witness 8 she/he felt harassed and caused her/him anxiety. Witness 8 stated Resident 46 used to come out of her/his room to read and socialize but now spent time in her/his room. Witness 8 stated the residents lived on separate halls and there was no reason Resident 29 needed to come down the 400 hall where Resident 46 resided. Witness 8 stated Resident 29 came to Resident 46's room, stood in the door way and stared at her/him. Witness 8 stated she was concerned for Resident 46's safety and was worried the situation would escalate.

Multiple observations from 7/16/24 through 7/19/24 on day and evening shifts revealed Resident 29 on the 400 hall by Resident 46's room staring at her/him. Staff intervened and Resident 29 began cursing.

On 7/16/24 at 11:05 AM Resident 29 stated Resident 46 was mean and yelled at her/him in the dining room and when she/he was in the 400 hall. Resident 29 sated Resident 46 started the argument not her/him.

On 7/17/24 at 3: 09 PM Resident 46 stated Resident 29 came into the dining room on 6/2/24 and started yelling at staff and banged on the tables. Resident 46 stated she/he politely asked Resident 29 to not be disruptive while residents ate their meal. Resident 46 stated Resident 29 became angry, left the dining, room, but came back and started cursing at her/him. Resident 46 stated after the incident Resident 29 continued to come down the 400 hall, stand in her/his doorway and stare at her/him. Resident 46 stated she/he felt scared, intimidated, and uncomfortable. Resident 46 stated she/he spoke with management but nothing was done.

On 7/18/24 at 3:01 PM Staff 32 (LPN-RCM) stated Resident 29 was targeting and making Resident 46 uncomfortable by coming down the 400 hall and staring at her/him. Staff 32 stated there are multiple doors Resident 29 can exit from but chose the 400 hall door. Staff 32 stated management indicated if Resident 29 talked to Resident 46 staff can intervene otherwise there was noting staff could do because Resident 29 had a right to be wherever she/he wanted. Staff 32 stated Resident 46 had become more anxious, PTSD was intensified, and stated she/he felt targeted by Resident 29. Staff 32 stated management was aware of the incident but nothing was done to protect Resident 46.

On 7/18/24 at 3:15 PM Staff 46 (CNA) stated Resident 29 intimidated Resident 46 all day. Resident 29 came down Resident 46's hall and stalked her/him. Staff 46 stated management told staff when Resident 29 came down the 400 hall to encourage her/him to go somewhere else, but Staff 46 indicated this caused Resident 29 to yell at staff. Staff 46 stated Resident 46 was more anxious and now stayed in her/his room due to Resident 29's behavior. Staff 46 stated management was aware of the situation but nothing was done to protect Resident 46.

On 7/19/24 at 12:34 PM Staff 16 (CMA) stated Resident 29 never came down the 400 hall until the 6/2/24 incident. Staff 16 stated management told staff there was nothing they could do because Resident 29 had the right to go wherever she/he wanted to go. Staff 16 stated staff saw Resident 29 outside Resident 46's window staring at her/him. Staff 16 stated Resident 46 stated she/he felt scared, anxious, not protected, and her/his rights were violated. Staff 16 stated management was aware of the situation but nothing was done to protect Resident 46.

On 7/19/24 at 2:22 PM Staff 1 (Administrator) stated Resident 46 indicated she/he felt intimidated by Resident 29, and Resident 29 glared and made faces at her/him. Staff 1 stated staff were instructed to redirect Resident 29 but this angered Resident 29. Staff 1 stated staff were to continue redirecting Resident 29.

Based on observation, interview, and record review it was determined the facility failed to investigate allegations of abuse for 1 of 1 sampled resident (#46) reviewed for abuse. This placed residents at risk for abuse. Findings include:

Resident 46 admitted to the facility in 2024 with diagnoses including PTSD (post traumatic stress disorder) and anxiety disorder.

The 4/5/24 Admission MDS indicated Resident 46 had a BIMS of 15 which indicated she/he was cognitively intact.

The 4/1/24 care plan indicated Resident 46 was on behavior monitoring related to a history of PTSD, depression, and anxiety. Resident 46's triggers for PTSD included:
-overwhelmed
-feeling loss of control
-upset with situation

On 6/13/24 a public complaint was received which indicated Resident 46 was being harassed and intimidated by Resident 29. The facility was not doing enough to keep her/him safe and it was an ongoing issue. Witness 8 (Complainant) stated on 6/2/24 Resident 29 came into the dining room and was disruptive. Resident 46 politely asked her/him to to not be disruptive while they were having their meal. Resident 29 became angry and began yelling and cursing, and ever since then Resident 29 continued to come in the dining room on her/his electric scooter, ride around Resident 46 and stare at her/him. Resident 46 told Witness 8 she/he felt harassed and caused her/him anxiety. Witness 8 stated Resident 46 used to come out of her/his room to read and socialize but now spent time in her/his room. Witness 8 stated the residents lived on separate halls and there was no reason Resident 29 needed to come down the 400 hall where Resident 46 resided. Witness 8 stated Resident 29 came to Resident 46's room, stood in the door way and stared at her/him. Witness 8 stated she was concerned for Resident 46's safety and was worried the situation would escalate.

Multiple observations from 7/16/24 through 7/19/24 on day and evening shifts revealed Resident 29 on the 400 hall by Resident 46's room staring at her/him. Staff intervened and Resident 29 began cursing.

On 7/16/24 at 11:05 AM Resident 29 stated Resident 46 was mean and yelled at her/him in the dining room and when she/he was in the 400 hall. Resident 29 sated Resident 46 started the argument not her/him.

On 7/17/24 at 3: 09 PM Resident 46 stated Resident 29 came into the dining room on 6/2/24 and started yelling at staff and banged on the tables. Resident 46 stated she/he politely asked Resident 29 to not be disruptive while residents ate their meal. Resident 46 stated Resident 29 became angry, left the dining, room, but came back and started cursing at her/him. Resident 46 stated after the incident Resident 29 continued to come down the 400 hall, stand in her/his doorway and stare at her/him. Resident 46 stated she/he felt scared, intimidated, and uncomfortable. Resident 46 stated she/he spoke with management but nothing was done.

On 7/18/24 at 3:01 PM Staff 32 (LPN-RCM) stated Resident 29 was targeting and making Resident 46 uncomfortable by coming down the 400 hall and staring at her/him. Staff 32 stated there are multiple doors Resident 29 can exit from but chose the 400 hall door. Staff 32 stated management indicated if Resident 29 talked to Resident 46 staff can intervene otherwise there was noting staff could do because Resident 29 had a right to be wherever she/he wanted. Staff 32 stated Resident 46 had become more anxious, PTSD was intensified, and stated she/he felt targeted by Resident 29. Staff 32 stated management was aware of the incident but nothing was done to protect Resident 46.

On 7/18/24 at 3:15 PM Staff 46 (CNA) stated Resident 29 intimidated Resident 46 all day. Resident 29 came down Resident 46's hall and stalked her/him. Staff 46 stated management told staff when Resident 29 came down the 400 hall to encourage her/him to go somewhere else, but Staff 46 indicated this caused Resident 29 to yell at staff. Staff 46 stated Resident 46 was more anxious and now stayed in her/his room due to Resident 29's behavior. Staff 46 stated management was aware of the situation but nothing was done to protect Resident 46.

On 7/19/24 at 12:34 PM Staff 16 (CMA) stated Resident 29 never came down the 400 hall until the 6/2/24 incident. Staff 16 stated management told staff there was nothing they could do because Resident 29 had the right to go wherever she/he wanted to go. Staff 16 stated staff saw Resident 29 outside Resident 46's window staring at her/him. Staff 16 stated Resident 46 stated she/he felt scared, anxious, not protected, and her/his rights were violated. Staff 16 stated management was aware of the situation but nothing was done to protect Resident 46.

On 7/19/24 at 2:22 PM Staff 1 (Administrator) stated Resident 46 indicated she/he felt intimidated by Resident 29, and Resident 29 glared and made faces at her/him. Staff 1 stated staff were instructed to redirect Resident 29 but this angered Resident 29. Staff 1 stated staff were to continue redirecting Resident 29. Staff 1 stated he was not made aware of the 6/2/24 incident until 6/5/24 and the police were not called until 6/5/24. Staff 1 acknowledged the investigation should have started on 6/2/24 the date of the incident.

Based on observation, interview, and record review it was determined the facility failed to revise care plan interventions for 3 of 13 sampled residents (#s 10, 17 and 24) reviewed for ADLS, medications, positioning and mobility. This placed residents at risk for unmet needs. Findings include:

1. Resident 10 admitted to the facility in 5/2024 with diagnoses including a broken arm.

The Admission MDS dated 5/14/24 revealed Resident 10 had a BIMS score of 10, which indicated the resident was moderately impaired cognitively. Resident 10 was at risk for contracture to the left fingers.

A review of a TAR for 7/2024 instructed staff to soak and wash her/his hand in warm water every shift and apply a hand brace every day and evening shift for the hand contracture with a start date of 6/11/24.

Review of Resident 10's current care plan revealed no documentation related to the hand contracture.

On 7/19/24 at 7:54 AM Staff 16 (CMA) stated she was the one who started soaking Resident 10's hand as her/his hand was "crusty" and smelled bad. She requested the brace and she used to apply it, but now Staff 43 (Restorative Aide) applied the brace.

On 7/19/24 at 8:07 AM Staff 43 stated "everyone" soaks Resident 10's hand and applied her/his brace. Staff 43 stated Resident 10's fingernail broke off into the palm of her/his hand due to the hand contracture.

In an interview on 7/19/24 at 12:42 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) confirmed Resident 10's hand contracture should have been added to the care plan.

2. Resident 24 admitted to the facility in 1/2024 with diagnoses including aphasia (damage or injury to the language area of the brain) and stroke.

A review of the care plan dated 1/23/24 indicated Resident 24 had deficits in ADL performance and nutritional issues due to dysphagia (difficulty in swallowing), poor intake and leaving 25 percent of food uneaten. Interventions included easy-to-chew textures, nutritional supplement four times a day. There was no documentation specifying whether Resident 24 required supervision or assistance with eating.

On 7/18/24 at 10:54 AM, Staff 14 (CNA) stated Resident 24 did not require assistance with eating she/he just needed some cues to eat at times.

On 7/19/24 at 8:35 AM Resident 24 was observed eating breakfast in her/his room. Staff 43 (Restorative Aide) stated Resident 24 did not require assistance with eating and she/he usually ate breakfast in her/his room.

In an interview on 7/19/24 at 12:12 PM, Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) acknowledged that supervision and cueing for eating assistance should have been specified on Resident 24's care plan.

, 3. Resident 17 admitted to the facility in 9/2019 with diagnoses including alcohol dependency and narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance).

A review of Resident 17's care plan revealed a behavior care plan related to a history of behaviors and a diagnosis of narcissistic personality disorder.

On 7/19/24 at 10:16 AM Staff 2 (DNS) stated any alcohol consumption by Resident 17 would result in worsening behaviors.

A 7/19/24 care plan review revealed no evidence Resident 17 was care planned for alcohol dependency or worsening behaviors with alcohol consumption.

On 7/19/24 at 1:02 PM Staff 32 (LPN RCM) stated alcohol consumption by Resident 17 made her/his behaviors worse. Staff 32 confirmed Resident 17 was not care planned for alcohol dependency or for worsening behaviors with alcohol consumption.

On 7/19/24 at 1:12 PM Staff 2 confirmed Resident 17 was not care planned for alcohol dependency or worsening behaviors with alcohol consumption.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 6 sampled residents (#s 16, 24, and 40) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include:

1. Resident 16 admitted to the facility in 2/2017 with diagnoses including a fractured pelvis.

The quarterly MDS dated 3/21/24 revealed Resident 16 had a BIMS score of 15 indicating the resident was cognitively intact. The resident required substantial to maximal assistance with transfers related to toileting.

A review of Resident 16's care plan revised 7/5/21 revealed Resident 16 had bladder incontinence. Interventions included to notify staff of toileting needs. Resident 16 was occasionally incontinent before reaching the bathroom and required one-person assistance for toilet transfers.

On 5/30/24 the State Survey Agency received a public complaint which indicated staff were busy with dinner one night the week of 5/20/24. Resident 16 activated her/his call light for toileting assistance, but staff did not respond for 45 minutes.

A review of a 5/2024 Documentation Survey Report revealed the week of 5/20/24 to 5/27/24, on the evening shift, Resident 16 was continent twice, was both continent and incontinent seven times, and incontinent once.

Witness 1 (Staff) was interviewed on 7/17/24 at 9:31 AM and confirmed the complaint that Resident 16 did not receive timely toileting assistance the week of 5/2024, and was upset she/he had an incontinent episode.

During an interview on 7/17/24 at 9:58 AM Resident 16 confirmed that in 5/2024, during dinner time, she/he waited 45 minutes after activating her/his call light for toileting assistance. Resident 16 indicated she/he could not wait and had an incontinent episode.

During an interview on 7/18/24 at 12:00 PM Staff 13 (CNA) stated when toileting assistance was documented as both continent and incontinent during a shift it indicated a resident was continent one time and incontinent another time on the same shift.

In an interview on 7/19/24 at 12:12 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated the expectation for a call light to be answered was 15 to 20 minutes.

2. Resident 24 admitted to the facility in 1/2024 with diagnoses including stroke and dementia.

The quarterly MDS dated 4/26/24 revealed Resident 24 was rarely or never understood and experienced short-term and long-term memory issues. Resident 24 was dependent on staff for bathing.

A review of the care plan dated 1/23/24 indicated Resident 24 had deficits in ADL performance and required two-person physical assistance for bathing.

A review of the 4/2024 and 5/2024 Documentation Survey Reports indicated Resident 24 refused showers eight times and received nine showers. On 5/17/24 there was no documentation that Resident 24 received a shower.

On 5/30/24 the State Survey Agency received a public complaint which indicated staff were unable to complete showers for all residents. Resident 24 missed showers and developed body odor due to lack of bathing.

A review of a 6/2024 Documentation Survey Report indicated Resident 24 refused showers four instances and received four showers.

On 7/17/24 at 10:59 AM Staff 18 (CNA) stated not all tasks for residents, including showers, could always be completed due to time constraints.

On 7/17/24 at 11:53 AM, Witness 1 (Staff) stated when showers could not be completed she/he documented that the resident refused, as there was no option to document that the shower was not completed.

In an interview on 7/19/24 at 12:12 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated staff were expected to not document if a shower was not completed and for the next shift to complete the shower if a shower was not completed.

, 3. Resident 40 admitted to the facility in 2022 with diagnoses including dementia and depression.

The 5/2024 Documentation Survey Report indicated Resident 40 received two showers during the month on 5/24/24 and 5/28/24 and refused showers on 5/2/24, 5/3/24, 5/21/24 and 5/31/24.

A 6/6/24 revised care plan indicated Resident 40 needed physical assistance for personal hygiene and bathing.

The CNA Tasks: Bathe/Shower on 7/15/24 revealed Resident 40 received four showers in the past 30 days on 6/21/24, 7/5/24, 7/9/24 and 7/15/24, and refused showers on 6/18/24, 6/25/24 and 7/2/24.

On 7/16/24 at 9:24 AM Resident 40 was observed to have dry flakes on her/his head and hair which appeared to stick together.

On 7/17/24 at 10:07 AM Staff 27 (LPN) stated showers for Resident 40 were not completed two times each week as assigned to CNAs due to lack of available staff.

On 7/18/24 at 12:32 PM Staff 30 (CNA) stated Resident 40 rarely refused showers when she/he was properly approached. Staff 30 acknowledged staffing was a challenge in order to accomplish evening showers.

On 7/18/24 at 6:09 PM Staff 28 (LPN-Unit Manager) acknowledged improved training for CNAs was necessary in order for Resident 40 to accept her/his needed showers.

Based on observation, interview and record review it was determined the facility failed to assess and provide meaningful activities for 2 of 2 sampled resident (#s 36 and 42) reviewed for activities. This placed residents at risk for lack of social interaction. Findings include:

1. Resident 36 admitted to the facility in 2024 with diagnoses including diabetes and a foot ulcer.

A 5/21/24 Admission MDS revealed Resident 36 was cognitively intact and it was very important to choose activities which were important to her/him.

A 5/28/24 Activity Profile indicated Resident 36 desired group activities which included exercise.

A 5/29/24 care plan indicated Resident 36 wanted staff to discuss her/his likes and dislikes related to activities.

The 7/15/24 [CNA] Tasks: Activity revealed Resident 36 did not engage in any group or one on one activities during the previous 30 days.

On 7/16/24 at 8:42 AM Resident 36 was observed in bed and stated she/he was bored and there were no exercise options presented.

On 7/17/24 at 3:09 PM Staff 37 (Activities Director) stated Resident 36 had no interest in current activities. Staff 37 stated in room activities were offered to Resident 36 although Staff 37 was aware of Resident 36's interest in exercise. Staff 37 acknowledged current activities did not include exercise programming.

, 2. Resident 42 admitted to the facility in 2024 with diagnoses including anxiety disorder.

A 6/27/24 care plan indicated Resident 42 had no activity care plan.

The 7/19/24 [CNA] Tasks: Activity revealed Resident 42 did not engage in any group or one on one activities during the previous 30 days.

On 7/19/24 at 12:04 PM Staff 31 (Social Services) stated she did not find any activity preferences in the care plan for Resident 42.

On 7/19/24 at 12:30 PM Staff 37 (Activities Director) stated she did not get an activity preference sheet completed for Resident 42.

2. Resident 33 admitted to the facility in 6/2024 with a diagnosis including arthritis.

A review of the Documentation Survey Report for 6/2024 revealed from 6/7/24 through 6/13/24 Resident 33 did not have a bowel movement.

A review of the 6/2024 MAR indicated staff were instructed to administer milk of magnesia every 24 hours as needed for constipation. Resident 33 received the medication on 6/12/24, five days after not having a bowel movement.

In an interview on 7/19/24 at 11:48 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) confirmed Resident 33 should have received bowel care sooner.




, Based on interview and record review it was determined the facility failed to implement bowel care, notify the physician and follow physician orders for 2 of 8 sampled residents (#s 17 and 33) reviewed for skin, change of condition, and medications. This placed residents at risk for unmet needs. Findings include:

1. Resident 17 admitted to the facility in 9/2019 with diagnoses including diabetes.

A review of Resident 17's medical record revealed 5/7/24 orders to increase Lisinopril (a medication used to treat high blood pressure).

A 6/20/24 Progress Note stated Resident 17's provider wrote orders on 5/7/24 to increase her/his Lisinopril and the order was not entered into Resident 17 chart.

On 7/17/24 at 1:31 PM Staff 25 (LPN) stated she discovered the pharmacy sent Lisinopril 7.5 mg, but the order in Resident 17's chart was for Lisinopril 5 mg. Staff 25 stated she checked the orders written by the provider and discovered Resident 17's Lisinopril was increased from 5 mg daily to 7.5 mg daily on 5/7/24. Staff 25 stated she was unsure when the pharmacy sent the correct dose.

On 7/17/24 at 1:42 PM Staff 24 (CMA) stated she would have given Resident 17 Lisinopril 5 mg as indicated in the resident's chart.

On 7/19/24 at 10:17 AM Staff 2 (DNS) stated Resident 17's Lisinopril order changed on 5/8/24 but was not input into the resident's chart until 6/15/24. Staff 2 stated the pharmacy sent the correct dose for Lisinopril but acknowledged she was unable to determine if and how long Resident 17 received the wrong dose of Lisinopril.

Based on observation, interview, and record review it was determined the facility failed to replace hearing aids in a timely manner for 1 of 3 sampled residents (#40) reviewed for sensory needs. This placed residents at risk for a decline in hearing and impaired communication. Findings include:

Resident 40 admitted to the facility in 2022 with diagnoses including dementia and depression.

A 5/17/24 Quarterly MDS indicated Resident 40's hearing was adequate and she/he was assessed for the use of hearing aids or a hearing appliance.

A 6/6/24 revised care plan indicated Resident 40 was to wear hearing aids in both ears in order to address her/his mild hearing deficit.

On 7/16/24 at 9:24 AM Resident 40 was observed seated at a dining room table with no hearing aid in either ear. Staff 29 (CNA) stated Resident 40 did not use her/his hearing aids because they were broken for the last three to four months, and the resident was on a list to have her/his hearing aids repaired.

On 7/17/24 at 10:07 AM Staff 27 (LPN) stated Resident 40 had no hearing aids since the resident moved to a new hall on 4/19/24.

On 7/17/24 at 3:35 PM Staff 31 (Social Service Director) stated she believed Resident 40 chose not to wear hearing aids and acknowledged she was not aware her/his hearing aids were missing or broken.

Based on interview and record review it was determined the facility failed to implement pressure ulcer treatments and care plans for 2 of 2 sampled residents (#s 1 and 3) reviewed for pressure ulcers and incontinent care. This placed residents at risk for pressure ulcers. Findings include:

1. Resident 3 admitted to the facility in 7/2021 with diagnoses including stroke.

A 5/31/24 Weekly Skin Audit revealed Resident 3 had new skin irregularities with significant redness to the peri area and sacral (large, triangular bone at the base of the spine) area. There was no documentation indicating the physician was informed.

Review of the 6/2024 TAR instructed staff to conduct bi-weekly skin checks and document in the assessment tab which was discontinued on 6/16/24. The TAR indicated the task was completed on 6/2/24, 6/5/24, 6/12/24, and 6/16/24. On 6/13/24 it referred the reader to notes. There were no corresponding assessments found in the assessment tab for those dates.

A 6/12/24 Order Note revealed the weekly skin check was not completed as it was completed on 6/9/24.

A review of External Visit physician notes dated 6/20/24 indicated Resident 3's only concern was her/his buttocks soreness. Resident 3 reported a sore on her/his buttocks. Visit diagnoses included an unstageable pressure injury of the back and buttock. The physician requested an off-loading mattress and a facility skin assessment.

No documentation was found in clinical records Resident 3 received a skin assessment in 6/2024.

In an interview on 7/19/24 at 11:48 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated it was expected of staff to complete skin and wound checks and evaluations.

, 2. Resident 1 admitted to the facility in 3/2016 with diagnoses including anoxic brain injury (brain damage related to a lack of oxygen).

A 7/17/24 medical record review revealed Resident 1 had an in-house acquired Stage 4 pressure ulcer (a wound caused by pressure resulting in full thickness tissue loss with exposed bone, tendon or muscle) on her/his left upper abdomen.

On 7/18/23 at 3:20 PM Staff 23 (RN Regional Nurse Consultant) stated there was no investigation completed for Resident 1's in-house acquired pressure ulcer.

On 7/19/24 at 7:55 AM Staff 32 (LPN RCM) stated Resident 1's left arm was contracted, and the in-house pressure ulcer was caused from her/his left elbow pressing against her/is left upper abdomen. Staff 32 confirmed there was no investigation completed for Resident 1's in-house acquired pressure ulcer.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 1 sampled resident (#66) reviewed for accidents, and respond to changes in condition in a timely manner for 1 of 1 sampled resident (#65) reviewed for change of condition. This placed residents at risk for injury and untimely care needs. Findings include:

1. Resident 65 admitted to the facility in 2024 with diagnoses including leg fracture.

A progress note dated 12/15/23 at 5:33 PM indicated Resident 65 had a recent fall and her/his right lower extremity was swollen, bruised, and and painful. A STAT (immediate) x-ray was ordered to rule out injury.

A progress note dated 12/16/23 at 2:41 AM indicated the x-ray revealed Resident 65 had a right ankle fracture.

A progress note dated 12/18/23 at 9:40 AM indicated Staff 41 (LPN) sent a message to the physician that Resident 65 had a fractured ankle. The physician replied the x-ray was noted on 12/16/23. Staff 41 indicated Staff 42 (LPN) sent a message to the physician but did not call the on-call physician regarding Resident 65's fracture. Resident 65 was sent to the emergency room on 12/18/23 two days after the right ankle fracture was verified.

On 7/19/24 at 1:34 PM Staff 42 stated she did not call the on-call physician she only sent a message through the hospital messaging system. Staff 42 acknowledged she should have called the on-call physician to get Resident 65 the care she/he needed.

On 7/19/24 at 2:39 PM Staff 1 (Administrator) stated he did not know why the resident was not sent to the emergency room on 12/16/23 when the fracture was verified. Staff 1 stated his expectation is for nurses to call the on-call physician for after hour emergencies and notify the physician in a message through the hospital messaging system.

, 2. Resident 66 admitted to the facility in 2023 with diagnoses including COPD (chronic obstructive pulmonary disease), generalized muscle weakness, and Transient Ischemic Attack (slight stroke).

An Incident Report dated 11/11/23 indicated Resident 66 required two staff to assist with all mechanical lift transfers. The Incident Report revealed Resident 66 fell out of the lift sling while a CNA was transferring the resident. The incident report also indicated the care plan was not followed as indicated for two staff at all times for in and out of bed transfers.

Review of hospital notes dated 11/13/23 indicated Resident 66 did not have any acute traumatic abnormalities.
In an interview on 7/18/24 at 7:20 AM Staff 1 (Administrator) stated he was aware of Staff 43 (RA) not following the care plan that indicated the resident was to be transferred by two people. Staff 1 indicated that Staff 43 communicated to Staff 1 that she knew she wasn't following the care plan and she should have waited for an additional staff member to assist in the Hoyer transfer.

In an interview on 7/18/24 at 7:46 AM Staff 43 (RA) stated she attempted to transfer Resident 66 by herself. As the mechanical lift was elevated, she heard the sling rip, the resident slid out of the sling backwards hitting her head on the floor. Resident 66 was painful and crying and was sent to the hospital. Staff 43 stated she was aware of the care plan indicated the resident was to be transferred by two people, however she was rushed and thought she could transfer the resident alone.

Based on interview and record review it was determined the facility failed to provide adequate catheter care for 1 of 2 sampled residents (#14) reviewed urinary catheter. This placed residents at risk for urinary infections. Findings include:

Resident 14 admitted to the facility in 2023 with diagnoses including chronic kidney disease and displacement of a nephrostomy catheter (tube that diverts urine from kidney).

A 6/14/23 Discharge Summary indicated Resident 14 had a nephrostomy tube placed.

An 10/13/23 through 3/13/24 physician order indicated to cover Resident 14's nephrostomy tube site and change the bandage daily.

The 4/2024 TAR indicated to ensure catheter straps were attached to the lower left extremely for the nephrostomy bag. Treatments were discontinued on 4/30/24.

A 5/9/24 physician order indicated to change Resident 14's nephrostomy tube dressing, remove the old dressing, cleanse, dry and apply a new dressing.

A 7/2/24 revised care plan indicated Resident 14 had a left nephrostomy related to end stage kidney disease, the goal was to have no infections, and interventions included to monitor for complications related to seizures. No other interventions related to Resident 14's nephrostomy were indicated.

On 7/15/24 at 11:31 AM Resident 14 stated she/he had concerns about the placement and staff knowledge related to her/his nephrostomy bag. Resident 14 stated the bag burst or leaked because it was not checked or properly closed.

On 7/17/24 at 9:32 AM Staff 29 (CNA) stated for a period of time it was not clear who was responsible for changing or addressing the needs of Resident 14's nephrostomy bag. Staff 29 stated the correct placement or strap to be used for Resident 14's nephrostomy bag was unclear and at times nephrostomy bag supplies were unavailable.

On 7/17/24 at 10:07 AM Staff 27 (LPN) acknowledged there were previous challenges with Resident 14's nephrostomy supplies and CNAs began to monitor supplies within the last two weeks. Staff 27 stated the placement of Resident 14's nephrostomy bag was important for her/his comfort and not all CNAs knew how or where to position the nephrostomy bag.

On 7/18/24 at 5:42 PM and 7/19/24 at 12:11 PM Staff 28 (LPN-Resident Care Manager) acknowledged a systematic method to maintain the preferred nephrostomy supplies for Resident 14 was needed, CNAs needed more training, and a detailed care plan related to Resident 14's nephrostomy bag care and placement was necessary.

On 7/19/24 at 3:25 PM Staff 23 (Regional Nurse Consultant) acknowledged there were no orders for Resident 14's nephrostomy care from 3/13/24 through 5/9/24 as expected.

2. Resident 63 admitted to the facility in 2024 with diagnoses including COPD (chronic obstructive pulmonary disease).

A physician order dated 6/2/24 indicated Resident 63 received oxygen via nasal cannula (nasal tube allowing continuous oxygen delivery) at three liters a minute (LPM) as needed.

A review of Resident 63's medical record revealed from 5/29/24 through 6/26/24 Resident 63 had oxygen on every day except for six days she/he was on room air. There was no documentation the resident was on three LPM of oxygen as ordered and no documentation of how often oxygen tubing was to be changed.

On 7/17/24 at 10:49 AM Witness 7 (Caregiver) stated Resident 63 wore continuous oxygen on three LPM due to COPD.

On 7/17/24 at 11:38 AM Staff 39 (CNA) stated she took care of the resident and she/he wore continuous oxygen or she/he became short of breath.

On 7/17/24 at 11:11 AM Staff 26 (RN) and Staff 24 (CMA) stated Resident 63 wore continuous oxygen.

On 7/18/24 Staff 28 (RCM-LPN) stated Resident 63 wore continuous oxygen. Staff 28 acknowledged the resident did not have an order for continuous oxygen, and no documentation could be found in the resident's medical record that oxygen tubing was changed.




, Based on observation, interview, and record review it was determined the facility failed to obtain orders for oxygen for 2 or 2 sampled residents (#s 30 and 63) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include:

1. Resident 30 admitted to the facility in 4/2022 with diagnoses including chronic obstructive pulmonary disease (a lung disease which causes restricted airflow and breathing problems).

A review of Resident 30's care plan revealed a 12/21/23 care plan for oxygen use as needed.

A 7/18/24 review of Resident 30's medical record revealed no evidence of a current order for oxygen use.

On 7/18/24 at 11:49 AM Staff 17 (CNA) stated Resident 30 used oxygen as needed almost daily.

On 7/18/24 at 3:37 PM Staff 32 (LPN RCM) stated Resident 30 used oxygen as needed when she/he was short of breath. Staff 32 confirmed Resident 30 had no orders for oxygen use.

Based on observation, interview, and record review it was determined the facility failed to ensure residents received proper dialysis care and services after dialysis for 1 of 1 sampled resident (#55) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include:

Resident 55 admitted to the facility in 2024 with diagnoses including end stage kidney disease.

On 7/17/24 at 12:37 PM Resident 55 was observed to have a fistula (surgically created connection between an artery and a vein to provide access for dialysis) in her/his left arm. Resident 55 stated she/he had dialysis three times a week, when she/he returned staff were not checking her/his access site for thrill and bruit (two ways to check for good blood flow in a dialysis fistula).

The 2/7/24 care plan for dialysis indicated the resident had dialysis three times a week, staff were to monitor the access site for infection and bleeding. Staff were to also obtain and document weights. Resident 55 had six weights documented in the electronic record from 2/7/24 through 6/29/24.

No evidence was found in the resident's clinical record to indicate monitoring of the resident's access site or monitoring of weights were completed.

On 7/18/24 at 11:41 AM Staff 28 (RCM-LPN) acknowledged there was nothing on the resident's care plan to indicate the type of dialysis access site the resident had or care needs for the site, and Resident 55 should have daily weights documented.

Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 8 sampled residents (#16) and 2 of 2 halls (North and 2nd South) reviewed for staffing. This placed residents at risk for unmet needs. Findings include:

1. A review of Council Minutes revealed the following:
-4/29/24 Staff were overworked. Staff left a resident unattended during care resulting in the resident being stuck in the bathroom. Another resident was left in the shower for an extended period. Staff checked on one resident in a room but not their roommate. Call light response times were "too long" while residents were in the bathroom.
-5/29/24 staff lacked the time to spend with residents and had poor attitudes. Call lights went unanswered for 20 minutes or more. Staff did not assist each other. If a staff member was not assigned to a resident, they did not answer their call light.

On 7/15/24 the following interviews occurred:
-8:46 AM, Resident 36 reported waiting 45 minutes for incontinent care three times during the week of 7/8/24. On 7/14/24 she/he waited 45 minutes to be assisted off the bedside commode and experienced pain as a result.
-10:12 AM, Resident 42 reported staff did not respond promptly to call lights and frequently apologized for being too busy.
-10:30 AM, Resident 27 reported waiting up to an hour for assistance.
-10:33 AM, Resident 55 expressed dissatisfaction with call light wait times across all shifts, particularly night shift.
-11:03 AM, Resident 14 stated the week of 7/8/24 she/he waited for staff to answer her/his call light when needing to use the bathroom for over 20 minutes
-12:29 PM Witness 5 (Family Member) stated Resident 3 was supposed to go to the dining room for meals to be supervised but she/he refused and there was not enough staff to supervise her/him in her/his room.

On 7/17/24 at 9:31 AM Witness 1 (Staff) stated insufficient staffing led to new skin issues for a resident due to delayed incontinent care. Witness 1 sometimes could not complete resident showers because of time constraints.

On 7/17/24 at 10:59 AM Staff 18 (CNA) stated the facility was consistently short-staffed. Staff 18 could not complete all her required tasks, including assisting with showers. After Staff 18's 30-minute lunch break the same call lights remained unanswered. Staff 18 witnessed residents with skin breakdown due to prolonged exposure to soaked incontinent briefs. Shift change was often disorganized, sometimes taking 30 to 40 minutes to determine staff assignments. Staff 18 stated staff did not receive breaks due to short staffing.

On 7/17/24 at 12:03 PM Staff 38 (LPN) stated completing assigned tasks was a struggle as staff called off work two hours before the shift which resulted in CNA shortages. Staff 38 assisted CNAs during short-staffed periods but fell behind on her own work. The facility did not staff according to the residents' needs. Staff 38 stated short staffing occurred approximately three to four days a week.

On 7/18/24 at 9:42 AM Staff 10 (CNA) stated the residents' needs exceeded the available staff capacity. Staff 10 sometimes struggled to complete her required daily tasks. The facility instructed CNA staff not to stay beyond their shifts to finish tasks. Some residents experienced skin issues due to delayed incontinent care by CNAs. Staff 10 reported when a fall-risk resident attempted to get up, she could not simultaneously monitor them and perform checks on other residents.

On 7/18/24 at 10:54 AM Staff 14 (NA) stated understaffing was a significant issue at the facility. Staff continued to request additional staff. Staff experienced "burnout" because of ongoing understaffing. Staff 14 stated she faced challenges providing showers to residents due to short staffing.

On 7/18/24 at 12:00 PM Staff 13 (CNA) reported ongoing concerns about short staffing in the facility. Residents become agitated waiting for their call lights to be answered. Short staffing occurred one or two days a week. Staff 13 stated many staff quit because of "burnout."

On 7/19/24 at 11:05 AM Staff 17 (CNA) stated sometimes she did not have enough time to complete resident showers. When she started her shift she found residents soaked in urine or bowel movements because the previous shift did not have time to complete incontinent care. Staff 17 stated she observed residents with skin redness because of sitting in urine or bowel movement.

In an interview on 7/19/24 at 11:48 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) confirmed staffing issues.

2. Resident 16 admitted to the facility in 2/2017 with diagnosis including a fractured pelvis.

The quarterly MDS dated 3/21/24 revealed Resident 16 had a BIMS score of 15 indicating the resident was cognitively intact. The resident required substantial to maximal assistance with transfers for toileting.

Review of Resident 16's care plan revised 7/5/21 revealed Resident 16 had bladder incontinence. Interventions included to notify staff of toileting needs. Resident 16 was occasionally incontinent before reaching the bathroom and required one-person assistance for toilet transfers.

On 5/30/24 the State Survey Agency received a public complaint which indicated staff were busy with dinner one night the week of 5/20/24. Resident 16 activated her/his call light for toileting assistance, but staff did not respond for 45 minutes.

A review of a 5/2024 Documentation Survey Report revealed the week of 5/20/24 to 5/27/24, on the evening shift, Resident 16 was continent twice, was both continent and incontinent seven times, and incontinent once.

Witness 1 (Staff) was interviewed on 7/17/24 at 9:31 AM and confirmed the complaint that Resident 16 waited 45 minutes for toileting assistance one evening the week of 5/20/24.

During an interview on 7/17/24 at 9:58 AM Resident 16 confirmed in 5/2024, during dinner time, she/he waited 45 minutes after activating her/his call light for toileting assistance. Resident 16 stated that about once a week she/he waited 20 minutes or more for the call light to be answered, with the afternoons being the worst.

During an interview on 7/18/24 at 12:00 PM Staff 13 (CNA) reported call wait times sometimes were up to 30 minutes and residents became "agitated." Staff 13 stated when toileting assistance was documented as both continent and incontinent during a shift it indicated a resident was continent one time and incontinent another time on the same shift.

In an interview on 7/19/24 at 12:12 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated the expectation for a call light to be answered was 15 to 20 minutes.

Based on interview and record review it was determined the facility failed to staff a registered nurse for eight consecutive hours per day 7 days per week for 34 out of 126 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include:

Review of the Direct Care Staff Daily Report sheets from 1/1/24 through 1/28/24, 2/3/24 through 2/25/24, 3/10/24 through 3/24/24, 5/1/24 through 5/30/24, 6/14/24 through 6/30/24, 7/1/24 through 7/14/24 revealed the facility did not have RN coverage for eight consecutive hours on the following days: 1/20/24, 1/21/24, 1/28/24, 2/3/24, 2/4/24, 2/5/24, 2/7/24, 2/8/24, 2/10/24, 2/11/24, 2/13/24, 2/16/24, 2/17/24, 2/18/24, 2/19/24, 2/21/24, 2/23/24, 3/10/24, 3/11/24, 3/12/24, 3/13/24, 3/14/24, 3/15/24, 3/16/24, 3/17/24, 3/18/24, 3/19/24, 3/20/24, 3/21/24, 3/22/24, 3/23/24, 3/24/24, 6/30/24 and 7/3/24.

In an interview on 7/19/24 at 11:48 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated they thought RN coverage was better than what was documented and reported two RN's employment was terminated.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 1 of 5 sampled CNA staff (#9) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include:

A review of the facility's performance review records revealed the following:
-Staff 9 (CNA) was hired on 3/23/21, the provided performance review was dated 4/30/22.

In an interview on 7/19/24 at 12:02 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated the missed review occurred during a staffing transition.

Based on observation, interview, and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents and visitors at risk for incomplete and inaccurate staffing information. Findings include:

On 7/15/24 at 9:41 AM the DCSDR (Direct Care Staff Daily Report) was observed posted on the wall. The DCSDR did not have any staff hours documented for LPNs or CNAs.

On 7/16/24 at 7:38 AM and 8:25 AM the 7/15/24 DCSDR was still posted on the wall.

On 7/17/24 at 7:57 AM the DCSDR was observed on posted on the wall with no LPN or CNAs documented on the form.

On 7/17/24 at 11:53 AM Witness 1 (Staff) stated in the last few months the nurses were informed to just fill in the staff numbers without staff hours and the administration would complete the form the next day.

On 7/18/24 at 7:51 AM and 9:11 AM the 7/18/24 DCSDR was observed posted on the wall with no LPN or CNA hours documented for all three shifts.

On 7/18/24 at 8:40 AM a text message was received from Witness 1 which was a photo of the DCSDR for 6/1/24 which was posted behind glass showing day shift and evening shift with LPN's signatures. Day shift was missing hours worked for RN, LPN, and CNAs, Evening shift was missing resident census, number of CNA staff and hours worked for RN, LPN, and CNA staff.

On 7/19/24 at 8:43 AM the 7/19/24 DCSDR was observed posted on the wall with no CNA or LPN hours documented.

In an interview on 7/19/24 at 11:48 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated completing the DCSDR was an ongoing issue with staff not adding up the hours.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 2 of 5 sampled residents (#s 10 and 17) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include

1. Resident 10 admitted to the facility in 5/2024 with diagnosis including dementia.

The 5/31/24 and 6/28/24 Note to Attending Physician Prescriber indicated Resident 10 was prescribed trazodone (an antidepressant to treat depression) PRN and promethazine (an antihistamine to prevent and treat nausea and vomiting) for agitation, both limited to 14 days. The note requested either discontinuation or a rationale for extended use, but lacked the physician's signature, date, or clinical justification.

The 7/2024 MAR instructed staff to administer trazodone every 12 hours as needed for agitation starting on 5/9/24. The MAR also indicated to administer Promethazine every four hours as needed for agitation, nausea and vomiting starting 5/8/24.

In an interview on 7/19/24 at 11:48 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated there was a communication breakdown between the provider and the facility.

, 2. Resident 17 admitted to the facility in 9/2019 with diagnoses including diabetes.

A review of Resident 17's 5/2024 pharmacy recommendation revealed recommendations for laboratory testing.

A 7/17/24 review of Resident 17's medical record revealed the last lab tests completed were on 4/26/23.

A 7/17/24 review of Resident 17's medical record revealed no evidence of documentation related to Resident 17's 5/2024 pharmacy recommendations for laboratory testing.

On 7/18/24 at 3:43 PM Staff 32 (LPN RCM) stated Resident 17 often refused lab testing due to a fear of needles. Staff 32 confirmed there was no documentation related to Resident 17's 5/2024 pharmacy recommendation for lab testing.

Based on interview and record review it was determined the facility failed to monitor anticoagulant medication for 1 of 5 sampled residents (#27) reviewed for medications. This placed residents at risk for adverse side effects of medications. Findings include:

Resident 27 admitted to the facility in 2023 with diagnoses including stroke and blood clot.

A 3/28/24 signed physician order indicated Resident 27 received Apixaban (anticoagulant medication used to treat and prevent blood clots).

There was no monitoring in the resident's electronic record for adverse side effects for Apixaban.

On 7/18/24 at 9:41 AM Staff 28 (RCM-LPN) acknowledged there was no monitoring for adverse side effects of Apixaban in Resident 27's electronic record.

3. Resident 27 admitted to the facility in 2023 with diagnosis including depression.

A 12/30/23 signed physician order indicated Resident 27 received Zoloft (antidepressant), and a 1/4/24 signed physician order indicated Resident 27 received Remeron (antidepressant).

There was no monitoring in the resident's electronic record for adverse side effects of Zoloft and Remeron.

On 7/18/24 at 9:41 AM Staff 28 (RCM-LPN) acknowledged there was no monitoring for adverse side effects of Zoloft and Remeron in Resident 27's electronic record, and stated the expectation was to monitor daily for adverse side effects.


, Based on interview and record review it was determined the facility failed to consistently monitor residents on psychotropic medications and ensure residents did not receive unnecessary medications for 3 of 5 sampled residents (#10, 17 and 27) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include:

1. Resident 10 admitted to the facility in 5/2024 with diagnoses including dementia.

A review of 7/2024 MAR revealed Resident 10 was administered haloperidol (antipsychotic medication) daily.

A review of monitors revealed no daily documentation of daily monitoring for antipsychotic side effects.

In an interview on 7/19/24 at 12:43 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated the expectation was to monitor daily for adverse side effects.

, 2. Resident 17 admitted to the facility in 8/2019 with diagnoses including narcissistic personality disorder (a mental health condition in which people have an unreasonably high sense of their own importance).

A review of Resident 17's Physician Orders revealed she/he took four psychotropic medications (medications that affect the mind, emotions and behaviors), olanzapine (an antipsychotic medication), diazepam (an anti-anxiety medication), and duloxetine and trazodone (antidepressant medications).

A review of Resident 17's care plan revealed a 5/27/21 care plan to monitor for adverse side effects of antipsychotic medications, and to monitor for anti-anxiety and antidepressant medications.

A 7/18/24 review of Resident 17's medical record revealed no evidence of documentation for monitoring for adverse side effects of psychotropic medications.

On 7/18/24 at 3:43 PM Staff 32 (LPN RCM) stated she expected monitoring for adverse side effects to psychotropic medications to be documented daily on the MAR. Staff 32 confirmed there was no documentation related to monitoring for adverse side effects of psychotropic medications.

Based on observation and interview it was determined the facility failed to follow recipes to meet menu and therapeutic standards for 1 of 1 kitchen. This place residents at risk for lack of meal satisfaction and compromised nutrition. Finding include:

The 7/18/24 posted lunch menu included breaded pork cutlet, au gratin potatoes, cauliflower and the alternative menu was sloppy joes, cheddar mash potatoes and broccoli.

On 7/18/24 at 11:20 AM Staff 35 (Cook) was observed to assemble lunch and was asked to provide the recipes used to prepare the meal. Staff 35 stated he worked in the facility for three weeks and no recipes were provided during his training. Staff 35 stated no recipes were followed to prepare any of the foods served for lunch.

On 7/18/24 at 12:03 PM and 12:53 PM Staff 5 (Certified Dietary Manager) stated a new menu system with recipes was introduced to the facility in 6/2024 and recipes should have been printed for all therapeutic diets and followed.

2. Resident 27 admitted to the facility in 2023 with diagnoses including malnutrition and diabetes.

On 7/16/24 at 10:16 AM Resident 27 stated the flavor of the food was "bland with no taste", the bananas were over-ripe, the meat was dry and tough, and the food was always cold.

On 7/18/24 at 9:43 AM Resident 27 was observed in the dining room during breakfast which included eggs, sausage, muffin, and an over-ripe banana. Resident 27 stated breakfast was cold and had no flavor.

On 7/18/24 at 1:12 PM Resident 27 was in the dining room for lunch which included sloppy joe, broccoli, and mashed potatoes. Resident 27 stated the food was cold and tasted "bad."

On 7/18/24 at 1:29 PM Staff 28 (RCM-LPN) observed Resident 27's meal and stated the meal did not appear appetizing or appealing.























































, Based on observation, interview, and record review it was determined the facility failed to ensure proper flavor and food temperatures were maintained for meals served for 1 of 5 sampled resident (#27) and 1 of 1 facility kitchen reviewed for dining services. This placed residents at risk for food that was not palatable, safe, or appetizing. Findings include:

1. The 7/18/24 posted lunch menu included breaded pork cutlet, au gratin potatoes, cauliflower and the alternative menu was sloppy joes, cheddar mash potatoes and broccoli. The desert was ice cream.

On 7/18/24 at 1:20 PM two sample plates were received. The first plate included minced and moist textured sloppy joes, mashed potatoes and gravy and broccoli. The second sample plate included easy to chew textured au gratin potatoes and cauliflower. The au gratin potatoes had crunchy pieces of dried potatoes, the moist and minced broccoli was cold with pieces that were firm to chew, the ice cream was melted and the milk was served warm.

On 7/18/24 at 1:27 PM Staff 5 (Certified Dietary Manager) acknowledged the au gratin potatoes were cold and underdone, the broccoli was cold with no flavor, the ice cream should not be melted and milk was too warm and served at 64 degree. Staff 5 acknowledged the meal temperatures, flavors and palatability were not appropriate.

2. Resident 3 admitted to the facility in 7/2021 with diagnoses including difficulty swallowing.

A 9/5/21 physician order instructed staff to provide Resident 3 with easy-to-chew textured diet.

Review of Resident 3's care plan dated 4/18/24 indicated Resident 3 had impaired swallowing and was at risk for aspiration following a choking incident. Interventions included providing meals as ordered, ensuring Resident 3 remained upright for 30 minutes after eating, and serving an easy-to-chew texture diet. It was recommended to encourage Resident 3 to eat outside of bed; if in bed, the bed should be elevated to 90 degrees with the TV off.

A Nursing Care Note on 4/18/24 documented Resident 3 choked on a piece of meat during lunch, which became lodged in the throat. Resident 3 was unable to clear the obstruction and was unable to swallow anything else. The physician was notified, was onsite at the facility at the time of the incident, and recommended transfer to the emergency department for treatment.

An 4/18/24 physician Progress Notes indicated Resident 3 choked on a piece of pork during lunch, aspirating for approximately 20 minutes before medical intervention. The physician adjusted the bed to 90 degrees and attempted to provide water, which was coughed back up. The decision was made to transfer Resident 3 to the emergency department.

A review of an 4/18/24 Emergency Department Encounter indicated Resident 3 sought medical attention for a feeling of a foreign body in the throat after eating pork.

A review of the Documentation Survey Report from 7/1/24 through 7/17/24 revealed Resident 3 was to be supervised in the dining room for all meals. For day and evening shift Resident 3 refused 16 instances on day shift and one instance had no documentation, refused 10 times on evening shift, accepted two times and for five instances there was no documentation. Documentation revealed staff were to encourage Resident 3 to be out of bed for meals to decrease risk for aspiration with 16 refusals for breakfast and one accepted, 14 refusals for lunch with three accepted, nine refusals for dinner, and five instances with no documentation and three accepted.

In an interview on 7/15/24 at 12:29 PM Witness 5 (Family Member) stated Resident 3 had a choking episode while she/he was lying down and had to go to the hospital. Witness 5 stated Resident 3 was supposed to go to the dining room for meals to be supervised but she/he refused and there was not enough staff to supervise her/him in her/his room.

During observation and interview on 7/18/24 at 1:20 PM an easy-to-chew test tray was provided to the survey team and found to have inadequately cooked potatoes with crunchy pieces, and tough portions in the breaded pork. At 1:27 PM Staff 5 (Certified Dietary Manager) confirmed these findings.

During an interview on 7/19/24 at 7:47 AM Staff 16 (CMA) stated Staff 17 (CNA) reported Resident 3 was choking and staff rushed into her/his room. Staff could hear Resident 3 trying to expel a piece of pork out of her/his throat. When she/he tried to swallow it made a "horrible" sound. Staff 16 stated "everyone" complained that day about how dry the pork was.

On 7/19/24 at 10:54 AM Staff 17 stated on 4/18/24 she delivered Resident 3's tray and cut up everything on her plate and she remembered the pork being dry.

, 3. Resident 39 admitted to the facility in 4/2022 with diagnoses including a stroke and dysphagia (swallowing difficulties).

A review of Resident 39's record revealed a 4/14/22 order for easy chew 7 diet texture (foods the require less chewing and reduce the risk of choking).

A review of a 5/13/24 Physician Progress Note revealed Resident 39 had an episode of post-tussive emesis (vomiting produce by coughing) while eating her/his lunch.

A review of Resident 39's record revealed a 5/22/24 care plan for dysphagia and an 4/14/22 intervention to monitor and document ability to chew and swallow, and if presenting with problems obtain an order for ST to evaluate and treat.

Resident 39 was observed eating lunch on 7/15/24. At approximately 1:00 PM Resident 39 was observed coughing on a tortilla for about 20 seconds.

On 7/15/24 at 2:03 PM Staff 5 (Certified Dietary Manager) confirmed Resident 39 should have received a piece of bread instead of a tortilla based on her/his diet texture of easy chew 7.









, Based on observation, interview, and record review it was determined the facility failed to ensure physician ordered diets were provided as ordered for 3 of 5 sampled residents (#s 3, 39 and 57) reviewed for nutrition. This deficient practice was determined to be an immediate jeopardy situation. Resident 57 was provided food not prepared according to their physician ordered diet texture, and this resulted in a severe coughing episode and risk of choking and/or aspiration. Staff were aware the food they were providing the resident was not appropriate. Findings include:

1. Resident 57 admitted 3/2024 with a diagnosis of pneumonitis (inflamation of lung tissue) due to inhalation of food and vomit, and CVA (cerebral vascular accident) with severe expressive aphasia (non-verbal) as well as severe oropharyngeal dysphagia (difficulty swallowing).

Resident 57 was physician ordered for minced and moist textured food and care planned to be supervised for all oral intake. She/he had a recent history of aspiration (food or fluid enters the lungs), and pneumonia related to aspiration.

Resident 57 was non-verbal and required total assistance from staff for eating. On 7/15/24 at 1:04 PM Resident 57's midday meal was observed. The chicken on the meal tray prepared by the kitchen was white meat with no gravy. While Staff 4 (CNA) assisted Resident 57 with eating a bite of chicken, she/he had a severe coughing episode for approximately three minutes. Resident 57's eyes became large, watery and she/he appeared panicked, and her/his face became flushed. Staff intervened and altered Resident 57's posture forward to assist with coughing until the coughing episode subsided. The resident's meal was discontinued. She/he had an elevated respiratory rate and appeared fatigued.

On 7/15/24 at 1:08 PM Staff 4 stated she knew Resident 57's diet texture order was minced and moist, but no gravy was on or mixed in to the minced chicken. Staff 4 stated she was aware of the diet texture error, but did not obtain the necessary gravy because the kitchen was busy and "chaotic."

On 7/15/24 at 5:27 PM the faciity administrative staff including Staff 1 (Administrator), Staff 2 (DNS)and Staff 3 (Regional Support Lead)were notified of the immediate jeopardy (IJ) situation related to the facility's failure to provide a physician ordered diet.

On 7/15/24 at 6:44 PM an acceptable immediate risk removal plan to to address the serious risk to residents' health and welfare was received from and implemented by the facility. The plan indicated the following facility actions:
-Resident 57 was assessed for s/sx of aspiration, her/his physician was notified, and the resident was placed on alert charting.
-Staff 4 was suspended and slated for 1:1 inservice training prior to returning to work related to food textures, ensuring food textures served matched the meal ticket, and the process for what to do if there was a discrepency.
- Kitchen staff currently working were trained regarding proper diet textures. Other kitchen staff were slated to be educated prior to the start of their next shift until 100% were inserviced. Inserving was scheduled to be provided by a Certified Dietary Manager independent of the facility.
-Nursing staff were slated to be inserviced regarding appropriate food textures and ensuring residents received the correct texture.
-All residents with mechanically altered diets would have their meal tickets audited for correct texture prior to leaving the kitchen by the Certified Dietary Manager or designee, and a second check would occur by IDT team members in collaboration with CNAs prior to meals being served to residents.
-Audits would be conducted of each meal for two weeks, then daily for four weeks, then weekly for four weeks. All findings were to be reported to the QAPI committee. Audits were to be conducted by the Certified Dietary Manager or designee.

Based on observation, interview and record review it was determined the facility failed to ensure residents' food preferences were honored for 1 of 1 sampled resident (#27 ) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include:

Resident 27 admitted to the facility in 2023 with diagnoses including malnutrition and diabetes.

Resident 27's dietary card had "lactose intolerant" listed in two places.

On 7/17/24 at 1:34 PM Resident 27 was observed to have a glass of milk on her/his meal tray.

On 7/18/24 at 1:12 PM Resident 27 was observed to have a glass of milk on her/his meal tray. Resident 27 became angry regarding the milk and asked staff to remove the milk immediately.

On 7/18/24 at 1:29 PM Staff 28 (RCM-LPN) acknowledged the resident's dietary card indicated she/he was lactose intolerant and should not receive milk.

Based on observation, interview and record review it was determined the facility failed to ensure sanitation processes were followed for 1 of 1 observed kitchen. This placed residents at risk for food borne illnesses. Findings include:

A 7/2024 Dishwasher Temperature Log revealed a low-temperature dishwasher was monitored from 7/1/24 through 7/14/24, but with no evidence chemical concentration levels were documented.

On 7/15/24 at 10:02 AM Staff 44 (Dietary Aide) was observed loading dishes into a low-temperature dishwasher that used chlorine to sanitize dishes. Staff 44 stated she cleaned dishes routinely, monitored the wash and rinse temperatures daily, but was never instructed to monitor the chemical concentration of the dish machine.

On 7/15/24 at 10:17 AM Staff 45 (Dietary Services Manager) acknowledged she was aware the dish machine chemical concentration was to be monitored with the use of chemical test strips, which did not occur, and relied on monthly dish machine inspections by the chemical supplier to ensure the dish machine operated correctly.

On 7/15/24 at 10:55 AM Staff 5 (Certified Dietary Manager) stated the form used to monitor the dish washer was incorrect since it provided no place to document any evidence of chemical sanitizer concentration. Staff 5 acknowledged he expected dish machine sanitation levels should be monitored and logged daily to ensure dishes were properly sanitized.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 2 sampled residents (#30) and 2 of 2 unsampled residents (#s 6 and 11) reviewed for respiratory care. This placed residents at risk for exposure and contraction of infectious diseases. Findings include.

1. Resident 6 admitted to the facility in 2024 with diagnoses including sleep apnea (sleep related breathing disorder).

On 7/16/24 at 9:55 AM Resident 6's CPAP mask was observed under her/his pillow against her/his mattress.

On 7/17/24 at 1: 53 PM Resident 6's CPAP mask was observed resting on her/his bedrail.

On 7/18/24 at 9:33 AM Resident 6's CPAP mask was observed on the floor.

On 7/19/24 at 10:50 AM Staff 27 (LPN) stated Resident 6's CPAP mask should be stored in a sanitary manner.

2. Resident 11 admitted to the facility in 2024 with diagnoses including sleep apnea (sleep related breathing disorder).

On 7/16/24 at 9:55 AM Resident 11's CPAP mask was observed on her/his nightstand.

On 7/17/24 at 1:53 PM Resident 11's CPAP mask was observed hanging off her/his nightstand.

On 7/18/24 at 9:33 AM Resident 11's CPAP mask was observed resting against her/his commode.

On 7/19/24 at 10:50 AM Staff 27 (LPN) stated Resident 11's CPAP mask should be stored in a sanitary manner.

, 3. Resident 30 admitted to the facility in 4/2022 with diagnoses including chronic obstructive pulmonary disease (a lung disease which causes restricted airflow and breathing problems).

On 7/15/24 at 2:21 PM Resident 30 stated she/he used oxygen as needed; an oxygen concentrator was observed next to her/his bed.

A review of Resident 30's care plan revealed a 12/21/23 care plan for oxygen use as needed.

On 7/18/24 at 11:49 AM Staff 17 (CNA) stated Resident 30 used oxygen as needed, almost daily. Staff 17 stated Resident 30 applied oxygen by her/himself when needed.

On 7/18/24 at 3:37 PM Staff 32 (LPN RCM) stated Resident 30 used oxygen as needed when she/he was short of breath.

On 7/19/24 at 9:18 AM Resident 30's oxygen tubing was observed to be on the floor. Staff 32 confirmed Resident 30's oxygen tubing was on the floor. Staff 32 stated oxygen tubing should be placed in a bag to prevent it from falling to the floor.

Based on observation, interviews and record review it was determined the facility failed to ensure resident rooms were free from pests for 1 of 10 sampled residents (#36) and 1 of 3 dining rooms reviewed for environment. This placed residents at risk for pest infestation. Findings include:

Resident 36 admitted to the facility in 2024 with diagnoses including diabetes and foot ulcer.

A 7/6/24 Work Order indicated there was an excessive amount of flies in the main area and resident rooms in the south part of the building.

A 7/13/24 at 6:10 AM SBAR (Situation, Background, Assessment, Recommendation) Change of Condition note indicated on 7/13/24 Staff 26 (RN) reported at 5:00 AM to Staff 27 (LPN) Resident 36 had maggots (fly larva) on her/his bed that came from her/wound dressing. Resident 36 was transported to the hospital.

On 7/15/24 at 12:30 PM five flies were observed in the resident dining room around residents' food. Residents continued to swat the flies away from their meals.

On 7/16/24 at 8:50 AM Resident 36 stated around 7/4/24 she/he complained about flies in her/his room that continued to land on her/his food and foot. Resident 36 stated she/he asked if something could be done about the flies and the answer was "no."

On 7/17/24 at 9:48 AM Staff 27 stated she found maggots in the early morning in Resident 36's room on 7/13/24, and administration was contacted but did not arrived until after 12:30 PM. Staff 27 stated staff were directed to deep clean Resident 36's room. Resident 36 remained in the room during the deep cleaning so it was necessary for the process to be completed a second time. Staff 27 stated when Resident 36 returned from the hospital that same day, Resident 36 was placed in her/his room with flies still present.

On 7/18/24 at 9:09 AM Staff 19 (Maintenance Lead) confirmed he received a work order related to flies on 7/6/24 and did not address the issue until after the weekend on 7/8/24 when Staff 19 walked around the building. Staff 19 stated he saw no issue with flies on 7/8/24.

On 7/19/24 at 10:48 AM Staff 2 (DNS) and Staff 23 (Regional Nurse Consultant) stated an investigation was completed for the 7/13/24 issue with Resident 36's maggots. Staff 23 acknowledged the facility was not aware there was a 7/6/24 work order related to flies in the building that was addressed days later when pest control arrived on 7/10/24.

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 5 of 5 randomly selected staff members (#s 6, 7, 8, 9, and 10) reviewed for evidence of in-service training. This placed residents at risk for lack of competent staff. Findings include:

A review of the facility's staff training records revealed the following:
- Staff 6 (CNA), hired 5/30/22, had 15 minutes of documented training from 5/30/23 through 5/30/24.
- Staff 7 (CNA), hired 6/20/19, had one hour of documented training from 6/20/23 through 6/20/24.
- Staff 8 (CNA), hired 5/14/20, had two hours of documented training from 5/14/23 through 5/14/24.
-Staff 9 (CNA), hired 3/23/21, had 7.25 hours of documented training from 3/23/23 through 3/23/24
-Staff 10 (CNA) hired 6/16/21, had 15 minutes of documented training from 6/16/23 through 6/16/24.

In an interview on 7/19/24 at 12:03 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) stated staff were not obtaining the sign-up sheets for the trainings to keep track of staff training hours.

Based on interview and record review it was determined the facility failed to complete reference checks for 2 of 5 staff (#s 21 and 22) reviewed for hiring practices. This placed residents at risk for unqualified staff. Findings include:

On 7/18/24 at 12: 42 PM employee reference check records for five staff hired in the previous four months were reviewed with Staff 40 (Human Resources-Payroll). Two employee records contained no evidence reference checks were completed prior to the staff being hired:
-Staff 21 (RN)
-Staff 22 (Charge Nurse)

On 7/18/24 at 2:09 PM Staff 40 verified the reference checks were not completed for Staff 21 and Staff 22.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained on 45 of 394 shifts reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

1. A review of the Direct Care Staff Daily Reports from 1/1/24 through 1/28/24, 2/3/24 through 2/25/24, 3/21/24 through 3/24/24, 5/1/24 through 5/30/24, 6/14/24 through 6/30/24, and 7/1/24 through 7/14/24 revealed the facility did not have sufficient CNA staff to meet the minimum CNA to resident staffing requirements for 31 of 84 shifts on the following days:
-1/1/24 day shift
-1/3/24 day shift
-1/5/24 day shift
-1/6/24 evening shift
-1/13/24 day shift
-1/14/24 day, evening, and night shift
-1/15/24 day and night shift
-1/16/24 day shift
-1/17/24 day shift
-1/19/24 evening shift
-1/20/24 evening shift
-1/21/24 day shift
-1/22/24 day shift
-1/25/24 night shift
-2/11/24 day shift
-2/17/24 day shift
-3/22/24 evening shift
-3/23/24 evening shift
-5/1/24 day shift
-6/14/24 night shift
-6/15/24 night shift
-6/21/24 evening shift
-6/22/24 evening shift
-7/6/24 day and evening shift
-7/7/24 evening shift
-7/8/24 night shift
-7/14/24 evening shift

In an interview on 7/19/24 at 11:48 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Support Lead), and Staff 23 (Regional Nurse Consultant) confirmed staffing issues.

, 2. Review of the facility's Direct Care Staff Daily Report sheets from 2/29/24 through 3/20/24, revealed the facility did not meet minimum CNA staff requirements for 14 shifts on the following days:
-2/29/24 evening shift
-3/1/24 day and evening shift
-3/2/24 day shift
-3/3/24 day shift
-3/8/24 evening shift
-3/9/24 evening shift
-3/10/24 day shift
-3/13/24 day shift
-3/15/24 day shift
-3/16/24 day and evening shift
-3/17/24 day and evening shift

On 7/19/24 at 10:08 AM Staff 2 (DNS) and Staff 23 (RN Regional Nurse Consultant) acknowledged the facility did not meet the CNA ratios on the above shifts.

*****************************************
OAR 411-085-0310 Resident Rights: Generally

Refer to F552, F553 and F561
*****************************************
OAR 411-086-0130 Nursing Services: Notification

Refer to F580
*****************************************
OAR 411-087-0100: Physical Environment: Generally

Refer to F584 and F925
******************************************
OAR 411-085-0360 Abuse

Refer to F600 and F610
******************************************
OAR 411-86-0060 Comprehensive Assessment and Care Plan

Refer to F657
*****************************************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F677, F684, F685, F695 and F698
*****************************************
OAR 411-086-0230 Activity Services

Refer to F679
******************************************
OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care

Refer to F686, F689, F690, F757 and F758
***************************************
OAR 411-086-0100 Nursing Services: Staffing

Refer to F725 and F727
****************************************
OAR 411-086-0310 Employee Orientation and In-Service Training

Refer to F730 and F947
****************************************
OAR 411-085-0030 Required Postings

Refer to F732
***************************************
OAR 411-086-0260 Pharmaceutical Services

Refer to F756
****************************************
OAR 411-086-0250 Dietary Services

Refer to F803, F804, F805, F806 and F812
****************************************
OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880
****************************************

Based on interview and record review it was determined the facility failed to complete a comprehensive dementia assessment for 2 of 3 sampled residents (#s 2 and 47) reviewed for dementia. This place residents at risk for unassessed needs. Findings include:

1. Resident 2 admitted to the facility in 2018 with diagnoses including dementia.

The 8/28/22 Annual MDS Dementia comprehensive assessment indicated Resident 2 was unable to answer a lot of questions, struggled with the answers and had some dementia. Resident 2 believed her/his memory was due to old age.

No further information was provided related to Resident 2's history of dementia, extent of the resident's cognitive loss, mood and behaviors or medical issues that may impact cognition.

On 3/23/23 at 9:11 AM Staff 10 (Social Service Director) stated social services completed the dementia MDS assessments. Staff 10 confirmed Resident 2's dementia assessment was not comprehensive.

, 2. Resident 47 readmitted to the facility in 2022 with diagnoses including dementia.

The 12/18/22 Annual MDS Cognitive Loss/Dementia CAA indicated Resident 47 was easily distracted and her/his mood could vary.

No further information was provided related to Resident 47's history of dementia, extent of the resident's cognitive loss, mood and behaviors or medical issues that may impact cognition.

On 3/23/23 at 12:50 PM Staff 2 (DNS) acknowledged Resident 47's dementia CAA was not comprehensive.

Based on observation, interview and record review it was determined the facility failed to provide diabetic nail care for 1 of 4 sampled residents (# 51) reviewed for ADLs. This placed residents at risk for lack of nail care. Findings include:

Resident 51 admitted to the facility in 2022 with diagnoses including diabetes.

On 3/20/23 at 1:12 PM and 3/24/23 at 10:00 AM Resident 51 was observed to have long fingernails.

Review of Resident 51's current physician orders revealed no orders for diabetic nail care and the 3/2023 TAR revealed no indication diabetic nail care was being completed.

On 3/24/23 at 10:03 AM Staff 24 (CNA) stated Resident 51 was diabetic and nursing staff were to complete nail care.

On 3/24/23 at 10:10 AM Resident 51 stated her/his nails were long.

On 3/24/23 @ 10:11 AM Staff 8 (Resident Care Manager/LPN) stated nursing staff were to monitor diabetic nail care weekly and it was to be documented on the TAR. Staff 2 acknowledged Resident 51's nails were long and there were no orders in place and no diabetic nail care on the TAR.

Based on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 2 of 2 halls (200 and 400) reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include:

On 3/22/23 the facility provided a list of residents who:
-Required assistance or were dependent with eating: three,
-Required two-person assistance with a mechanical lift: 16,
-Required two-person assistance with sit-to-stand: three,
-Required two-person assistance with bathing: three,
-Were fully dependent on staff for bathing: three

A review of the Direct Care Staff Daily Reports revealed 60 days out of 150 days when the state minimum CNA staffing ratios were not met for one or more shifts.

Interviews with residents revealed the following concerns:
-On 3/20/23 at 10:27 AM Resident 45 stated the facility was "often" short staffed and call light response times could take greater than 30 minutes to answer. Resident 45 stated because of long call light response times she/he sat in a soiled brief which "burned" her/his skin, this happened the week of 3/12/23.

-On 3/20/23 at 11:46 AM Resident 61 stated call light response times could take up to 30 minutes to answer and she/he had incontinence episodes due to long call light response time. Resident 61 further stated staff assisted with setting up her/his urinal if they "got there in time."

-On 3/20/23 at 12:26 PM Resident 216 stated she/he required assistance to get on the bedside commode but had transferred herself/himself due to long call light response time. Resident 216 further stated this occurred "often" on evening shift and waited 45 minutes or greater because no staff were available to assist her/him.

-On 3/20/23 at 12:49 PM Resident 7 stated she/he used her/his call light on the evening of 3/19/23 and got herself/himself seated on the edge of the bed but needed staff to assist with getting her/his feet up onto the bed, it took 30 to 45 minutes before staff assisted her/him. Resident 7 further stated call light response times were an "ongoing" concern.

-On 3/20/23 at 12:56 PM Resident 33 stated call light response times on an average took 30 minutes or longer before answered. Resident 33 stated she/he had a colostomy bag which burst open due to long call light response times.

-On 3/20/23 at 1:30 PM Resident 23 stated call light response times could take 30 minutes or longer and staff did not answer the call light in an "orderly fashion." Resident 23 stated long call light response times occurred on a regular basis.

Interviews with staff revealed the following concerns:
-On 3/21/23 at 11:30 AM Staff 19 (CNA) stated the facility was short staffed on evening shift and call light response times could take greater than 30 minutes. Staff 19 stated they had high acuity residents with roughly 10 residents who required a mechanical lift and three residents were a sit to stand which required two staff to assist with those residents. Staff 19 stated at times showers were difficult to complete due to being short staffed.

-On 3/21/23 at 1:14 PM Staff 18 (CNA) stated she worked multiple shifts on the 200 and 400 halls, and the facility was short staffed at times. Staff 18 stated when the facility was short staffed call light response times were greater than 20 minutes. Staff 18 stated there were times Resident 15's call light would be on for 30 minutes (while she was on lunch break) because not all the staff would answer her/his call light.

-On 3/22/23 at 10:59 AM Staff 20 (Admission Coordinator [Former CNA/RA]) stated the facility struggled with staffing at times and in 8/2022 she was the Restorative Aide and was pulled two or three times during the week to cover as a CNA and those residents who were scheduled for restorative services would not receive RA on those days.

-On 3/22/23 at 12:04 PM Staff 17 (CNA) stated at times the facility was short staffed which caused call light response times to be greater than 20 minutes at times. Staff 17 stated she had a consistent routine but could be difficult to find help from other staff or CNAs due to being short staffed. Staff 17 further stated weekends could be a challenge due to lack of CNA coverage.

-On 3/22/23 at 1:19 PM Staff 16 (CNA) stated the facility struggled with staffing and call light response times could be greater than 15 minutes. Staff 16 stated residents had complained to her of not getting showers due to staffing and she would attempt to complete them if she had time.

-On 3/22/23 at 1:58 PM Staff 15 (CNA) stated residents complained about not having enough staff and long call light response times. Staff 15 stated when the facility was short staffed call light response times could take longer than 20 minutes to answer. Staff 15 stated scheduled showers for residents were not "always" completed timely and residents would complain.

-On 3/22/23 at 2:28 PM Staff 14 (LPN) stated the facility was short staffed at times and made call lights difficult to answer. Staff 14 stated call light response times could be greater than 15 minutes and residents had complained about long call light response times.

-On 3/22/23 at 5:17 PM Staff 13 (LPN) stated when she worked as the charge nurse she was responsible for 20 to 25 residents depending on the census and could be difficult to complete all her tasks when the facility was short staffed. Staff 13 stated call light response times could be greater than 20 minutes due to being short staffed.

-On 3/24/23 at 9:15 AM Staff 5 (Staffing Coordinator) stated he was new to the position and indicated the facility struggled with CNA coverage.

-On 3/24/23 at 11:20 AM Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 and Staff 2 acknowledged they struggled with staffing shortages at the facility. Staff 2 stated all staff were expected to respond to the call lights within 15 minutes. Staff 2 acknowledged this was difficult at times because of the acuity of the residents at the facility.

Based on observation, interview and record review it was determined the facility failed to ensure proper food temperatures for 3 of 9 sampled residents (#s 33, 46 and 218) reviewed for food. This placed residents at risk for cold food and impaired nutrition. Findings include:

On 3/20/23 at 10:30 AM Resident 46 stated the food was not warm enough and was "always cold."

On 3/20/23 at 10:30 AM Resident 218 reported the food was not always warm.

On 3/20/23 at 12:59 PM and 3/22/23 at 10:52 AM Resident 33 reported her/his breakfast was the "usual", cold eggs, hot cereal and the "food is a disaster."

On 3/22/23 at 12:30 PM Resident 33 stated the meatloaf served at lunch was good, but not particularly warm.

On 3/22/23 at 12:36 PM surveyors sampled a regular textured lunch meal and a mechanical soft/small bites meal. The lunch meals consisted of meatloaf, mashed potatoes, green beans and strawberry shortcake. The surveyors agreed the meatloaf was cool on the regular/small bites tray and cold on the mechanical soft tray.

On 3/22/23 at 12:41 PM Staff 4 (Regional Nurse Consultant) sampled the meatloaf on both trays and confirmed the meatloaf on the regular tray was cool and the meatloaf on the mechanical soft tray was cold.

Based on observation and interview it was determined the facility failed to maintain the ice machine reviewed for 1 of 1 kitchen. This placed residents at risk for contamination. Findings include:

On 3/20/23 at 9:45 AM the inside of the ice machine was observed to have a black mildew substance across the entire trim of the plastic ice dispenser. Water droplets were observed to fall from the dispenser trim onto the ice on the bottom of the ice machine.

On 3/20/23 at 9:50 AM Staff 9 (Dietary Manager) stated the ice machine was used for the entire facility. Staff 9 acknowledged the ice machine should not have a visible black mildew substance and the ice machine needed to be cleaned.

Based on interview and record review it was determined the facility failed to ensure reference checks were completed for 4 of 5 sampled staff (#s 3, 5, 6 and 7) reviewed for reference checks. This placed residents at risk for care being provided by unqualified staff. Findings include:

On 3/22/23 Reference checks were requested for Staff 3 (LPN), Staff 5 (Staffing Coordinator), Staff 6 (CNA) and Staff 7 (Activity Director).

On 3/22/23 at 1:40 PM Staff 22 (HR Director) stated reference checks were not completed for Staff 3, Staff 5, Staff 6 and Staff 7. Staff 22 reported due to a change in the hiring process, reference check requests were sent but not returned prior to the staff being hired.

Based on interview and record review it was determined the facility failed to meet the required CNA staffing ratio 60 for 150 days reviewed for staffing. This placed residents at risk for unmet care needs. Findings include:

A review of the Direct Care Staff Daily Reports from 8/1/22 through 8/31/22, 11/1/22 through 11/31/22, 12/1/22 through 12/31/22, 1/1/23 through 1/31/23, and 2/19/23 through 3/20/23 revealed the following days when the state minimum CNA staffing ratios were not met for one or more shifts:

-8/13/22 evening shift.
-8/18/22 evening shift.
-8/19/22 day shift.
-8/22/22 night shift.
-11/1/22 evening shift.
-11/2/22 evening shift.
-11/4/22 evening shift.
-11/5/22 day and evening shift.
-11/6/22 day shift.
-11/7/22 day and evening shift.
-11/12/22 evening shift.
-11/13/22 evening shift.
-11/14/22 day shift.
-11/20/22 day shift.
-11/21/22 evening shift.
-11/22/22 evening shift.
-11/23/22 evening shift.
-11/24/22 evening shift.
-11/25/22 day and evening shift.
-11/26/22 evening and night shift.
-11/27/22 evening and night shift.
-11/28/22 evening.
-12/3/22 evening and night shift.
-12/4/22 day shift.
-12/5/22 evening shift.
-12/6/22 day and evening shift.
-12/7/22 evening shift.
-12/8/22 evening shift.
-12/9/22 evening shift.
-12/10/22 evening shift.
-12/11/22 day and evening shift.
-12/16/22 evening shift.
-12/17/22 day and evening shift.
-12/22/22 evening shift.
-12/23/22 evening shift.
-12/24/22 day and evening shift.
-12/25/22 evening shift.
-12/30/22 day shift.
-12/31/22 day shift.
-1/1/23 evening shift.
-1/3/23 evening shift.
-1/7/23 day and evening.
-1/8/23 day shift.
-1/13/23 evening shift.
-1/16/23 evening shift.
-1/21/23 day shift.
-1/22/23 day and evening shift.
-1/23/23 evening shift.
-1/28/23 day shift.
-1/29/23 day shift.
-1/31/23 evening shift.
-2/19/23 day and evening shift.
-2/20/23 day shift.
-2/21/23 evening shift.
-2/22/23 evening shift.
-2/24/23 day shift.
-2/25/23 evening shift.
-2/28/23 evening shift.
-3/4/23 evening and night shift.
-3/6/23 day shift.

On 3/23/23 at 11:22 AM Staff 2 (DNS) stated during the months of 8/2022, 11/2022, 12/2022 and 1/2023 the facility was in a COVID-19 outbreak and struggled with adequate CNA ratios.

On 3/24/23 at 11:20 AM Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 1 and Staff 2 acknowledged they struggled with staffing shortages and did not meet the CNA ratios for 8/2022, 11/2022, 12/2022 1/2023, 2/2023 and 3/2023.

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

Refer to F636
*****
OAR-411-086-0110: Nursing Services: Resident Care

Refer to F677
*****
OAR-411-086-0100: Nursing Services: Staffing

Refer to F725
*****
OAR-411-086-0250: Dietary Services

Refer to F804 and F812

Based on observation, interview and record review, it was determined the facility failed to develop a person-centered comprehensive care plan for 2 of 4 sampled residents (#s 32 and 158) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include:

1. Resident 32 was admitted to the facility in 12/2021 with diagnoses including hip fracture and stroke.

The 12/13/21 Admission MDS revealed Resident 32 had physical impairment on one side of her/his body due to a stroke and required extensive one-person physical assistance with personal hygiene.

The 12/13/21 care plan indicated Resident 32 had an ADL self-care deficit related to weakness.

Random observations from 2/7/22 through 2/14/22 on day and evening shift revealed Resident 32 had a chin full of long white hairs. Resident 32 stated she/he did not like the hair on her/his chin and had asked staff multiple times for assistance to shave but staff stated they were busy.

On 2/7/22 at 3:29 PM Staff 3 (NA) stated Resident 32 was a total assist with all her/his ADLs. Staff 3 stated she was aware of the resident's chin hairs but did not offer to shave the resident.

On 2/14/22 at 12:56 PM Staff 4 (CNA) stated Resident 32 was a total assist with all ADLs including her/his personal hygiene care. Staff 4 was aware of Resident 32's chin hair but did not offer to shave the resident.

On 2/14/22 at 12:22 PM Staff 3 (Resident Care Manager/LPN) and Staff 4 (Resident Care Manager/LPN) acknowledged they were aware of Resident 32's chin hairs, did not include this as a preference on the resident's care plan and the care plan was not person-centered.


2. Resident 158 was admitted to the facility in 2/2022 with diagnoses including a fractured right wrist and a contracture (fixed tightening of muscle,tendons and ligament which prevented normal movement) to her/his left hand.

The 2/7/22 Admission MDS indicated Resident 158 required one-person physical assist with hygiene.

The 2/3/22 care plan indicated Resident 158 had an ADL self-care deficit related to limited mobility.

Random observations from 2/7/22 through 2/14/22 on day and evening shifts revealed Resident 158's fingernails were long, had dark brown debris under them and she/he had a couple days growth of facial hair. Resident 158 stated she/he had told staff she/he would like to shave daily and have her/his nails checked due to not being able to complete the tasks with a broken right wrist and contracted left hand.

On 2/7/22 at 3:29 PM Staff 3 (NA) stated Resident 158 was a total assist with all her/his ADLs. Staff 3 stated she was aware the resident preferred to be shaved daily and she/he was not. Staff 3 stated nail care was done on shower days but should be cleaned more regularly.

On 2/14/22 at 4:02 PM Staff 4 (CNA), Staff 8 (RN) and Staff 15 (LPN) stated Resident 158 was a one-person assist with personal hygiene due to immobility of her/his hands. Staff stated nail care should be done as needed and checked daily due to the resident's inability to complete the task on her/his own and Resident 158 should be shaved daily as preferred.

On 2/14/22 at 4:45 PM Staff 5 (Resident Care Manager/LPN) stated she had observed the resident's dirty nails and facial hair. Staff 5 acknowledged Resident 158's preferences to be shaved daily and have nail care performed should have been on her/his care plan and the care plan was not person-centered.

Based on observation, interview and record review it was determined the facility failed to revise a care plan for 1 of 1 sampled resident (#22) reviewed for tube feeding. This placed residents at risk for unmet care needs. Findings include:

Resident 22 was admitted to the facility in 2016 with diagnoses including brain injury and swallowing problems.

a. On 2/7/22 at 1:50 PM Resident 22 was observed in bed. A sign above the bed indicated the resident was to wear a hand brace or a cloth carrot (a device in the hand to reduce contractures[fixed tightening of muscle, tendons and ligament which prevents normal movement]) in her/his right hand at all times. No brace or carrot was observed to be in place.

A review of the 2/2022 MAR/TAR included:
-A nursing order dated 7/2019 for use of a splint to her/his right hand for six plus hours a day as tolerated.
-A nursing order dated 12/2020 for the right hand splint to be removed every evening.
-A nursing order dated 6/2021 for daily skin checks before and after placing the right hand splint to monitor for swelling and skin impairment.

The current ADL care plan indicated Resident 22 was to wear the carrot in her/his right hand at night. Separate instruction under the RA program indicated staff were to place the right hand brace on for six plus hours a day as tolerated.

The current ADL care plan and separate RA instructions were in contradiction of the posted signage above the resident's bed for use of the brace or carrot.

The current care plan was not revised to reflect the current interventions related to Resident 22's brace or carrot use.

On 2/15/22 at 8:27 AM Staff 7 (Resident Care Manager/LPN) stated she was not aware of the sign above Resident 22's bed and had no additional information to provide related to multiple different instructions for the right hand brace or carrot.

b. On 2/10/22 at 8:07 AM Resident 22 was observed to be in bed and an enteral formula was infusing ( method to deliver nutrition directly into the stomach). The tube feeding bag was labeled as Isosource and the feeding pump indicated the formula was infusing at 85 ml per hour.

A review of the 2/2022 MAR/TAR included:
-A physician order dated 1/7/22 to start Isosource 1.5 at 85 ml per hour for a total of 16 hours a day.
-A physician order dated 10/7/21 for Isosource 1.5 at 75 ml per hour for a total of 16 hours a day.

The current Nutrition care plan instructed staff to provide Isosource 1.5 at 85 ml per hour for 16 hours a day and Isosource 1.5 at 75 ml per hour. The care plan contained two conflicting interventions for Resident 22's nutritional needs.

On 2/15/22 at 8:27 AM Staff 7 (Resident Care Manger/LPN) agreed there were two conflicting tube feeding orders and the care plan was not updated.

Based on observation, interview and record review, it was determined the facility failed to ensure dependent residents received necessary services to maintain personal hygiene for 2 of 2 sampled residents (#s 32 and 158) reviewed for ADL care. This placed residents at risk for unmet care needs. Findings include:

1. Resident 32 was admitted to the facility in 12/2021 with diagnoses including hip fracture and stroke.

The 12/13/21 Admission MDS revealed Resident 32 had physical impairment on one side of her/his body and required extensive one-person physical assistance with personal hygiene.

Random observations from 2/7/22 through 2/14/22 on day and evening shifts revealed Resident 32 had a chin full of long white hairs. Resident 32 stated she/he did not like the hair on her/his chin and asked staff multiple times to be shaved but she/he did not receive assistance.

On 2/7/22 at 3:29 PM Staff 3 (NA) stated Resident 32 was a total assist with all her/his ADLs. Staff 3 stated she was aware of the resident's chin hair and she/he should have been shaved.

On 2/14/22 at 12:22 PM Staff 3 (Resident Care Manager/LPN) and Staff 4 (Resident Care Manager/LPN) acknowledged they were aware of Resident 32's chin hair and she/he should have been shaved.


2. Resident 158 was admitted to the facility in 2/2022 with diagnoses including a fractured right wrist and a contracture (fixed tightening of muscle,tendons and ligament which prevents normal movement) to her/his left hand.

The 2/3/22 care plan indicated Resident 158 was a one-person physical assist for personal hygiene.

Random observations from 2/7/22 through 2/14/22 on day and evening shifts revealed Resident 158's fingernails were dirty, with dark brown debris under them and she/he had facial hair. Resident 158 stated she/he told staff she/he would like to be shaved daily and have her/his nails checked due to not being able to complete the tasks with a broken wrist and contracted left hand. Staff stated they would help but did not come back to complete the tasks.

On 2/7/22 at 3:29 PM Staff 3 (NA) stated she was aware the resident was not shaved for a couple of days and the resident's nails were dirty.

On 2/14/22 at 4:02 PM Staff 4 (CNA), Staff 8 (RN) and Staff 15 (LPN) stated Resident 158 needed one-person assist with personal hygiene due to immobility with her/his hands. Staff 4 stated resident 158 had facial hair and dirty nails.

On 2/14/22 at 4:45 PM Staff 5 (Resident Care Manager/LPN) stated she had observed the resident's dirty nails and facial hair and her expectation of staff was for them to provide ADL assistance to Resident 158 to complete the tasks.

Based on observation, interview and record review it was determined the facility failed to correctly use PPE based on infection control standards for COVID-19 for 1 of 1 facility reviewed for infection control. This placed residents at risk for infections. Findings include:

On 2/7/22 at 10:45 AM the face shield disinfection station, supplies and instructions were observed at the front entrance to the facility. The facility also had portable shelving near the front entrance which staff used to store their face shields.

On 2/11/22 at 10:23 AM Staff 24 (CNA) was observed to place her face shield into her plastic storage box, place the box on a table at the entrance and left the facility wearing an N95 mask worn in the facility. Upon her return at 10:52 AM she wore an N95 mask, obtained her face shield from her storage box, put it on and placed her storage box back on the shelf.

On 2/11/22 at 11:14 AM an observation of the break room noted a container of disinfectant wipes on the counter. A staff member was sitting at the table with her face shield pushed up onto the top of her head and her N95 mask was pulled down under her chin. There was no designated area for staff to disinfect their face shields, or instructions for the disinfection of the time clock, the coffee maker or the microwave to ensure staff were disinfecting high touch areas in the breakroom.

On 2/14/22 at 11:46 AM Staff 20 (dietary aide) was observed to return to the facility and pulled up her N95 mask up from her chin. Staff 20 entered the facility, obtained her face shield from the plastic storage box and put it on. Staff 20 was asked about practices when leaving the facility for a break. She stated she took her N95 mask with her, placed her face shield in her plastic storage box and upon return put her face shield back on. Staff 20 was asked about disinfection of her face shield and stated no one told her to disinfect it.

On 2/14/22 at 4:45 PM Staff 22 (CNA) returned from a break outside the facility wearing an N95 mask. Staff 21 (CNA) reached over the counter to the front desk, obtained a face shield and gave it to Staff 22.

On 2/14/22 at 4:47 PM Staff 21 (CNA) was asked about the face shield on the desk and stated he found it on the table and Staff 22 (CNA) was the last one to leave so he assumed it was his. Staff 21 (CNA) stated he disinfected the face shield and placed it behind the counter.

On 2/15/22 at 10:11 AM Staff 19 (housekeeper) entered the facility wearing an N95 mask, performed hand hygiene and obtained her face shield and put it on.

On 2/15/22 at 10:21 AM Staff 19 was asked about mask and face shield practices and stated she came in, got her shield, put it on and cleaned her hands. Staff 19 was asked about disinfection of her shield and stated she disinfected it at the end of the day and placed it into her storage box. She was asked about her mask and confirmed she wore the same mask all day. Staff 19 stated she used to keep her mask in the plastic storage box but got in trouble for that and then asked if she could keep it in her pocket.

On 2/15/22 at 1:43 PM management of PPE was discussed with Staff 23 (Infection Preventionist). Staff 23 stated when staff left the facility they were to disinfect their shield, place it in a plastic storage box, discard their N95 mask, perform hand hygiene and upon return obtain a new N95 mask. Staff 23 added when staff used the break room, they were to take off their PPE and place them on a barrier. Staff 23 stated she needed to re-educate staff related to mask and face shield practices.

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OAR 411-085-0310 Residents' Rights: Generally

Refer to F550


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OAR 411-086-0040 Admission of Residents


Refer to F635 and F657
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OAR 411-086-0060 Comprehensive Assessment and Care Plan


Refer to F656 and F657

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OAR 411-086-0110 Nursing Services: Resident Care


Refer to F677

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OAR 411-086-0330 Infection Control and Universal Precautions


Refer to F880

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Based on interview and record review it was determined the facility failed to assess, treat and follow physician orders for skin wounds for 1 of 3 resident (#1) reviewed for skin wounds. This placed residents at risk for delayed treatments and risk of worsening wounds. Findings include:

Resident 1 was admitted to the facility in 8/2021 with a diagnosis including abscess to lower left limb.

An 8/2021 TAR instructed staff to complete the following wound care to Resident 1's left thigh:
-Cleanse, apply black foam and wound vacuum pressure every Monday, Wednesday and Friday with an order date of 8/11/21 and discontinued on 8/20/21. No treatment was completed on 8/20/21.
-Cleanse, apply white foam over base of wound where possible tendon was exposed, then pack with black foam and apply wound vacuum pressure every Monday, Wednesday and Friday with an order date of 8/20/21 and discontinue date of 9/8/21. Treatment was not completed on 8/20/21 or 8/27/21.

The 9/2021 TAR instructed staff to cleanse Resident 1's left thigh, apply white foam over base of wound where possible tendon was exposed, then pack with black foam and apply wound vacuum pressure every Monday, Wednesday and Friday with an order date of 8/20/21 and discontinue date of 9/8/21.

A 9/11/21 Re-Entry Nursing Database indicated Resident 1 had a wound vacuum applied to the left hip.

No additional orders were found in Resident 1's clinical record from 9/11/21 through 9/16/21 for treatment to Resident 1's left thigh wound.

A 9/13/21 Wound Evaluation indicated Resident 1 had an abscess to the left hip with an area of 2.12 cm squared, 2.91 cm length and 1.15 cm width, deepest point was 2 cm with undermining of .5 cm and longest tunneling of 1.5 cm. The evaluation did not describe Resident 1's wound bed, surrounding skin, pain, documentation of treatment or progress.

On 9/17/21 at 9:56 AM Staff 18 (LPN) stated she did not have time to complete Resident 1's wound evaluation on 9/13/21 as she was also completing medication pass. Staff 18 stated she cleaned the wound and applied the wound vac after treatment. Staff 18 stated she did not remember putting the treatment into the TAR. Staff 18 stated she had been out of the facility for approximately 12 days and did not review Resident 1's left thigh wound treatment orders before completing her/his treatment.

In an interview on 9/27/21 at 1:11 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 34 (Regional Nurse Consultant) stated they expected staff to confirm wound treatment orders after re-admission, to check orders before completing treatment and to complete a full evaluation of a resident's wound.

Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 2 of 2 units (Units North and South) reviewed for staffing. This placed residents at risk for unmet needs. Findings include:

The facility's Direct Care Staff Daily Reports revealed from 8/24/21 through 9/19/21 there were failures to meet state minimum staffing requirements. There were eight out of 27 days without eight consecutive hours of RN coverage between the start of day shift and the end of evening shift and minimum CNA staffing was not met for 39 out of 81 shifts.

On 9/16/21 at 1:49 PM and 9/23/21 at 8:51 AM Resident 1 stated call light wait times could be up to 20 to 40 minutes. Resident 1 stated her/his urinal was not emptied regularly and one instance she/he was using her/his urinal and it was too full from previous use and she/he spilled urine all over herself/himself. There were a few incidents where the staff walked out and did not come back. Resident 1 stated there were two fecal episodes where she/he sat in fecal matter from 15 to 20 minutes and she/he was yelling to attempt to receive care. Resident 1 stated it was humiliating as she/he attempted to clean her/himself and got fecal matter on her/his hands. Resident 1 stated she/he was given a suppository and pushed her/his call light and it was over 20 minutes and no one came to assist herself/him.

On 9/17/21 at 9:56 AM Staff 18 (LPN) stated on 9/13/21 she did not have time to complete Resident 1's wound evaluation as she was also responsible for completing medication pass.

On 9/20/21 at 9:34 AM Staff 7 (CNA) stated if she did not take her breaks, she completed her first and last rounds of checking on her assigned residents. Staff 7 stated there was usually no way to complete a third round on residents. Staff 7 stated staffing was worse since approximately 7/2021. Staff 7 stated residents complained of incontinent episodes due to waiting for long call light response times. Staff 7 was requested daily through text notifications to work additional hours.

On 9/20/21 at 9:46 AM Staff 11 (CNA) stated when the facility was short staffed, she did not have enough time to complete all her assigned tasks in a day which included showering residents and charting. Often she stayed late to complete charting. Staff 11 stated the facility was habitually short staffed and she was asked to stay late, come in early and work overtime. Staff 11 stated residents complained of long call light wait times, had incontinent episodes due to waiting and sat in soiled briefs for extended time period.

On 9/21/21 at 11:16 AM Staff 9 (CNA) stated one instance she and another CNA were responsible for over 30 residents for four hours on evening shift. Staff 9 stated it was "scary". Staff 9 stated she could not always complete her required daily assignments. Staff 9 stated she took her lunch breaks about 60 percent of the time but did not get her two 15-minute breaks due to being so busy and stressful. Staff 9 stated when the facility had a COVID outbreak there was no agency staff coming to assist the CNAs.

On 9/21/21 at 9:55 AM Staff 10 (CNA) stated the facility was short staffed quite often. Staff 10 stated she could not always complete her daily required tasks. Staff 10 stated she did not receive her lunches and breaks because it did not leave enough CNAs on the floor to assist with resident care.

On 9/21/21 at 10:22 AM Resident 8 stated call light wait times could last up to a half an hour. Resident 8 stated at night if staff took too long to answer her/his call light she/he got up on her/his own and went to the rest room. Resident 8 stated she/he did not like to do that as it was exhausting.

On 9/21/21 at 10:39 AM Staff 22 (anonymous) stated she felt "forgotten" in the COVID unit. Some days there were three to four staff for 34 COVID residents. Staff were crying daily as there was so much work to do. Staff worked many hours and without adequate laundry services or housekeepers. Residents kept being admitted to the North unit and they had no additional staff to assist with the new admits. Staff 22 stated when residents were coming back from the hospital not all their orders were put into the system. It was a choice of either providing hands on care with the residents or complete charting; there was not enough time to complete both. The residents needed additional care due to their acuity and it was difficult to provide proper hydration and eating assistance.

On 9/23/21 at 12:01 PM Staff 12 (CNA) stated she did not have enough time to complete her required daily assignments. The incontinent residents only received incontinent care once a shift. There were seven residents who needed assistance with eating and the med aide had have to assist with meal pass as it took over an hour. Residents soak through their briefs and into the beds so it took longer to change, causing other residents not to get the care they needed.

On 9/23/21 at 1:16 PM Staff 26 (CNA) stated when she worked the first part of 9/2021 there were times she was responsible for 17 to 18 residents on day shift. During those time she could not complete bed baths and some residents ended up with incontinent episodes which would soak their beds, which ended up taking more time away from other residents. Staff 26 was asked daily to stay late, and stated she did not get breaks. Staff 26 did not have time to ensure residents were hydrated appropriately and residents complained of call light wait times of 20 to 30 minutes. Staff 26 stated there were about seven to eight residents who needed assistance eating from two to three CNAs.

On 9/24/21 at 6:49 AM Staff 3 (RN) stated she had to work 16 hour days five days straight and never worked that hard. RCMs were assisting on the floor to attempt to get everything completed with only two to three CNAs on a day shift with 36 high acuity residents. There was not enough staff to assist residents with incontinent care and with bariatric residents. Staff 3 stated "Resident are not getting the care they deserve."

In an interview on 9/27/21 at 1:19 PM Staff 1 (Administrator) Staff 2 (DNS) and Staff 34 Regional Nurse Consultant) stated the facility was recently having staffing issues during the COVID outbreak.

Based on interview and record review it was determined the facility failed to maintain appropriate RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift seven days a week for 8 of 27 days reviewed for staffing. This placed residents at risk for unmet assessment and care needs. Findings include:

The facility's Direct Care Staff Daily Reports revealed from 8/24/21 through 9/19/21 there were eight out of 27 days without eight consecutive hours of RN coverage between the start of day shift and the end of evening shift as follows:

-8/29/21, 8/30/21, 9/6/21, 9/9/21, 9/10/21, 9/13/21, 9/14/21, and 9/15/21.

On 9/21/21 at 10:48 AM and in an interview on 9/27/21 at 1:19 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 34 (Regional Nurse Consultant) stated Staff 29 (RNCM) worked the as the nurse on duty when Staff 30 (RN) did not work. With the COVID outbreak there were days the facility did not have an RN as Staff 30 was on vacation and Staff 29 needed days off.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 23 of 27 days reviewed for staffing. This placed residents at risk of for delayed care. Findings include:

Due to Oregon's current statewide hospital capacity crisis, the Oregon Department of Human Services, Safety, Oversight and Quality Unit temporarily revised the Oregon Administrative Rules (OARs) related to certified nursing assistant staffing, effective immediately. The Department temporarily amended the minimum certified nursing assistant ratios as follows:

Current OARs for Certified Nursing Assistants (411-086-0100(C)):
o DAY SHIFT: 1 certified nursing assistant per 7 residents.
o EVENING SHIFT: 1 certified nursing assistant per 9.5 residents.
o NIGHT SHIFT: 1 certified nursing assistant per 17 residents.

Effective August 24th, 2021, Temporary OARs for Certified Nursing Assistants (411-086-0100(C)):
o DAY SHIFT: 1 certified nursing assistant per 8.5 residents.
o EVENING SHIFT: 1 certified nursing assistant per 12 residents.
o NIGHT SHIFT: 1 certified nursing assistant per 18 residents.

The Department also temporarily expanded definitions of who can be counted towards the minimum certified nursing assistant ratios. Effective immediately, nursing facilities may temporarily utilize the services of nursing assistants, personal care assistants, physical therapists and occupational therapists to account for up to 25% of the required minimum staff required on each shift.

The revised staffing ratios and use of staff other than certified nursing assistants to meet the minimum CNA staffing ratio is a temporary measure and will only be allowed during this statewide emergency.

Review of the facility's Direct Care Staff Daily Report forms revealed the facility failed to meet the minimum staffing for CNAs 39 out of 81 shifts reviewed.

-8/24/21 through 8/31/21 eight out of 24 shifts did not have appropriate CNA coverage.
-9/1/21 through 9/19/21 31 out of 57 shifts did not have appropriate CNA coverage.

On 9/21/21 at 11:16 AM Staff 9 (CNA) stated one instance she and another CNA were responsible for over 30 residents for four hours on evening shift. Staff 9 stated it was "scary".

On 9/21/21 at 9:55 AM Staff 10 (CNA) stated the facility was short staffed quite often.

On 9/21/21 at 10:39 AM Staff 22 (Anonymous) stated she/he felt "forgotten" in the COVID unit. Some days there were three to four staff for 34 COVID residents. Staff were crying daily as there was so much work to do.

In an interview on 9/27/21 at 1:19 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 34 (Regional Nurse Consultant) confirmed the facility did not meet minimum CNA staffing ratios for 23 of 27 days reviewed.

Based on interview and record review, it was determined the facility failed to conduct a thorough investigation of an allegation of mistreatment for 1 of 4 sampled resident (#3) reviewed for falls. This placed residents at risk for abuse. Findings include:

The Facility 7/2017 Accident and Incidents-Investigating and Reporting indicated the following data should be included in an investigation report:
-The name(s) of witnesses and their accounts of the accident or incident.

Resident 3 was admitted to the facility in 2021 with diagnoses including a fracture of the lower left leg.

An 8/2021 Admission MDS revealed Resident 3 was cognitively intact.

On 8/19/21 at 1:19 PM Staff 9 (LPN-Care Manager) stated Resident 3 had a fall on 8/4/21, staff were interviewed and Resident 3 did not report any injuries. After a physician appointment the next day Resident 3 indicated she/he hit her/his head and bruises were discovered. Staff 9 stated on 8/6/21 a Nursing Facility Reported Incident Form was completed because Resident 3 now stated she/he had injuries. Staff witnesses were interviewed again and remained consistent with their original statements that Resident 3 was not close to furniture when she/he fell.

The 8/4/21 fall investigation revealed Staff 9 thought it was possible Resident 3 was confused about the details of the fall but remained admant she/he fell and hit her/his head and side. In the report Staff 11 (CNA) indicated the night stand was not close to where Resident 3 fell and Staff 8 (RN) witnessed the end of the incident when Staff 11 assisted Resident 3 to the floor.

On 8/23/21 at 10:45 AM Resident 3 stated on 8/4/21 she/he fell and "hit every piece of furniture on the way down". Resident 3 also stated that Resident 8 was a witness.

An 5/2021 Admission MDS revealed Resident 8 was cognitively intact.

On 8/23/21 at 11:54 AM Resident 8 stated on 8/4/21 she/he was in the room and saw Resident 3 fall. Resident 8 also stated she/he was not interviewed as a witness.

On 8/25/21 at 7:15 PM Staff 11 stated she was the only one in the room when Resident 3 fell on 8/4/21 and made no comment when reference was made to Resident 8 who stated she/he was also in the room. Staff 11 stated she did not believe Resident 3 hit or slid against furniture.

On 8/26/21 at 1:21 PM Staff 8 stated she initiated the fall investigation for Resident 3 but did not interview Resident 8 because it would violate Resident 3's protected health information.

On 8/30/21 at 4:31 PM Staff 2 (interim DNS) stated she looked at each section of the investigation form to ensure information was present and was unaware all witnesses were not interviewed. Staff 2 also stated she expected a roommate would be interviewed if her/his cognition was intact and the privacy curtain was open.

Based on interview and record review it was determined the facility failed to ensure referral agencies were contacted at the time of discharge for 1 of 3 sampled residents (#1) reviewed for discharge planning. This placed residents at risk for an unsafe discharge. Findings include:

Resident 1 was admitted to the facility in 2021 with diagnoses including spondylosis (degeneration of the spine) and anxiety disorder.

Review of a comprehensive care plan dated 7/5/2021 revealed the resident's discharge plan was to return to her/his apartment alone.

Review of a phyisician discharge summary dated 7/27/21 revealed Resident 1's home had 14 stairs which she/he was unable to climb. Resident 1's plan was to not leave her/his home until she/he was able to walk down the stairs, the resident's discharge plan was unsafe and if Resident 1 discharged Adult Protective Services would be contacted.

A 7/28/21 Discharge Summary and Plan revealed Resident 1 required a one-person standby assist for transfers and home health services for nursing, therapy and bath aide were scheduled for 7/30/21.

A 7/28/21 Social Services progress note revealed Resident 1 discharged on 7/28/21 and Adult Protective Services would be notified.

On 8/16/21 at 1:14 PM Staff 3 (Social Services Director) stated Resident 1 insisted on going home and Staff 3 did not contact Adult Protective Service because a social worker would be at Resident 1's home on 7/30/21 through home health services.

On 8/31/21 at 2:00 PM Staff 1 (Administrator) confirmed Adult Protective Services should be contacted at the time of discharge.

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OAR 411-085-0360 Abuse

Refer to F610
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OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F660
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