Creswell Post Acute

Resident 21 admitted to the facility in 1/2026 with a diagnosis of diabetes.-á On 1/26/26 at 11:04 AM Resident 21 was observed to have a box of Senokot (a laxative) on her/his overbed table, no staff were in the room, and Resident 21 stated she/he was told by a medical provider to take Senokot (a laxative) a couple times a day.-á A review of Resident 21's medical record revealed no order for self-administration of Senokot and no assessment for self-administration of Senokot.-á On 1/29/26 at 11:15 AM Staff 5 (LPN) reviewed Resident 21's medical record and stated there was no approval for her/him to keep medication at the bedside. Staff 5 went to Resident 21's room and confirmed there was Senokot on the overbed table and removed it from the room. Resident 21 told Staff 5 she/he had taken some of the Senokot during her/his stay in the facility.-á On 1/30/26 at 10:15 Staff 2 (DNS) stated residents who wished to have medication at bedside were to have an assessment completed, a physician order for self-administration, have a care plan in place, and the medication was to be stored in a lock box in the resident room.-á

Resident Cited: Resident # 21  has discharged. Residents at Risk: All residents who self-administer medications are at potential risk for deficient practice. House-wide sweep completed to ensure any residents with medications at bedside have an order to keep at bedside, and an assessment done. Any other medications at bedside removed from room. Education: Education completed with nursing staff regarding ensuring medications are not kept at bedside unless ordered by MD. Education with nursing staff to alert charge nurse regarding medications at bedside to ensure proper procedure is followed. Audits: DNS/designee to complete Audits of a random sample of resident rooms completed to ensure no medication is left at bedside without MD order/assessment weekly x 4 weeks, monthly x 3 months. Results of audits brought to QAPI for review.

2. Resident 77 was admitted to the facility on 1/22/26 with diagnoses including Stage 4 pressure ulcer on the sacral region (full-thickness skin and tissue loss on the lower back), and osteomyelitis (bone infection). -á On 1/27/26 at 12:59 PM,-á Staff 10 (CNA) was asked how she learned residents' care needs. Staff 10 stated she read the resident's Kardex. Staff 10 was asked to review the Kardex and confirmed no Kardex existed. Staff 10 further stated GÇ£oh she/he did not have one because she/he was a new resident.GÇ¥ -á On 1/27/26 at 1:07 PM, Staff 11 (Agency CNA) stated sometimes residents did not have a Kardex and staff would have to ask the charge nurse about the resident's care needs. Staff 11 was asked to review Resident 77GÇÖs Kardex and confirmed it only contained information related to catheter care.-á -á The 1/26/26 Baseline Care Plan Person-Centered Care Plan revealed Resident 77 had a Stage 4 pressure ulcer on her/his sacral region, required wound vac treatment (medical device that applies negative pressure to a wound bed), antibiotics, and had a lot of pain. Resident 77 was dependent on staff. -á No documentation was found in the clinical record to indicate Resident 77 had a baseline care plan addressing the Stage 4 pressure ulcer, including treatment, pain management, intravenous (IV) antibiotics, or any other identified needs. -á -á On 1/27/26 2:27 PM, Staff 12 (Regional Nurse) confirmed Resident 77GÇÖs baseline care plan was not completed timely.-á -á -á -á -á -á , 1. Resident 76 was admitted to the facility on 1/23/26 with diagnoses including diabetes and subarachnoid hemorrhage (bleeding in the brain). A 1/27/26 record review revealed no evidence of a baseline care plan. On 1/27/26 at 1:18 PM, Staff 25 (CNA) stated resident care needs are in the care plan and Staff 25 stated Resident 76 did not have a care plan. On 1/27/26 at 1:21 PM, Staff 3 (LPN Resident Care Manager) stated Resident 76 admitted on 1/23/26 and acknowledged Resident 76 did not have a care plan. -áOn 1/27/26 at 2:19 PM, Staff 2 (DNS) started it was the expectation for staff to formulate a baseline care plan for new residents at admission.

Resident Cited: Resident # 76 and #78 has discharged. Resident #77 baseline careplans completed. Residents at Risk: All residents who are newly admitted are at potential risk for this deficient practice. Residents who have admitted in the past 2 weeks to be audited to ensure baseline careplans are in place. Education: Nursing staff educated to ensure that baseline careplans are completed within 48 hrs of admission. Audits: DNS/designee to audit new admissions for baseline careplan completion weekly x 4 weeks, monthly x 3 months. Results of audits will be brought to QAPI for review.

2. Resident 9 was admitted to the facility in 6/2025 with diagnoses including hypertension (high blood pressure) and chronic obstructive pulmonary disease (a progressive, long-term lung disease that makes it hard to breathe by damaging the airways and air sacs). A review of Resident 9GÇÖs medical record revealed she/he was admitted to hospice in 6/2025. A review of Resident 9GÇÖs 6/27/25 care plan revealed no evidence of a hospice care plan. On 1/29/26 at 3:19 PM, Staff 3 (LPN Resident Care Manager) stated Resident 9 had been on hospice since 6/2025. Staff 3 acknowledged Resident 9 did not have a hospice care plan and stated it was expected for residents to have hospice included in their comprehensive care plans. , 1. Resident 3 admitted to the facility in 12/2025 with diagnoses including dysphonia (difficulty speaking) and depression. -á The 12/5/25 Hospital Discharge Summary revealed Resident 3 had a PHQ-9 (patient health Questionnaire) score of 21 which indicated severe depression. The 12/8/25 Admission MDS indicated Resident 3 was cogitatively intact, had no mood disorders, and she/he received scheduled antidepressant and antipsychotic medications. The 12/8/25 Psychosocial Well-Being CAA indicated Resident 3 had little interest and/or pleasure in doing things. Resident 3 reported over the last year she/he had significant health issues and was currently needing a trach to support breathing. Resident 3 was at risk for psychosocial issues secondary to a lack of interest in participating in favorite activities. No additional documentation was provided. A 12/9/25 at 5:10 PM Physician Note revealed Resident 3 reported GÇ£feeling emotionalGÇ¥ but did not want to make any psychotropic changes. The 12/9/25 Interdisciplinary Conference Note revealed Resident 3 felt uncomfortable around others. Staff were to encourage activity participation. Residents 3GÇÖs Care Plan did not include resident-centered interventions related to depression, anxiety or mood. On 1/30/26 at 11:28 AM, Staff 4 (LPN/Resident Care Manager) confirmed Resident 3GÇÖs care plan was not comprehensive. On 1/30/26 at 12:35 PM, Staff 13 (Social Service Director) stated she was not aware Resident 3 was taking antipsychotic mediations and confirmed the resident's care plan was not comprehensive. -á 3. Resident 32 was admitted to the facility in 8/2023 with diagnoses including retention of urine (inability to completely empty the bladder) and protein malnutrition. The 7/12/24 Care Plan indicated Resident 32 was at risk for bowel incontinence related to reduced mobility. The 10/11/25 Care Plan indicated Resident 32 was at risk for skin impairment related to mixed incontinence and occasional diarrhea. The 11/11/25 Quarterly MDS revealed Resident 32 had moderate cognitive impairment and was always continent of bowel. The Physician Follow up notes from 12/4/25, 12/11/25, 12/18/25, 1/1/26, and 1/6/26 indicated Resident 32 had a history of chronic diarrhea. The Bowel Task from 12/29/25 through 1/27/26 indicated Resident 32 had 19 episodes of loose diarrhea.-á On 1/26/26 at 1:01 PM, Resident 32 reported experiencing frequent diarrhea for the past the year. Resident 32 stated she/he was taking medications for this condition, which provided some relief. Resident 32 stated a couple months ago she/he asked to see a gastroenterologist to help better understand the underlying cause of her/his chronic diarrhea. On 1/28/26 at 9:36 AM, Staff 15 (CMA) stated Resident 32 experienced both diarrhea and constipation for at least the past six months. Staff 15 stated recent adjustments to her/his bowel medications appeared to be more effective for the past few months. On 1/28/26 at 9:46 AM, Staff 16 (CNA) stated resident 32 was prone to diarrhea and may have multiple episodes in a day, sometimes up to four. Staff reported resident 32 consistently notified them of bowel issues and requested anti-diarrheal medication as needed. On 1/28/2026 10:15 AM-áResident 32 was observed lying in bed, wearing a shirt and gray brief, in the fetal position. The brief contained a stool stain approximately 3 inches long and .5 inches wide, appearing to be diarrhea. The residentGÇÖs wheelchair was covered with disposable chucks. During observation, resident 32 did not respond to verbal stimuli. On 1/28/26 at 10:16 AM, Resident 32GÇÖs roommate stated over the past six months Resident 32 frequently complained about her/his diarrhea, and she/he spent a significant amount of time in the bathroom because she/he had frequent diarrhea, sometimes up to five times per day. On 1/28/26 at 10:19 AM, Staff 14 (CNA) stated last night, he found Resident 32 sleeping on the toilet where she/he had been for approximately 30 to 45 minutes. Staff 14 reported Resident 32 had experienced multiple episodes of diarrhea. Staff 14 further stated over the past four to five weeks Resident 32 had regular episodes of diarrhea. On 1/30/26 at 11:40 AM, Staff 4 (LPN/RCM) stated she was aware Resident 32 had chronic diarrhea and her/his care plan was not comprehensive. On 1/30/26 at 2:51 PM, Staff 2 (DNS) confirmed Resident 32 had a history of diarrhea and expected her/his care plan to be comprehensive.

Resident Cited: Resident # 3  has discharged from facility. Resident # 9 has hospice careplan put in place. Resident # 32 has careplan regarding chronic GI issues put in place. Residents at Risk: Residents who reside in facility are at potential risk for this deficient practice. House-wide audit completed to ensure residents who are on Hospice have care plans in place and those with psychotropic medications have behavior monitors in place, and those with chronic GI issues have care plans in place. Education: Nurse management/Social services educated regarding ensuring residents have careplans in place that are comprehensive. Audits: DNS/designee will audit careplans of a random sample of residents weekly x 4 weeks, monthly x 3 months to ensure compliance. Results of audits will be brought to QAPI for review.

2. Resident 21 was admitted to the facility on 1/16/2026 with a diagnosis of diabetes. A 1/26/26 Admission MDS revealed Resident 21 had a BIMS of 13, which indicated she/he was cognitively intact, and required assistance with bathing.-á A comprehensive care plan revised 1/19/26 revealed Resident 21 required extensive assistance with bathing.-á A 1/21/26 facility shower schedule revealed Resident 21 was to be bathed during the day on Mondays and Thursdays.-á A review of Resident 21's Bathing Tasks revealed she/he was bathed on 1/22/26. The scheduled shower days of 1/19/26 and 1/26/26 were documented as ""no (not scheduled for this shift)"" and no additional showers were documented as completed.-á-á On 1/26/26 at 11:03 AM Resident 21 was observed in bed in a hospital gown and her/his hair appeared unwashed and uncombed. Resident 21 stated she/he was bathed only one time since admission on 1/16/26. Resident 21 stated she/he asked about being bathed, but the staff did not do it. On 1/26/26 at 9:20 AM Resident 21 was observed in a hospital gown and her/his hair appeared unwashed. Resident 21 stated she/he was not yet bathed that week. On 1/28/26 at 2:40 PM Staff 9 (CNA) stated on days when the designated shower aid was moved to CNA she would focus on basic care and may miss completing bathing for the residents.-á On 1/29/26 at 9:50 AM Staff 7 (CNA) stated on days when there was less staff, she would not always assist residents with bathing.-á -á On 1/29/26 at 2:25 PM Staff 3 (LPN Resident Care Manager) stated staff were expected to offer bathing as scheduled and if missed during the week, bathing was to be offered on Saturdays.-á -á , 1. Resident 20 was admitted to the facility on 1/2025 with diagnoses including chronic pain syndrome. The 1/29/25 Admission MDS revealed Resident 20 had a BIMS score of 9 indicating moderate cognitive impairment and was dependent for bathing. On 1/26/26 at 1:21 PM Resident 20 stated feeling she/he did not get as clean as she/he would like due to staff rushing through showers and not cleaning her/his genitals thoroughly. The resident stated she/he needed help bathing due to pain.-á The 1/2026 shower schedule specified Resident 20GÇÖs bathing days were Sundays and Wednesdays. Saturdays were the make-up bathing day for any residents who missed a scheduled shower during the week. The bathing task was reviewed for 12/31/25 through 1/28/26. Resident 20 declined bathing Wednesday 1/7/26 and 1/21/26 with no documented follow up attempts. There was no documented bathing on Sunday 1/4/26 or Sunday 1/11/26. No make-up bathing was documented for any Saturday during 1/2026.-á Resident 20GÇÖs 1/2026 progress notes revealed no documented attempts at make-up bathing on Saturdays or a reason bathing was not completed 1/4/26 and 1/11/26.-á On 1/28/26 at 9:35 AM Resident 20 was observed in bed with greasy hair. The resident was unable to recall her/his bathing schedule.-á On 1/28/26 at 1:36 PM Staff 24 (CNA) said the bathing schedule was inconsistent due to agency staff in the building, showers did not always get done or rescheduled. Staff 24 said when a resident refused their scheduled bathing time, the expectation was to try again at another time or have a different staff offer.-á On 1/29/26 at 9:50 AM Staff 22 (CNA) reported residents had two scheduled days per week for bathing. If a resident declined a shower on their scheduled day, the expectation was for staff to offer a make-up shower on Saturdays. On 1/29/26 at 11:17 AM Staff 4 (LPN Resident Care Manager) reported facility staff were available at any time to provide bathing services. She said there was no formal process for adding a resident to the Saturday make-up schedule, but the expectation was for staff to follow through on re-scheduling missed showers.-á

Resident Cited: Resident # 20 offered shower and documented Resident # 21discharged from facility. Residents at Risk: All residents who currently reside in the facility are at potential risk for this deficient practice. House-wide audit completed to ensure residents have showers scheduled and are being offered/documented as given/refused as scheduled. Education: Education completed with nursing staff regarding giving residents showers as scheduled/documenting as given/refused. Audits: DNS/designee will conduct audits weekly of showers scheduled/showers given or refused to ensure showers are being completed as residents allow weekly x 4 weeks, monthly x 3 months. Results of audits will be brought to QAPI for review.

2. Resident 4 was admitted to the facility in 10/2025 with diagnoses including chronic obstructive pulmonary disease (a progressive, long-term lung disease that makes it hard to breathe by damaging the airways and air sacs). A review of orders revealed an 8/15/25 physician order for oxygen as needed. On 1/27/26 at 8:47 AM, Resident 4 was observed with oxygen on, the concentrator filter was observed to be dirty. On 1/29/26 at 11:15 AM, Staff 12 (Regional Nurse) observed the oxygen concentrator filter and acknowledged the filter was dirty and needed cleaning. Staff 12 stated staff were expected to clean the concentrator filters regularly. , The 8/1/24 Tracheostomy Care Policy and Procedure Revealed staff were to verify physician orders and identify the resident. -á The 2025 facility assessment revealed: staff training/competencies and skill sets are required. Clients are reviewed prior to admission to determine if additional training is needed and is provided. 1. Resident 3 admitted to the facility on 12/5/25 with diagnoses including dysphonia (difficulty speaking), dysphagia (difficulty swallowing) and BarrettGÇÖs esophagus without dysplasia (lining of the food pipe has changed due to acid reflux). -á -á The 12/5/25 Hospital Discharge Orders indicated tracheostomy care as directed. No additional tracheostomy specific care instructions were included in the discharge documentation. The 12/5/25 Nursing Admission/Readmission Evaluation Assessment revealed Resident 3 required tracheostomy care (small opening in the neck that helps a person breathe). The residentGÇÖs daughter provided all tracheostomy supplies. The resident had difficulty communicating verbally but was to notify staff when care was needed.-á A 12/8/25 at 11:45 AM, Nurse's Note revealed Resident 3 did not have tracheostomy care orders in place. The residentGÇÖs tracheotomy appeared to be dislodged (the hole in their neck used for breathing come out completely), and the resident was sent to the hospital for evaluation and placement of the tracheostomy tube. The resident requested transfer to the hospital and returned at 10:30 PM.-á A 12/9/25 Physician Order directed staff to clean around the tracheostomy site with normal saline and apply gauze around the insertion site every evening shift. -á A 12/18/25 Physician Order directed staff to suction Resident 3GÇÖs trach at 120 mm using a suction catheter kit with normal saline for a maximum of 15 seconds in a circular motion every four hours for trach care. -á A 12/19/25 at 11:54 PM, Nurse's Note revealed during suctioning, thick secretions were noted, and the inner cannula was found to be completely occluded (blocked or closed off). The resident requested to be sent to the hospital for further evaluation. -á A 12/20/25 at 2:34 PM, Nurse's Note revealed staff were unable to replace Resident 3's tracheostomy inner cannula and provide suctioning. During the attempt, the nurse noted the residentGÇÖs tracheostomy had become displaced. The nurse attempted to reposition the tracheostomy; however, placement could not be successfully re-established. The resident reported extreme discomfort. Due to concerns with the resident's breathing, the resident was transferred to the hospital for replacement of the tracheostomy cannula.-á -á A 12/20/25 at 6:00 PM, Nurse's Note revealed Resident 3 returned from hospital and was sent with three additional inner cannulas from the emergency department. -á The 12/20/25 Emergency Department Encounter revealed Resident 3 was admitted for tracheostomy obstruction. Resident 3 reported a nurse from the care facility inserted the wrong tracheostomy tube size two weeks ago and she/he had increasing pain since. The resident stated she/he had her/his tracheostomy cannula for the past two weeks and reported increased secretions form her/his tracheostomy and tonight, it was all plugged up, prompting her/him to present to the emergency department. -á The 12/20/25 through 12/21/25 Emergency Department Encounter revealed Resident 3 admitted with tracheostomy concerns. Hospital staff had difficulty replacing the tracheostomy tube because of swelling. After consulting with the specialist, a smaller tube was used, and the airway was gradually widened to allow placement. The resident was then discharged back to the facility. At discharge, the resident's tracheostomy supplies were different brands than those available at the facility. Resident 3 was noted to have heavy secretions, requiring regular inner cannula replacement. -á A 12/21/25 Physician Order directed staff to change Resident 3GÇÖs tracheostomy tube to size 5.5 and tracheostomy ties daily as needed for obstruction on every day shift for tracheostomy care. -á The 12/30/25 Emergency Department Encounter revealed Resident 3 was admitted to the hospital due to shortness of breath and reported difficulty getting enough air through the tracheostomy. Resident 3 stated this occurred multiple times. The resident's tracheostomy was found to be plugged. -á A 12/31/25 at 12:48 AM, Nurse's Note revealed Resident 3 had difficulty breathing at the beginning of the shift. The nurse attempted suctioning and replacement of the inner cannula. The resident continued to have difficulty breathing and requested transfer to the hospital and was sent for evaluation. -á A 1/3/26 at 11:00 PM, Nurse's Note revealed the residentGÇÖs humidifier machine was continuously cycling between high and low settings with no visible mist output into the residentGÇÖs tracheostomy. -á A 1/3/26 at 11:35 PM, Nurse's Note revealed Resident 3 frequently called throughout the shift requesting assistance with suctioning and stated she/he did not believe the humidifier was functioning.-á -á A 1/10/26 at 5:13 PM, Nurse's Note revealed Resident 3GÇÖs cannula was nearly completely blocked and could not be cleared. The resident showed minimal response, and no additional secretions were able to be suctioned at that time. -á A 1/10/26 at 5:18 PM, Nurse's Note revealed Resident 3 stated that it felt like her/his tracheostomy tube was not in the correct position. The nurse assessed the site and noted the cannula had been displaced. The resident requested transfer to the hospital for evaluation.-á -á A 1/18/26 Physician Order directed staff to administer seven percent sodium chloride inhalation motion via nebulizer every six hours as needed for thick secretions, and three ml every six hours for secretions for two days.-á -á Review of Resident 3's clinical record revealed staff did not obtain orders for tracheostomy care after admission. During this period, Resident 3 experienced multiple episodes of respiratory distress that resulted in hospitalizations. -á Multiple attempts were made to contact the nursing staff who authorized the Nursing Notes; however, these attempts were unsuccessful, and staff were not available to provide additional clarification. -á On 1/26/26 at 2:43 PM, Resident 3 reported she/he requested assistance for tracheostomy suctioning multiple times and stated she/he experience extended wait times before care was provided. -á On 1/29/26 at 12:38 PM, Staff 26 (Agency LPN) stated not all nurses were trained to provide tracheostomy care. Staff 26 stated she had to provide instructions to some nurses regarding tracheostomy care. Staff 26 stated the facility did not always have the correct tracheostomy supplies readily available. Staff 26 reported on one occasion; the facility did not have the correct tracheostomy tube size on hand and obtained a replacement tube the following day. Staff 26 stated Resident 3 was dependent on staff for tracheostomy care needs and experienced anxiety related to difficulty breathing. Staff 26 stated she overheard an agency nurse state in the presence of the resident, that she did not know how to provide tracheostomy care. Staff 26 further stated the residentGÇÖs facial expression appeared concerned at the time of the statement.-á -á On 1/29/26 at 2:14 PM, Staff 27 (Admission/Marketing/LPN) reviewed Resident 3GÇÖs Hospital Discharge Orders and confirmed the tracheostomy orders were unclear and lacked detailed instructions. Staff 27 stated nursing staff were expected to follow up in a timely manner. -á On 1/29/26 at 7:13 PM, Witness 1 stated she provided tracheostomy care for Resident 3 prior to the residentGÇÖs admission to the facility and reported the resident had not experienced the frequency of tracheostomy related complications observed after admission to the facility. Witness 1 stated shortly after Resident 3GÇÖs admission the resident began experiencing breathing difficulties. Witness 1 stated during visits to the facility, she observed delays in staff responding to Resident 3GÇÖs request for tracheotomy suctioning. She reported this on multiple occasions; she performed suctioning herself due to the delay. Witness 1 stated Resident 3 removed her/his inner cannula on occasion because of anxiety and fear of not being able to breathe. Witness 1 expressed concerns to nursing staff stating she was worried nursing staff were not knowledgeable or competent in providing tracheostomy care and suctioning.-á -á On 1/30/26 at 1:07 PM, Staff 6 (LPN) stated Resident 3 requested replacement of her/his inner cannula. Staff 6 stated he was unfamiliar with the procedure and requested assistance. After removal of the tracheostomy tube, staff were unable to locate the correct size replacement and did not know where the resident's tracheostomy supplies were kept. The resident was then transferred to the hospital. -á On 1/30/26 at 3:43 PM, Staff 2 (DNS) stated the facility expected nursing staff to be competent prior to providing tracheostomy care and to follow up on resident orders in a timely manner. Staff 2 stated Resident 3GÇÖs tracheostomy tube and supplies were expected to be available as needed. Staff 2 further stated if staff had appropriate tracheostomy supplies and training, some of the residentGÇÖs hospitalizations could have potentially been avoided.

Resident cited: Resident # 3 discharged from facility. Resident #4  Oxygen concentrator filter was removed and cleaned. Residents at risk : All residents who reside in facility with a trach are at potential risk for this deficient practice. House-wide audit to be completed to ensure supplies for residents with Tracheostomies are in hand as needed. All residents who reside in facility with oxygen concentrators are at potential risk for this deficient practice. House-wide audit to be completed to ensure all concentrators have clean filters. Education: Education completed with nursing staff regarding ensuring that oxygen concentrator filters are checked and cleaned as needed to ensure proper working of machine. Education completed with nursing staff/management to ensure that supplies are in stock for residents with tracheostomy. Audits: DNS/Designee will conduct audits weekly for tracheostomy supplies in stock for residents with trachs weekly x 4 weeks, monthly x 3 months. DNS/designee will conduct audits of oxygen concentrator filters in use weekly x 4 weeks, monthly x 3 months. Results of audits will be brought to QAPI for review.

The 2025 Facility Assessment identified the Competencies and skills required for staff. The facility implemented an orientation program for new hires that included completion of a competency checklist. Staff competencies are evaluated annually, continuously monitored, and supplemented with additional training as necessary.-á Resident 3 admitted to the facility on 12/5/25 with diagnoses including dysphonia (difficulty speaking), dysphagia (difficulty swallowing) and BarrettGÇÖs esophagus without dysplasia (lining of the food pipe has changed due to acid reflux). -á-á The 12/5/25 Hospital Discharge Orders revealed tracheostomy care as directed. No additional tracheostomy specific care instructions were included in the discharge documentation. The 12/5/25 Nursing Admission/Readmission Evaluation Assessment revealed Resident 3 required tracheostomy care (surgical opening created in the trachea (windpipe) through the neck to provide an airway and/or allow removal of secretions from the lungs.-á On 1/26/26 at 2:43 PM, Resident 3 reported she/he requested assistance for tracheostomy suctioning multiple times and experienced extended wait times before care was provided. On 1/29/26 at 12:38 PM, Staff 26 (Agency LPN) stated not all nurses were trained to provide tracheostomy care. Staff 26 stated she provided instructions to some nurses regarding tracheostomy care. Staff 26 stated Resident 3 was dependent on staff tracheostomy care needs and experienced anxiety related to difficulty breathing. Staff 26 stated she overheard an agency nurse state in the presence of the resident, that she did not know how to provide tracheostomy care.-á On 1/29/26 at 7:13 PM, Witness 1 reported overhearing a nurse tell another nurse that she did not know how to provide tracheostomy care for Resident 3. Witness 1 also stated she had to provide suctioning on multiple occasions due to delays in staff response, and she believed staff were not competent to provide tracheostomy care. On 1/30/26 at 1:07 PM, Staff 6 (LPN) stated Resident 3 was admitted to the facility with tracheostomy care needs and reported he did not know how to provide tracheostomy care and had not received prior training from the facility. Staff 6 stated he requested assistance from another nurse during an attempt to change the resident's tracheostomy tube, Staff 6 reported the incorrect tube size was used, and the tracheostomy tube was inadvertently removed. Staff 6 further stated staff were unsure where the resident's tracheostomy supplies were located and the resident was sent to the hospital. On 1/30/26 at 3:43 PM, Staff 2 (DNS) stated the facility expected nursing staff to be competent prior to providing tracheostomy care.-á Staff 2 further stated if staff had appropriate tracheostomy supplies and training, some of the residentGÇÖs hospitalizations could have potentially been avoided.

Resident Cited: Resident # 3 discharged from facility. Residents at Risk: All current residents in the facility with a Trach are at potential risk for this deficient practice. House-wide audit to ensure that nurses who are caring for trachs have been signed off on their competency. Currently there are no residents in the facility with a Trach.  Education: Education: Education completed with nurse management regarding completing competencies on trach care prior to admitting a resident/caring for a resident with a trach to ensure that staff are comfortable and competent with caring for residents who have a trach. Audits: To ensure ongoing compliance, DNS/designee will audit to ensure that if there is a resident with a trach in the facility, that staff have been marked off on a competency for caring for trachs weekly x 4 weeks, monthly x 3 months. Results of audits will be brought to QAPI for review.

Resident 56 was admitted to the facility 1/2026 with diagnoses including a skin infection and wounds. On 1/26/26 at 10:40 AM Resident 56 reported missed medication doses due to the facility not ordering medications before they ran out. On 1/6/26 Resident 56 was prescribed oral antibiotic Rifaximin 550 mg tablets with one tablet given two times a day. The 1/2026 Medication Administration Record revealed missed doses of Rifaximin on 1/8/26, 1/9/26, 1/15/26, 1/16/26, and 1/25/26.-á Progress notes indicated the Rifaximin was on order 1/8/26, 1/9/26, 1/15/26, 1/16/26, and 1/25/26. There was no documentation indicating follow up with the pharmacy to check the medicationGÇÖs order status. On 1/29/26 at 10:40 AM Staff 21 (CMA) stated it was the responsibility of staff administering medications to put in an order prior to medications running out.-á On 1/29/26 at 11:38 AM Staff 2 (DNS) reported Rifaximin was not a medication kept on hand in the facility and required ordering. Staff 2 said the expectation was for staff to follow up with the pharmacy to see if a medication on hand in the facility was an acceptable substitute or if the pharmacy could satellite the medication to the facility, which typically had a four-hour turnaround time. She said communication with the pharmacy should have been documented.-á

Resident cited: Resident #56 has medication in stock. Residents at Risk: All residents who reside in the facility are at potential risk for this deficient practice. House-wide audit to be completed to ensure all residents medications have been re-ordered from pharmacy as needed and medications are in stock. Education: Education completed with nurses/CMAs regarding the reordering process and what to do if a medication is not on hand. Audits: DNS/designee will conduct audits of random sample of residents to ensure medication is available and administered as ordered weekly x 4 weeks, monthly x 3 months. Results of audits will be brought to QAPI for review.

On 1/28/26 at 10:04 AM, Staff 8 (Maintenance Director) was observed cleaning the ice machine in the janitor closet on the North Hall. Staff 8 stated he did not know what an airgap was or if the ice machine had an airgap (space between a water pipe sink or drain that prevents dirty water from flowing back into the clean water supply). Staff 8 confirmed the drainpipe was located below the sink basin and stated he did not believe this presented a problem in the event of the sink backflow. -á , On 1/28/26 at 10:34 AM the ice machine in the janitor closet on the North Hall was observed. The ice machine drained into a sink on the floor with the top of the sink extending above the bottom of the drain, resulting in no air gap between the drain and the sink. The sink on the floor had trash in it, appeared dirty, and had reddish discoloration where the ice machine dripped into the sink. Staff 8 (Maintenance Director) confirmed the ice machine drain placement but did not feel it was an issue.-á On 1/28/26 at 11:54 AM Staff 1 (Administrator) reviewed the ice machine and drain and stated it would be repaired.-á-á -á

Resident Cited: No specific resident was cited Residents at risk: All residents who reside in the facility are at potential risk for this deficient practice. Ice machine drain tube fixed in order to have a bigger gap between it and the drain. Education: Education completed with Maintenance Director regarding air gap requirements for ice machines. Audits: DNS/designee will complete audits of ice machine drain air gap weekly x 4 weeks, monthly x 3 months to ensure compliance. Results of audits will be brought to QAPI for review.

2. On 1/27/26 at 3:00 PM a gray plastic bedpan was observed lying on the floor, beneath the sink of the restroom shared between Rooms 15-16. The bedpan was sitting directly on the floor and was uncovered. This restroom was shared by two rooms with total capacity of four residents.-á On 1/28/26 at 9:19 AM a gray plastic bedpan was observed lying on the floor beneath the sink, uncovered and lying partially on top of a clear plastic bag. Part of the bedpan directly touched the floor of the restroom shared between Rooms 15-16. Staff 23 (CNA) indicated on 1/28/26 at 10:07 AM bedpans were labeled with resident names and stored in plastic bags in the restroom when not being used. Staff 2 (DNS) stated on 1/28/26 at 10:45 AM the expectation for bedpans was for them to be labeled by staff, cleaned after use, and stored in a closed plastic bag in the restroom when not in use. On 1/30/26 at 10:35 AM two gray bedpans were observed lying stacked one atop the other in the shared restroom between Rooms 15-16. The bottom bedpan was partially within a clear plastic bag but not enclosed. The top bedpan had no bag around it.-á Staff 2 observed the bedpans in the shared restroom between Rooms 15-16 at 10:36 AM and confirmed this was not the proper process for storage of bedpans when they were not in use. -á , 1. On 1/28/26 at 11:19 AM Staff 6 (LPN) was on the central hall checking CBGs (blood sugar measurement) and moved to the south hall. Staff 6 had one glucometer on top of the medication cart with no cleaning supplies in sight. Staff 6 stated he cleaned the glucometer with an alcohol pad and opened the drawer and pointed to small alcohol prep pads. At this time another staff provided Staff 6 with the purple top Super Sani-Cloth Wipes.-á On 1/28/26 at 11:43 AM Staff 6 stated prior to moving to the south hall he checked one CBG with the glucometer and cleaned it with an alcohol prep pad.-á On 1/28/26 at 12:46 PM Staff 2 (DNS) stated the staff were to use the purple top wipes, Super Sani-Cloth Wipes, when cleaning the glucometer and the alcohol prep pads were not an appropriate cleaning product.-á -á

Resident Cited: No specific residents were cited. Residents at risk: All residents who reside in the facility and require CBG checks or use bedpans are at potential risk for this deficient practice. House-wide audit completed to ensure all glucometers are cleaned using required product and all bed pans are clean and stored appropriately. Education: Education completed with nursing staff regarding proper procedure for glucometer cleaning and bed pan cleaning/storage. Audits: DNS/designee will conduct audits weekly of glucometer cleaning procedure/bed pan cleaning procedures/storage on a random sample of residents weekly x 4 weeks, monthly x 3 months. Results of audits will be brought to QAPI for review.

Resident 6 admitted to the facility in 9/2022 with a diagnosis of diabetes.-á An 8/19/25 Informed Consent revealed Resident 6 consented to receive a pneumonia vaccine. A review of Resident 6's medical record revealed no indication she/he was offered a current influenza vaccine.-á A review of Resident 6's immunization record revealed no evidence Resident 6 received a pneumonia vaccine or an influenza vaccine.-á On 1/30/26 at 1:59 PM Staff 2 (DNS) stated the facility offered influenza vaccines in 9/2025 and 10/2025 and it should have been offered to Resident 6. Staff 2 stated the pneumonia vaccine should have been administered to Resident 6 at the same time as the influenza vaccine, and she/he did not receive the vaccines.-á -á

Resident Cited: Resident #6 received his Flu/PNA vaccine as requested. Residents at Risk: All residents who reside in the facility and consent to the flu/PNA vaccine are at potential risk for this deficient practice. House-wide audit conducted to ensure all residents who consented to the Flu/PNA vaccine received these as requested/ordered and administer them to those that still need them. Education: Education completed with nurses ensuring that residents receive flu/PNA vaccines when consented to if appropriate. Audits: DNS/designee will conduct audits of newly admitted residents to ensure flu/PNA vaccines are administered if appropriate weekly x 4 weeks, monthly x 3 months. Results of audits will be brought to QAPI for review.

Resident 13 admitted to the facility in 2018 with a diagnosis of respiratory failure. A 11/6/25 Informed Consent revealed Resident 13 consented to receive a COVID-19 vaccine. A review of Resident 13's immunization record revealed she/he did not receive a COVID-19 vaccine. On 1/30/26 at 1:59 PM Staff 2 (DNS) confirmed Resident 13 did not receive the COVID-19 vaccine during the facility's 11/2025 COVID-19 clinic.-á -á

Resident Cited: Resident # 13 received COVID vaccine as requested. Residents at Risk: All residents who reside in the facility and consent to the COVID vaccine are at potential risk for this deficient practice. House-wide audit conducted to ensure all residents who consented to the COVID vaccine received these as requested/ordered and administer them to those that still need them as soon as possible. Education: Education completed with nurses ensuring that residents receive COVID vaccines when consented to if appropriate. Audits: DNS/designee will conduct audits of newly admitted residents to ensure COVID vaccines are administered if appropriate weekly x 4 weeks, monthly x 3 months. Results of audits will be brought to QAPI for review.

On 1/30/26 at 12:35 PM Staff 17, 18, and 19 were identified as employees hired within the last four months.-á On 1/30/26 at 3:18 PM Staff 20 (Staffing Coordinator) reported the facility had not completed reference checks for Staff 17, 18, and 19.

Resident Cited: No specific resident was cited. Residents at Risk: All residents who reside in facility are at potential risk for this deficient practice. Audit of employees hired in the last 30 days audited to ensure references are completed. Education: Education completed with HR to ensure reference checks are completed on new hires prior to them starting. Audits: Administrator/designee to conduct audits weekly of new hires to ensure reference checks completed prior to starting weekly x 4 weeks, monthly x 3 months. Results of audits brought to QAPI for review.

Resident 18 was admitted to the facility in 6/2022 with diagnoses including behavioral disturbance and dementia. -á A facility incident report dated 1/15/25 indicated Resident 18 was found on 1/15/25 with a bruise to the left eye. Staff did not know how the injury occurred and the resident was unable to explain what happened. -á An Incident Investigation dated 1/15/25 indicated on 1/10/25, Staff 24 (CNA) observed a bruise to Resident 18GÇÖs eye and reported the bruise to Staff 10 (LPN). -á On 12/11/25 at 9:45 AM, Staff 2 (DNS) confirmed the incident was not reported to the State Agency in a timely manner. -á The incident met the criteria for non-compliance as follows: 1. The incident indicated non-compliance for F609 -á 2. There was sufficient evidence the facility corrected the non-compliance and was in substantial compliance with F609 as evidenced by: -No deficient practice was found at F609 with additional sampled residents. -The facility identified the deficient practice and provided in-service training to nursing staff on reporting injuries of unknown origin. -Weekly audits were implemented for four weeks, followed by monthly audits for three months.

A review of the resident 21's clinical record revealed no evidence of a discharge plan in the resident file. A notification on the Evaluations tab of the clinical record indicated the discharge plan was 16 days overdue.-á The resident's Care Plan dated 11/26/25 revealed the resident's discharge preferences were not addressed in the Care Plan.-á Care Conference Notes dated 12/3/25 revealed no documentation of the resident's discharge plan. On 12/11/25 at 1:58 PM, Staff 36 (Social Services Coordinator) stated she should have had the resident's discharge plan completed.-á On 12/11/25 at 2:00 PM, Staff 2 (DNS) stated she was not familiar with the discharge planning procedure, but it was the responsibility of Social Services to complete a discharge plan.-á

Resident Cited Resident #21's discharge plan completed and documented. Residents at Risk All residents who reside in facility and plan to discharge are at potential risk for this deficient practice. An audit of residents who admitted in the last 30 days will be completed to ensure all residents have a documented discharge plan. Education IDT Team educated regarding completing/documenting resident's discharge plans timely. Audits To ensure ongoing compliance, the DNS/designee will complete audits on a sample of residents weekly x 4 weeks, monthly x 2 months to ensure that discharge plans are being completed/documented timely. Results of audits will be brought to QAPI for review.

1. Resident 27 was admitted to the facility in 11/2025 with diagnoses including fractured femur and osteoarthritis. -á On 12/8/25 a review of Resident 27's clinical record revealed the admission MDS assessment was marked ""in progress"" and overdue by 15 days. -á On 12/8/25 at 12:06 PM, Staff 11 (MDS Coordinator) confirmed she was behind on 11/2025's MDS reports. -á On 12/11/25 at 11:54 AM Staff 2 (DNS) confirmed MDS assessments should be completed timely. -á -á 2. Resident 34 was admitted to the facility in 11/2024 with diagnoses including pressure ulcer and chronic kidney disease. -á On 12/9/25 a review of Resident 34's clinical record revealed her/his annual MDS assessment was ""in progress"" and overdue by 15 days. -á On 12/11/25 at 11:54 AM Staff 2 (DNS) confirmed MDS assessments should be completed timely. -á -á

Resident Cited Resident #27's admission MDS assessment was completed. Resident #34's Annual MDS assessment was completed. Residents at Risk All residents who reside in facility are at potential risk for this deficient practice. House wide audit completed to ensure residents have all MDS assessments completed and up to date. Education Education completed with IDT team regarding completing MDS Assessments on time. Audits To ensure ongoing compliance, the DNS/designee will audit MDS assessments due to ensure completion by the deadline weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Resident 20 was admitted to the facility 5/1/25 with diagnoses-á including dementia.-á A Facility Reported Incident (FRI) dated 5/22/25 revealed Resident 20's care plan was revised to keep the resident further than an arm's length away from other residents when she/he appeared agitated.-á A FRI dated 6/5/25 revealed Resident 20 was involved in physical aggression towards another resident. Resident 20's Care Plan revealed the intervention to keep the resident away from other residents when she/he appeared agitated was added to the Care Plan on 6/5/25. -á On 12/11/25 at 12:35 PM, Staff 2 (DNS) stated the resident's care plan should have been updated within five days of the 5/22/25 FRI-á and she had failed to update the resident's care plan timely. -á

Resident Cited Resident #20 careplan was audited and revised as needed to ensure up to date interventions are in place regarding resident's history of physical aggression with other residents. Residents at Risk All residents who reside in facility that have been involved in resident to resident altercations are at potential risk of this deficient practice. Audit of FRIs for the past 30 days audited to ensure all planned interventions are in place if still applicable. Education IDT Team educated regarding timely careplan updates after an incident occurs and new interventions are needed. Audits To ensure ongoing compliance, the DNS/Designee will complete audits of FRIs weekly x 4 weeks, monthly x 2 months to ensure all planned careplan interventions were put in place timely. Results of audits will be brought to QAPI for review.

1. Resident 17 was admitted to the facility in 9/2025 with diagnoses including chronic kidney disease and epilepsy. -á An 8/20/25 Admission MDS indicated Resident 17 had a BIMS score of 14 (cognitively intact). -á On 12/9/25 at 9:23 AM, the call light monitor was observed and revealed Resident 17's call light was activated at 8:47 AM and completed at 9:34 AM, a total wait time of 47 minutes. -á On 12/9/25 at 9:53 AM, Resident 17 stated call light wait times were sometimes long. -á On 12/9/25 at 1:12 PM, Staff 29 (CNA) stated during Resident 17's call light wait time, he was assisting another resident with incontinent care. Staff 29 stated the facility used to have devices to communicate with other staff, but they were no longer available. -á On 12/11/25 at 11:55 AM, Staff 2 (DNS) stated she expected resident's needs to be met and confirmed Resident 17's call light wait time was too long. -á -á 2. Resident 33 was admitted to the facility in 9/2025 with diagnoses including anxiety and chronic pain. -á A 9/29/25 Admission MDS indicated Resident 33 had a BIMS score of 15 (cognitively intact). -á On 12/9/25 at 9:23 AM, an observation of the call light monitor revealed Resident 33's call light was activated at 8:53 AM and completed at 9:33 AM, a total wait time of 40 minutes. -á On 12/10/25 at 10:14 AM, Staff 34 (CNA) stated during Resident 33GÇÖs call light time, she was assigned to work in the dining room. -á On 12/11/25 at 11:55 AM, Staff 2 (DNS) stated she expected resident's needs to be met and confirmed Resident 33's call light wait time was too long. -á -á

Resident Cited Resident #17 was assessed for any unmet needs and concerns addressed as needed. Resident # 33 was assessed for any unmet needs and concerns addressed as needed. Residents at Risk All residents who reside in facility are at potential risk for this deficient practice. Interviews completed with alert and oriented residents to ensure their needs are being met and concerns addressed as needed. Education Education completed with nursing staff regarding answering call lights timely to ensure that resident's needs are being met. Audits To ensure ongoing compliance, the DNS/Designee will conduct audits of call light response time on a sample of residents through observation/interviews weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

The Direct Care Staff Daily Reports from 12/20/24 through 1/21/25 were compared to the staff daily assignment sheets. The following was found: The Direct Care Staff Daily Reports did not accurately represent actual staffing for the following 13 days: 12/21/24, 12/24/24, 1/1/25, 1/3/25, 1/4/25, 1/5/25, 1/11/25, 1/12/25, 1/13/25, 1/15/25, 1/16/25, 1/19/25, and 1/20/25.-á On 12/11/2025 at 10:33 AM Staff 35 (Staffing Coordinator/HR Director) acknowledged the Direct Care Staff Daily Reports were not accurate for the above-mentioned dates.-á On 12/11/2025 at 12:58 PM, Staff 2 (DNS) reviewed the dates with discrepancies and confirmed they were not accurate. Staff 2 confirmed the expectation was to ensure the Direct Care Daily Staff Report should be accurate. -á

Resident Cited No specific resident was cited. DHS sheets for dates listed were reviewed and updated to reflect accurate staffing levels for the 13 days identified. Residents at Risk All residents are at potential risk for this deficient practice. DHS sheets for the past 30 days audited to ensure accurate information is listed on the sheet. Education Education completed with nursing staff/staffing coordinator regarding ensuring that DHS public posting sheets are filled out with accurate information. Audits To ensure ongoing compliance, the DNS/Designee will conduct audits of DHS sheets for accurate information weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to complete a discharge summary which included a final summary of the resident's status for 3 of 4 sampled residents (#s 2, 4, and 5) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include: 1. Resident 2 was admitted to the facility in July 2024, with diagnoses including diabetes. Review of a Discharge Summary/Plan of Care form dated 8/28/24, revealed the final summary of the resident's status did not include all items consistent with the resident's most recent comprehensive assessment which included but not limited to functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcer and pain. 2. Resident 4 was admitted to the facility in July 2024, with diagnoses including heart failure. Review of a Discharge Summary/Plan of Care form dated 9/4/24, revealed the final summary of the resident's status did not include all items from the resident's most recent comprehensive assessment which included but not limited to functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcer and pain. 3. Resident 5 was admitted to the facility in June 2018, with diagnoses including dementia. Review of a Discharge Summary/Plan of Care form dated 8/26/24, revealed the final summary of the resident's status did not include all items from the resident's most recent comprehensive assessment which included but not limited to functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcer and pain. In an interview on 10/9/24 at 2:01 PM, Staff 1 (DNS) acknowledged Resident 2, 4 and 5's discharge summaries did not include a complete summary of the resident's final status on discharge.

Resident Cited: Resident # 2 is no longer a resident residing in facility. Resident # 4 is no longer a resident residing in facility. Resident #5 is no longer a resident residing in facility. Residents at Risk: Discharge Summaries audited for past 30 days to identify any trends and concerns addressed as needed. Education: Education completed with nurse management and social services regarding including summary of residents condition that includes all items that were triggered on the residents most recent comprehensive assessment. Audits: To ensure ongoing compliance, DNS/designee will complete audits of discharge summaries weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

************************************* OAR 411-086-0160 Nursing Services: Discharge Summary Refer to F661 *************************************

Based on interview and record review it was determined a resident was not spoken to in a dignified manner for 1 of 3 sampled residents (#47) reviewed for dignity. This placed residents at risk for lack of self-worth. Findings include: Resident 47 admitted to the facility in 7/2024 with a diagnosis of post-surgical procedure paraplegia. On 8/14/24 Witness 9 (Anonymous) reported to the State agency Staff 7 (CNA) would not change Resident 47's sheets and it caused Resident 47 to feel afraid and Resident 47 felt she/he had to "argue" to receive care. A 7/31/24 admission MDS revealed Resident 47 was cognitively intact. On 8/26/24 at 3:30 PM Resident 47 stated her/his sheets were wet from sweat and requested Staff 7 (CNA) to change the sheets. Staff 7 insisted the sheets were not wet. Resident 47 stated it was frustrating to have to always argue with staff to have care provided. Eventually the sheets were changed. On 8/28/24 at 10:31 AM Staff 2 (DNS) stated if a resident requested her/his sheets to be changed, staff should honor the request. Staff 2 stated Resident 47 reported she/he requested her/his sheets to be changed, staff left, and Resident 47 felt it took too long for staff to return. On 8/29/24 at 10:26 AM Staff 7 (CNA) stated on one occasion Resident 47 stated her/his sheets were wet from sweat and wanted the sheets changed. Staff 7 stated she checked the sheets and told resident the sheets were not wet and did not need to be changed. However, she left the room, found another CNA, returned to the resident's room, and they changed her/his sheets.

Resident Cited Resident # 47 is no longer a resident residing in the facility. Residents at Risk Current Resident that are able to be interviewed, interviews to be conducted to determine if there are any concerns regarding being treated with dignity from staff and concerns to be addressed as needed. Current residents that are unable to be interviewed family members/POA/Responsible parties will be interviewed regarding resident being treated with dignity any concerns will be addressed as needed. Education Staff to be re-educated regarding speaking with dignity to all residents. Audits To ensure ongoing compliance, DNS/designee will conduct random interviews with residents regarding any concerns with staff treating them with dignity weekly x 4 weeks, monthly x 2 months. Results of audits to be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to obtain consent for an influenza vaccination for 1 of 5 sampled residents (#16) reviewed for immunizations. This placed residents and responsible parties at risk for lack of informed consent. Findings include: Resident 16 admitted to the facility in 10/2023 with diagnoses including diabetes. An 8/25/24 Quarterly MDS indicated Resident 16 was cognitively intact. An 8/29/24 review of Resident 16's immunization record revealed she/he received the influenza vaccine in the facility on 12/13/23. An 8/29/24 review of Resident 16's medical record revealed no evidence of a signed consent for the influenza vaccine received in the facility on 12/13/23. On 8/29/24 at 3:35 PM Staff 2 (DNS) stated she was unable to locate a signed consent for Resident 16's influenza vaccine received in the facility on 12/13/23. Staff 2 stated consent needed to be obtained prior to a resident receiving vaccines.

Resident Cited Resident # 16 remains in facility. No adverse effects noted from flu vaccine administered. Residents at Risk House-wide audit completed to ensure that all consents/declinations are in place for vaccines and concerns addressed as needed. Education LNs re-education to be completed to ensure consents for vaccines are obtained for all vaccines prior to administering to residents. Audits To ensure ongoing compliance, DNS/designee will conduct audits to ensure consents are in place for vaccines given weekly x 4 weeks, monthly x 2. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to notify a resident's emergency contact of a hospitalization and a resident's physician for a change of condition for 2 of 6 sampled residents (#s 18 and 47) reviewed for hospitalization and pressure ulcers. This placed residents at risk for lack of family involvement and delayed treatment. Findings include: 1. Resident 18 admitted to the facility in 2010 with a diagnosis of delayed stomach and bowel emptying. An undated Admission Record revealed Witness 5 (Family Member), Witness 6 (Family Member), and Witness 7 (Family Member) were Resident 18's emergency contacts. An 10/26/23 Progress Note revealed Resident 18 was transported to the hospital for abdominal pain, nausea, vomiting, and uncontrolled diarrhea. There was no indication any of Resident 18's emergency contacts were notified. A 7/15/24 quarterly MDS indicated Resident 18 was cognitively intact. On 8/26/24 at 4:15 PM Resident 18 stated the facility did not call her/his emergency contacts when she/he was hospitalized. On 8/28/24 at 3:20 PM Staff 3 (RNCM) verified Resident 18's family was not notified of the 10/26/23 hospitalization. 2. Resident 47 admitted to the facility in 7/2024 with a diagnosis of paralysis after spinal surgery. Progress notes revealed the following: - 8/24/24 Resident 47 reported earlier in the day when she/he was assisted to turn there was a "pop" to her/his back. The nurse assessed the area to have a small "lump" above the surgical incision. The note indicated family stated they would communicate with the spinal surgeon on 8/26/24. There was no note to indicate staff notified the resident's physician. -8/25/24 Resident 47's pain was controlled with scheduled and PRN pain medications. -8/26/24 Staff 2 (DNS) and Staff 3 (RNCM) assessed the spine and did not see a "lump to back." On 8/28/24 at 10:05 AM Staff 2 and Staff 3 acknowledged the physician was not notified at the time staff identified a "lump."

Resident Cited Resident #18 remains in facility. Resident is at baseline. Resident # 47 no longer resides in facility. Staff educated to notify MD timely when resident has a change in condition. Residents at Risk House-wide audit completed to ensure all changes of condition/hospitalizations have been communicated with family/MD as appropriate. Education LNs re-education to be completed regarding notifying family when residents transfer to the hospital. Staff education to be completed regarding notifying physicians when changes of conditions occur and documenting in medical record. Audits To ensure ongoing compliance, DNS/Designee will conduct audits on residents with change of condition and residents that were transported to the hospital to ensure that family/MD were notified appropriately weekly x 4 weeks, monthly x 2 months. Results of Audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to respect the resident rights to deliver postal service mail unopened for 1 of 3 (#12) sampled resident reviewed for privacy. This placed residents at risk for lack of privacy and confidentiality. Findings include: Resident 12 admitted to the facility in 5/2023 with a diagnosis of diabetes. A 6/11/24 admission MDS revealed Resident 12 was cognitively intact. On 8/27/24 at 9:05 AM, Resident 12 stated she/he was upset because a staff member opened her/his mail "a box," which was addressed to her/him. The resident stated the box had supplements and acknowledged she/he needed a doctor's approval before taking the supplements. However, staff did not honor her/his "privacy or personal property." On 8/28/24 at 12:03 PM Staff 5 (CMA) stated on 6/3/24 she opened a package addressed to Resident 12's. After shaking the box, she heard a bottle which sounded like it contained supplements or medication. Staff 5 stated she should have let the resident open the box in front of her and acknowledged she violated Resident 12's rights. On 8/28/24 at 12:31 PM Staff 14 (Activity Director) stated she delivered the mail or received assistance to delivar the mail. Staff 14 stated Staff 5 accidentally opened Resident 12's package and immediately addressed the error with Resident 12. Staff 14 stated anything addressed to a resident should be delivered unopened. Staff 14 stated if staff thought there were medications in a box, they should be present and ask if it would be okay for the resident to open her/his mail in front of the staff member. On 8/29/24 at 1:39 PM Staff 3 (RNCM) stated she was unaware a staff member opened Resident 12's mail. Staff 3 stated if mail or a package sounded like it contained supplements or medications, staff could be present when the resident opened her/his mail. Staff 3 stated staff should never open any resident's mail because it was a violation of privacy.

Resident Cited Resident # 12 remains in facility no further concerns. Residents at Risk Interviews to be completed with residents in-house to identify any concerns residents have with mail being opened prior to them receiving and concerns addressed as needed. Education Activity and Social Services re-education to be completed regarding delivering residents mail to them unopened to ensure their right to privacy. Audits To ensure ongoing compliance, DNS/Designee will conduct random resident interview regarding concerns of mail being opened weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to initiate a grievance process for 1 of 2 sampled residents (#16) reviewed for personal property. This placed residents at risk for unaddressed concerns. Findings include: , 1. Resident 16 admitted to the facility in 10/2023 with diagnoses including diabetes. An 8/25/24 Quarterly MDS indicated Resident 16 was cognitively intact. On 8/27/24 at 8:32 AM Resident 16 stated her/his cell phone was stolen a couple of months ago and she/he spent $300 to replace it. Resident 16 stated the facility did not reimburse her/him. On 8/28/24 at 11:39 AM Staff 4 (Social Services) stated she was informed by Resident 16 she/he bought a new phone because she/he lost her/his old phone. Staff 4 stated Resident 16 never filled out a grievance form and she did not complete a grievance form for Resident 16. Staff 4 stated this was a grievance and should have had a grievance form filled out and investigated.

Resident Cited Resident # 16 remains in facility. Grievance was written up for this concern, and resident to be reimbursed for the missing cell phone. Residents at Risk House-wide audit completed to identify any other residents that have concerns regarding missing items. Grievances to be filled out as needed and investigated. Education Staff re-education completed with Social Services and staff regarding when to fill out grievances for residents and completion of follow through with investigation of grievances. Audits To ensure ongoing compliance, DNS/designee will conduct resident interviews to ensure that concerns are addressed appropriately through the grievance process as appropriate weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure a resident received a bed hold policy for 1 of 2 sampled residents (#47) reviewed for hospitalization. This placed residents at risk for not being informed of their rights to return to the facility. Findings include: Resident 18 admitted to the facility in 2018 with a diagnosis of delayed emptying of the stomach and intestines. Progress Notes from 10/2023 through 8/2024 revealed Resident 18 was hospitalized on 10/26/23, 11/8/23, and 2/10/24. The notes did not indicate Resident 18 or her/his emergency contacts were provided a bed hold policy. On 8/29/24 at 9:23 AM Staff 4 (Social Services) stated if she was in the facility when a resident was discharged to the hospital, she ensured the resident or representative was provided a bed-hold policy. If it was after hours or on the weekend, nursing staff were to provide the policy. Staff 4 stated Resident 18 was not provided bed-hold policies at the time of the resident's hospitalizations.

Resident Cited Resident #18 remains in the facility. Resident is at baseline. Residents at Risk Residents sent to hospital past 30 days audited that bed hold was provided any concerns addressed if needed. Education LNs and Social Services re-education to be completed regarding the bed hold policy and ensuring that all residents and/or representatives receive the bed hold policy upon transfer out to the hospital. Audits To ensure ongoing compliance, DNS/designee will conduct audits of all transfers to the hospital to ensure that the bed hold policy was provided to resident/representative weekly x 4 weeks, monthly x 2 months. Results of audits to be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to develop a baseline care plan for 1 of 2 sampled residents (#47) reviewed for constipation. This placed residents at risk for unmet care needs. Findings include: Resident 18 admitted to the facility on 7/25/24 with a diagnosis of paralysis after spinal surgery. A baseline care plan was initiated on 7/26/24 and did not include Resident 47 was to be log-rolled (ensuring the spine did not twist). The care plan was updated on 8/5/24 to include log rolling and spinal precautions, and no leg movement. An untitled therapy document form revealed on 8/5/24 therapy indicated a care plan change was made. The change indicated two staff were to assist Resident 47 for all bed mobility for log rolls, use spinal precautions, and to ensure no leg movement. A 7/31/24 Admission MDS revealed Resident 47 was cognitively intact. On 8/26/24 at 3:32 PM Resident 47 stated the staff did not follow therapy directions for turning. On 8/27/24 at 1:35 PM Staff 15 (Therapy Director) stated on 8/5/24 the care plan was updated and a communication form was created. On 8/28/24 at 11:46 AM Staff 16 (Occupational Therapist) stated Resident 47 reported staff did not implement spinal precautions and staff were educated on assisting Resident 47 to turn. On 8/29/24 at 9:00 AM Staff 17 (LPN) stated if a resident had special precautions, such as transfers, the information was located in the care plan and nursing tasks. On 8/29/24 at 9:02 AM Staff 18 (CNA) stated when a resident was admitted to the facility resident specific instructions were on the care plan. On 8/29/24 at 9:27 AM Staff 19 (CNA) stated if a resident was new to the facility the resident's immediate interventions were provided verbally by the nurse. Within 24 hours the information was on their care plan. On 8/29/24 at 11:08 AM Staff 4 (RNCM) acknowledged spinal precautions were not on the baseline care plan and were not added until 8/5/24.

Resident Cited Resident # 47 is no longer residing in facility. Residents at Risk Residents that admitted the past 30 days audit was conducted for thorough, accurate and special precautions in place. Any concerns addressed as needed. Education Staff re-education to be completed with Nurses/Nurse Management regarding ensuring baseline careplans are completed per policy and are thorough and and special precautions/needs are added as applicable. Audits To ensure ongoing compliance, DNS/designee will audit new admission baseline care plans to ensure they are accurate and thorough weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure safe discharge planning services for 1 of 5 sampled residents (#16) reviewed for unnecessary medications. This placed resident at risk for unsafe discharge. Findings include: Resident 16 admitted to the facility in 11/2023 with diagnoses including third degree burns to her/his left chest, abdomen and thigh. A review of a 11/10/23 facility discharge summary revealed Resident 16 was discharged from the facility to home on 11/10/23 with orders for home health, and Resident 16 had orders for daily wound care to her/his burn wounds. A review of a 11/15/23 hospital history and physical revealed Resident 16 went to the emergence room due to her/his concerns of a wound infection, inability to care for self at home and home health did not come to Resident 16's home since discharge from the facility on 11/10/23. The burn wounds on Resident 16's left chest, left abdomen and left thigh were described as having increased pain and purulent exudates (commonly referred to as pus) coming out of the wound with redness and swelling around the wounds. A review of a 11/16/23 hospital progress not stated Resident 16's burn wounds on her/his left chest, left abdomen and left thigh were infected and Resident 16 was receiving intravenous antibiotics. A review of Resident 16's 11/17/23 admission orders revealed Resident 16 was readmitted to the facility on two different antibiotics for burn wound infections. An 8/25/24 Quarterly MDS indicated Resident 16 was cognitively intact. On 8/28/24 at 11:39 AM Staff 4 (Social Services) stated home health was ordered for Resident 16 upon discharge on 11/10/23, but home health did not have time to see Resident 16 prior to her/him being admitted to the hospital on 11/15/23. On 8/28/24 at 2:54 PM Staff 3 (RNCM) stated Resident 16 was discharged on 11/10/23 with orders for daily wound care to her/his burn wounds. Staff 3 stated, according to Resident 16, her/his roommate was supposed to assist her/him with wound care upon discharge on 11/10/23. Staff 3 stated there was no evidence of wound care training completed with Resident 16 or her/his roommate. On 8/29/24 at 1:56 PM Resident 16 stated the facility discharged her/him by mistake. Resident 16 stated she/he was unable to do her/his own wound care and she/he had no family or friends that could do wound care for her/him. Resident 16 stated the facility did not talk to her/him about wound care or train her/him on wound care.

Resident Cited Resident #16 remains in facility has had no further concerns. Residents at Risk House-wide audit of residents who discharged from facility in the last 30 days with wound care completed to ensure wound care education was completed and Home Health set up. Education Education to be completed with Social Services, Nursing staff and Nurse Management regarding ensuring safe discharges of residents with wounds. Education to include ensuring Home Health is set up and Wound care education completed with resident/family prior to discharge. Audits To ensure ongoing compliance, DNS/designee will conduct audits of discharges to ensure that Home Health/wound care education was completed as appropriate weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#41) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: Resident 41 admitted to the facility in 1/2024 with diagnoses including diabetes. A 7/13/24 Quarterly MDS indicated Resident 41 had severe cognitive deficits. On 8/27/24 at 9:26 AM Resident 41 was observed to have dirty hair and dirty, jagged fingernails. An 8/28/24 review of shower/bathing documentation revealed the following: - On 7/26/24 shower/bathing activity did not occur due to resident refusal. - On 8/2/24 shower/bathing activity did not occur. - On 8/19/24 Resident 41 received a shower. There was no shower/bathing documentation between 8/3/24 and 8/18/24. An 8/29/24 medical record review revealed no evidence Resident 41 refused shower/bath or nail care on 7/30/24 or between 8/3/24 and 8/18/24. On 8/29/24 at 11:31 AM an observation of Resident 41's fingernails was made with Staff 18 (CNA). Staff 18 stated Resident 41's fingernails needed trimmed and cleaned. On 8/29/24 at 11:43 AM an observation of Resident 41's fingernails was made with Staff 3 (RNCM). Staff 3 stated Resident 41 needed her/his fingernails filed and cleaned. Staff 3 stated nail care should be completed with showers and as needed. On 8/29/24 at 4:01 PM Staff 3 stated Resident 41 should have received showers twice a week. Staff 3 was able to provide documentation which indicated Resident 41 refused her/his shower on 8/9/24. Staff 3 acknowledged Resident 41 should have received a shower/bath on 7/30/24, 8/2/24, 8/6/24, 8/13/24 and 8/16/24. Staff 3 confirmed there was no documentation Resident 41 refused bathing on 7/30/24, 8/2/24, 8/6/24, 8/13/24 and 8/16/24.

Resident Cited Resident # 41 remains in facility. Fingernails were trimmed and resident received a shower. Residents at Risk House-wide audit to be completed to ensure residents fingernails are trimmed as residents allow and showers are given/documented. Education Nursing staff re-education to be completed regarding completing showers as scheduled and documented/refusals documented as appropriate. Nursing staff re-education to be completed regarding nail care being completed as needed. Audits To ensure ongoing compliance DNS/Designee will complete audits of showers/nail care of a sample of residents weekly x 4 weeks, monthly x 2 months to ensure showers/nail care completed or refusals documented. Results of audits will be brought to QAPI for review.

Based on observation, interview, and record review it was determined the facility failed to follow physician orders, provide bowel care, and administer medications timely for 9 of 12 sampled residents (#s 2, 4, 8, 13, 14, 41, 43, 47, 203) reviewed for change of condition, restraints, pain, bowel care, and medication pass. This placed residents at risk for ineffective interventions. Findings include: 1. Resident 2 admitted to the facility in 3/2010 with a diagnosis of cancer. A care plan initiated in 2020 revealed Resident 2's bed had bed rails to improve bed mobility. On 8/26/24 at 2:47 PM Witness 1 (Family Member) stated Resident 2 used mobility bars to assist with bed mobility, the facility removed the bars, and she was not informed the reason the mobility bars were removed. On 8/27/24 at 1:59 PM Resident 2 was observed in bed. The bed did not have bed rails. On 8/27/24 at 2:46 PM Staff 3 (RNCM) stated Resident 2's original bed was replaced with a new bed and the rails were not transferred to the new bed. 2. Resident 47 admitted to the facility in 7/2024 with a diagnosis of paralysis after spinal surgery. a. A care plan initiated on 7/25/24 revealed Resident 47 was at risk for constipation. Interventions included: -Staff were to monitor Resident 47 for constipation. Symptoms to monitor included nausea, vomiting, and abdominal distention. -Provide non-pharmacological interventions. -Provide medications to relieve constipation. Resident 47's 7/2024 and 8/2024 Documentation Survey Report revealed: -7/27/24 day shift Resident 47 had a bowel movement. -7/28/24 no bowel movement. -7/29/24 no bowel movement. -7/30/24 no bowel movement. -7/31/24 no bowel movement. -8/1/24 day shift Resident 47 had a small bowel movement. A 7/2024 MAR revealed on 7/30/24 Resident 47 received Milk of Magnesia (laxative) which was documented as effectiveness "unknown." No additional laxatives were administered. An 8/2024 MAR revealed on 8/1/24 Resident 47 was administered Milk of Magnesia and sennoside (laxative) and the medication was effective. 7/2024 Progress Notes revealed no assessments of the resident's bowel status or abdomen. On 8/28/24 at 9:56 AM Staff 5(CMA) stated every morning she looked at the bowel report. If a resident did not have a bowel movement in two days, on the third day bowel care was provided. If a resident refused a medication the nurse was notified. On 8/28/24 at 10:11 AM Staff 2 (DNS) stated if a resident was constipated and a medication was not effective, additional interventions should be provided and documented in the progress notes. Staff 2 acknowledged there were no assessments in the progress notes and staff did not provide additional interventions prior to 8/1/24. b. Resident 47's 7/2024 and 8/2024 MARs revealed she/he was to be administered hydromorphone (narcotic pain medication) every four hours at 1200 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Medications were administered one hour or later on the following dates and times: -7/25/24 12:00 dose -7/27/24 8:00 AM dose -8/3/24 4:00 PM dose -8/4/24 4:00 PM dose -8/8/24 12:00 AM dose -8/9/24 8:00 PM dose -8/13/24 4:00 AM dose -8/15/24 8:00 PM dose -8/17/24 12:00 AM dose -8/20/24 12:00 MA dose -8/25/24 4:00 PM dose On 8/27/24 at 1:25 PM Staff 5 (CMA) stated it was difficult to pass the medications, especially in the morning, to 50 residents. Staff 5 also stated at times it was hard to administer Resident 47 her/his medications at the scheduled times and Resident 47 did not like to wait for her/his medications. On 8/28/24 at 10:25 AM Staff 2 (DNS) acknowledged there were multiple days when Resident 47's medications were administered more than one hour after the scheduled time. , 3. Resident 43 admitted to the facility in 2/2024 with diagnoses including alcohol use. A 6/1/24 Quarterly MDS indicated Resident 43 had moderate cognitive impairment. A review of a 7/30/24 progress note written at 2:26 PM revealed Resident 43 returned from an outing fatigued with a decreased level of responsiveness, was diaphoretic, had abnormal vitals signs and EMTs were called. A review of a 7/30/24 progress note written at 2:43 PM revealed Resident 43 returned to baseline after the EMTs arrived to the facility and refused to go to the hospital. Resident 43 reported he consumed four beers while out of the facility on an outing. An 8/2/24 public complaint alleged the facility failed to ensure resident safety regarding alcohol consumption during an outing and the facility failed to notify the resident representative in a timely manner regarding the resident's change of condition. An 8/7/24 public complaint alleged the facility failed to ensure the resident's safety during a community outing. An 8/14/24 public compliant alleged the facility failed to ensure a safe environment for the resident while on an outing with staff. An investigation dated 8/16/24 revealed two staff members, Staff 26 (Staffing Coordinator) and Staff 25 (HR), took Resident 43 to the river to go rock hunting. Orders were received for Resident 43 to have 12 ounces of beer while on the outing. Upon arrival to the river, Staff 26 gave one 12-ounce can of beer that she/he spilled; Resident 43 drank half to three quarters of this beer before it was spilled. Staff 26 gave another 12-ounce beer to Resident 43. Staff 26 and Staff 25 were in the river rock hunting, and Resident 43 was on the riverbank with Staff 25's son. Staff 25's son obtained the rest of the beers from the vehicle per Resident 43's request. Staff 26 and Staff 25 stated they were unaware Resident 43 drank more beers than beers Staff 26 gave to her/him. Resident 43 stated he drank three and a half 12-ounce beers in total. Upon return to the facility Staff 26 and Staff 25 stated Resident 43's nurse was not notified of her/his consumption of more than the 12-ounces of beer allowed by the physician order. Resident 43 went back to her/his room, staff noticed her/his change of condition and called EMTs. Resident 43 was back to baseline when the EMTs arrived and she/he declined to go to the hospital. On 8/29/24 at 11:53 AM Staff 25 stated Resident 43 asked her a week before they went to the river to go rock hunting she/he wanted a beer. Orders for the beer were obtained by Staff 2 (DNS). Staff 25 stated when they arrived at the river Resident 43 was given a beer which spilled and Staff 26 gave her/him another one. Staff 25 stated she and Staff 26 went into the river to rock hunt and Resident 43 stayed on the riverbank. Staff 25 stated she and Staff 26 were supervising Resident 43, but she was unaware Resident 43 drank more than the beer Staff 26 gave her/him and she was unaware of her son getting the rest of the beers and bringing them down to the river. Staff 25 stated her son was unaware of how many beers Resident 43 could drink. Staff 25 stated they became aware how many beers were consumed when they were cleaning up and heading back to the facility. Staff 25 stated Resident 43 drank 2 to 3 beers but she was unsure. Staff 25 stated Staff 26 brought Resident 43 into the facility. Staff 25 stated she did not inform anyone how many beers Resident 43 drank. On 8/28/24 at 12:07 PM Staff 26 stated she verified the order with Resident 43's provider prior to the outing at the river. Staff 26 stated the provider stated she gave orders for Resident 43 to have 12 ounces of beer. Staff 26 stated she and Staff 25 were supervising Resident 43 but she was unaware Resident 43 consumed more beers than what she provided to her/him. Staff 26 stated she was unaware how many beers Resident 43 consumed but thought she/he had two 12-ounce beers and maybe a sip of another can. Staff 26 stated she brought Resident 43 back into the facility after the outing and informed the nurse Resident 43 needed a change of clothes, a shower and a nap. Staff 26 stated she did not inform the nurse how many beers Resident 43 consumed. On 8/29/24 at 12:16 PM Staff 2 stated she received orders for Resident 43 to consume 12 ounces of beer on the outing to the river, and both Staff 26 and Staff 25 were aware of the order. Staff 2 stated Staff 25's son gave Resident 43 more beers and Resident 43 consumed three and a half 12-ounce cans of beer. Staff 2 stated Staff 26 and Staff 25 did not inform anyone how many beers Resident 43 consumed upon return to the facility. Staff 2 confirmed Resident 43's physician orders were not followed. Resident 43 should have had no more than one 12-ounce can of beer and Staff 26 and Staff 25 should have informed Resident 43's nurse how many beers Resident 43 consumed so the nurse could inform the provider. , 4. Resident 14 admitted to the facility 2/2022 with diagnoses including chronic obstructive pulmonary disease. A review of a nursing Progress Note dated 4/11/24 at 7:56 PM revealed Staff 10 (LPN) noted a discrepancy in the Medication Administration Record and the Narcotics Log and said she believed the resident was given oxycodone instead of methadone for pain that morning. A review of the Medication Error report completed by Staff 10 on 4/11/24 revealed Staff 12 administered oxycodone to Resident 14 during the morning medication pass instead of methadone. Staff 12 correctly completed the Narcotics Log for oxycodone but entered methadone in the Medication Administration Report. On 8/29/24 at 1:04 PM Staff 11 (CMA) stated she noted the discrepancy in the Narcotics Log while administering methadone to Resident 14 during her afternoon medication pass on 4/11/24, and reported the discrepancy to Staff 10. On 8/29/24 at 1:17 PM Staff 12 (CMA) stated she did not recall administering the wrong medication to Resident 14 on 4/11/24. On 8/29/24 at 3:47 PM Staff 10 stated Staff 11 alerted her of the discrepancy in the Medication Administration Record the afternoon of 4/11/24, and informed her Resident 14 was likely administered oxycodone instead of methadone during morning medication pass. Staff 10 stated Resident 14 had no adverse side effects from receiving oxycodone. On 8/29/24 at 3:53 PM Staff 2 (DNS) stated she was aware of the medication error on 4/11/24 regarding Resident 14. Staff 2 stated she expected staff to ensure they followed physician orders and verify residents received the correct medications. , 5. Resident 4 admitted to the facility in 5/2023 with diagnoses including a brain tumor and epilepsy (a seizure disorder). A review of Resident 4's 8/28/24 Medication Admin Audit Report revealed the following: -Staff were to administer levothyroxine sodium (endocrine medication) at 7:00 AM, but the levothyroxine was not administered until 8:45 AM (one hour and 45 minutes late). -Staff were to administer apixaban (blood thinner) at 10:00 AM, but the apixaban was not administered until 11:42 AM (one hour 42 minutes late). -Staff were to administer lacosamide (anti-seizure medication) at 10:00 AM, but the lacosamide was not administered until 11:41 AM (one hour and 41 minutes late). -Staff were to administer baclofen (muscle spasm medication) at 10:00 AM, but the baclofen was not administered until 11:42 AM (one hour and 42 minutes late). -Staff were to administer levetiracetam (anti-seizure medication) at 10:00 AM, but the levetiracetam was not administered until 11:42 AM (one hour and 42 minutes late). -Staff were to administer pregabalin (nerve pain medication) at 10:00 AM, but the pregabalin was not administered until 11:41 AM (one hour and 41 minutes late). On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift. 6. Resident 8 admitted to the facility in 7/2024 with diagnoses including stroke and chronic obstructive pulmonary disease. A review of Resident 8's 8/28/24 Medication Admin Audit Report revealed the following: -Staff were to administer acetaminophen (pain medication) at 8:00 AM, but the acetaminophen was not administered until 11:17 AM (three hours and 17 minutes late). On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift. 7. Resident 13 admitted to the facility in 6/2024 with diagnoses including chronic obstructive pulmonary disease and arthritis. A review of Resident 13's 8/28/24 Medication Admin Audit Report revealed the following: -Staff were to administer metoprolol tartrate (blood pressure medication) at 8:00 AM, but the metoprolol tartrate was not administered until 11:19 AM (3 hours and 19 minutes late). -Staff were to administer Oxycodone HCL (opioid pain medication) at 8:00 AM, but the Oxycodone HCL was not administered. This medication was scheduled every four hours and the last dose was administered at 4:00 AM on 8/28/24. -Staff were to administer gabapentin (nerve pain medication) at 8:00 AM, but the gabapentin was not administered. This medication was scheduled for every eight hours. On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were two medications not given (Oxycodone and gabapentin), and multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift. 8. Resident 41 admitted to the facility in 2/2024 with diagnoses including diabetes and chronic kidney disease. An 8/28/24 Medication Admin Audit Report of Resident 41's AM medication administration revealed the following: -Staff were to administer metformin HCL (diabetic medication) at 8:00 AM, but the metformin HCL was not administered until 11:35 AM (three hours and 35 minutes late). On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift. 9. Resident 203 admitted to the facility in 5/2024 with diagnoses including sepsis (severe infection) and chronic pain syndrome. An 8/28/24 Medication Admin Audit Report of Resident 203's AM medication administration revealed the following: -Staff were to administer gabapentin (nerve pain medication) at 8:00 AM, but the gabapentin was not administered until 9:38 AM (one hour and 38 minutes late). -Staff were to administer apixaban (blood thinner) at 8:00 AM, but the apixaban was not administered until 9:37 AM (one hour and 37 minutes late). -Staff were to administer acetaminophen (pain medication) at 8:00 AM, but the acetaminophen was not administered until 9:37 AM (one hour and 37 minutes late). -Staff were to administer Oxycontin (opioid pain medication) at 8:00 AM, but the Oxycontin was not administered until 9:38 AM (one hour and 38 minutes late). This medication was scheduled for every 8 hours. On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift.

Resident Cited Resident # 2 remains in facility. Bed canes were placed on residents bed. Resident #47 no longer resides in facility. Resident #43 remains in facility. MD was notified of resident drinking more than the prescribed amount of beer. Resident is at baseline medically and cognitively. Resident #14 remains in facility. MD was notified of resident receiving oxycodone instead of scheduled Methadone on 4/11/24. Resident assessed and has had no adverse effects from medication error. Resident # 4 remains in facility. MD notified of resident receiving medications late. No adverse effects noted from late medication administration. Resident # 8 remains in facility. MD was notified of medications that were received late. No adverse effects noted form late medication administration. Resident #13 remains in facility. MD was notified of medications that were not administered and medication that were received late on 8/28/24. No adverse effects noted. Resident #41 remains in the facility. MD was notified of medications that were received late on 8/28/24. No adverse effects noted from late medication administration. Resident #203 remains in the facility. MD was notified of medications that were received late on 8/28/24. Resident has had no adverse effects noted from late medication administration. Residents at Risk House-wide audit for the past 2 weeks to be completed to determine residents who had MD orders that werent followed and medications that were given late. MD to be notified as applicable for MD orders not followed. Education LNs and CMAs re-education to be completed regarding following doctors orders and administering medications timely. Audits To ensure ongoing compliance DNS/designee will conduct audits of MD orders on select number of residents to ensure MD orders were followed and meds administered timely weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation, interview, and record review it was determined the facility failed to assist residents to obtain prescription glasses for 2 of 2 sampled residents (#s 3 and 18) reviewed for vision. This placed residents at risk for impaired vision. Findings include: 1. Resident 18 admitted to the facility in 10/2018 with bowel and stomach dysfunction. A 6/13/24 Eye Exam Summary revealed Resident 18 reported blurred distant vision and a new prescription was provided. A 7/15/24 quarterly MDS revealed Resident 18 was cognitively intact. On 8/26/24 at 4:12 PM Resident 18 stated she/he had a vision appointment, was to get new glasses, but never received her/his glasses. On 8/28/24 at 12:22 PM and 3:16 PM Staff 4 (Social Services) and Staff 20 (Social Services Coordinator) stated Resident 18 just had her/his eyes examined and they did not have the after visit summary. If Resident 18 required new glasses the facility would assist the resident to obtain new glasses. Staff 4 and Staff 20 stated they did not know a new prescription was written. , 2. Resident 3 admitted to the facility in 3/2023 with diagnoses including diabetes. Progress Notes on 7/27/24 at 6:03 PM revealed Resident 3 inquired about the status of her/his prescription glasses. A review of Resident 3's clinical record revealed no evidence staff followed up on her/his prescription glasses. In an interview on 8/26/24 at 3:51 PM Resident 3 stated she/he saw an ophthalmologist about six weeks ago and was prescribed prescription glasses. Resident 3 said she/he was told it would take about three weeks to receive the glasses, but she/he had still not received them. In an interview on 8/28/24 at 3:20 PM Staff 4 (Social Services Director) and Staff 13 (Social Services Coordinator) stated they were aware Resident 3 had an appointment with the ophthalmologist. Staff 4 provided a copy of the invoice for Resident 3's prescription glasses dated 6/13/24. Staff 4 said the glasses had to be ordered through the insurance provider and said she would be meeting with Resident 3 to complete the order.

Residents Cited Resident # 18 remains in the facility. Glasses to be obtained as prescribed. Resident # 3 remains in facility. Glasses to be obtained as prescribed. Residents at Risk House-wide audit of residents who have had an eye exam in the last 30 days will be completed to ensure that glasses are ordered and received as ordered by the provider. Education Education to be completed with Social Services in regards to ensuring that all follow up is completed after Eye exams for residents including obtaining glasses as ordered. Audits To ensure ongoing compliance, Social services/designee will conduct audits of all residents who received eye exams weekly x 4 weeks and monthly x 2 months to ensure follow up was completed and glasses ordered/received as applicable. Results of audits will be brought to QAPI for review.

Based observation, interview, and record review it was determined the facility failed to prevent pressure ulcers for 1 of 4 sampled residents (#47) reviewed for pressure ulcers. This placed residents at risk for skin injury. Findings include: Resident 47 admitted to the facility in 7/2024 with a diagnosis of paralysis after spinal surgery. A 7/25/24 Admission Nursing Datbase (sic.) revealed Resident 47 did not have a pressure ulcer. A care plan was initiated on 7/26/24 indicating Resident 47 was at risk for pressure ulcers. Interventions included staff were to educate the resident and family on the requirements for positioning. 7/2024 and 8/2024 Progress Notes revealed the following: -7/26/24 Resident 47 was assisted to turn from side to side. The note did not indicate the frequency of turns. -7/27/24 no education was provided. -7/28/24 Resident 47 was assisted with bed mobility. The note did not indicate the frequency of bed mobility. -7/29/24 Resident 47 reported back incision pain and did not want to move any more than necessary. No education was provided. -7/30/24 Resident 47 was assisted to turn from side to side. The note did not indicate the frequency of turns. -7/31/24 no education was provided. -8/1/24 Resident 47 was assisted to turn from side to side. The note did not indicate the frequency of turns. -8/2/24 Resident 47 was assisted to turn from side to side. The note did not indicate the frequency of turns. -8/3/24 Resident 47 was assessed to have an open area less than a dime size on her/his sacrum. There was no additional description of the wound. Orders for wound care and an air mattress were requested. An 8/5/24 Skin Evaluation Form revealed on 8/3/24 Resident 47 was identified to have a deep tissue injury (no open area but the tissue beneath the surface was damaged; the area may be dark purple or red and could be caused by prolonged pressure and or shearing). An 8/5/24 Skin Tear/Bruise/Abrasion/Other Skin Impairment form revealed on 8/3/24 a nurse identified skin impairment to Resident 47's coccyx/sacral area. The Resident Care Manager assessed the wound to be a deep tissue injury with a moisture component observed to the center area of the ulcer. On 8/27/24 at 1:17 PM Staff 21 (CNA) stated Resident 47 was not able to turn independently and at times refused to be turned, especially on night shift. On 8/27/24 at 6:01 PM Witness 2 (Spouse) stated she/he often stayed at the facility for up to nine hours because she/he was from out of town. Witness 2 stated during her/his extended visits she did not observe staff to turn Resident 47 every two hours. On 8/28/24 at 3:10 PM Staff 11 (CMA) stated Resident 47 reported she/he was often not assisted to be turned every two hours. On 8/28/24 at 2:59 PM Staff 22 (LPN) stated Resident 47 was usually compliant with care but did not always stay on her/his side when turned. If education was provided to the resident it would be documented in the progress notes. On 8/28/24 at 11:06 AM Staff 3 (RNCM) stated when Resident 47 was first admitted to the facility the resident did not like to be turned and often was on her/his back. Staff placed pillows on each side of the resident but her/his coccyx was still on the bed. Staff 3 also stated Resident 47 liked to keep her/his head of bed elevated which placed additional pressure on her/his coccyx region. Staff 3 stated when the ulcer was first identified it was light purple with no open area. A request was made to provide documentation Resident 47 was provided risks of not turning prior to the development of a pressure ulcer. No additional information was provided On 8/29/24 at 10:26 AM Staff 6 (CNA) stated it was standard of care to turn a resident every two hours, but in reality, turning a resident every two hours could not be completed due to lack of time.

Resident Cited Resident #47 no longer resides in facility. Residents at Risk House-wide audit completed to identify residents who need assistance with bed mobility to ensure that careplans are in place with interventions to prevent pressure ulcers. Residents that do not allow repositioning per standard of care will be educated on the risks of not repositioning and this will be documented in medical record. Education Staff re-education to be completed regarding repositioning residents per protocol and documenting any refusals/education provided to resident/family. Audits To ensure ongoing compliance, DNS/designee will conduct audits of a sample of residents who require assistance with bed mobility to ensure that careplan interventions are in place, staff are completing repositioning per protocol, and refusals are documented and education is provided and documented weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation, interview, and record review it was determined the facility failed to provide a splint for 1 of 2 sampled residents (#2) reviewed for mobility. This placed residents at risk for worsening contractures. Findings include: Resident 2 admitted to the facility in 3/2010 with a diagnosis of cancer. Occupational Therapy Treatment Encounter Note dated 5/9/24 revealed staff obtained measurements for Resident 2's right finger splint to treat a contracture. An Occupational Therapy Discharge Summary form dated 6/27/24 revealed Resident 2 tolerated the right finger splint for approximately one hour. A care plan last revised on 7/5/24 did not include Resident 2 required a right finger splint. A 7/24/24 physician appointment note revealed Resident 2 was seen for right finger swelling and redness. The note indicated Resident 2 had a right finger contracture and a hand therapy referral for a finger splint was made. On 8/26/24 at 2:46 PM Witness 1 (Family) stated Resident 2 was not able to straighten her/his finger, needed a splint, but did not have one. On 8/27/24 at 1:59 PM Resident 2 was observed without a finger splint. On 8/29/24 at 12:21 PM Staff 4 (Social Services) stated she made appointments for referrals to outside providers. Staff stated she was not aware of the need for a hand therapist or splint. On 8/29/24 at 12:39 PM Staff 15 (Therapy Director) stated Resident 2 had an assessment for a contracture of the right finger and a splint was ordered. In 6/2024 at the end of therapy, Resident 2 was documented to tolerate one hour of splint use. On 8/29/24 at 12:47 PM Staff 23 (CNA) stated if a resident was to wear a splint it was on the care plan. Staff 23 stated she was familiar with Resident 23 and she/he did not have a splint. On 8/29/24 at 12:50 PM Staff 5 (CMA) stated she never saw Resident 2 wear a finger splint. On 8/29/24 at 12:56 PM Staff 24 (CNA) stated she never applied a splint to Resident 2's finger. On 8/29/24 at 1:22 PM Staff 3 (RNCM) stated Resident 2 should have a splint in her/his room because Staff 3 helped order one. Staff 3 acknowledged the splint was not on Resident 2's care plan.

Resident Cited Resident # 2 still remains in facility. Splint will be reorderd for resident. Careplan to be updated to reflect splint use and timeframe to be worn as recommended by therapy. Resident at Risk House-wide audit of residents with contractures who require splints to be completed to ensure that careplans are in place, splints obtained, and properly applied per recommendations. Education Staff re-education to be completed with nurse management to ensure that all residents who are identified as requiring splints to treat contractures have careplans in place and splints obtained. Staff education to be completed with nursing staff to ensure that all residents who have careplans in place for splints are worn per recommendations. Audits To ensure ongoing compliance, DNS/designee will conduct audits of all residents with contractures who require splints weekly x 4 weeks, monthly x 2 months to ensure careplans are in place and splints applied appropriately. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to provide supervision during an outing involving alcohol for 1 of 1 sampled resident (#43) reviewed for change of condition. This placed residents at risk for accidents. Findings include: Resident 43 admitted to the facility in 2/2024 with diagnoses including alcohol use. A 6/1/24 Quarterly MDS indicated Resident 43 had moderate cognitive impairment. A review of a 7/30/24 progress note written at 2:26 PM revealed Resident 43 returned from an outing fatigued with a decreased level of responsiveness, was diaphoretic, had abnormal vitals signs and EMTs were called. A review of a 7/30/24 progress note written at 2:43 PM revealed Resident 43 returned to baseline after the EMTs arrived to the facility and refused to go to the hospital. Resident 43 reported he consumed four beers while out of the facility on an outing. An 8/2/24 public complaint alleged the facility failed to ensure resident safety regarding alcohol consumption during an outing and the facility failed to notify the resident representative in a timely manner regarding the resident's change of condition. An 8/7/24 public complaint alleged the facility failed to ensure the resident's safety during a community outing. An 8/14/24 public compliant alleged the facility failed to ensure a safe environment for the resident while on an outing with staff. An investigation dated 8/16/24 revealed two staff members, Staff 26 (Staffing Coordinator) and Staff 25 (HR), took Resident 43 to the river to go rock hunting. Orders were received for Resident 43 to have up to 12 ounces of beer while on the outing. Upon arrival to the river, Staff 26 gave one 12-ounce can of beer that she/he spilled; Resident 43 drank half to three quarters of this beer before it was spilled. Staff 26 gave another 12-ounce beer to Resident 43. Staff 26 and Staff 25 were in the river rock hunting and Resident 43 was on the riverbank with Staff 25's son. Staff 25's son obtained the rest of the beers in the vehicle per Resident 43's request. Staff 26 and Staff 25 stated they were unaware Resident 43 drank more beers than what Staff 26 gave to her/him. Resident 43 stated he drank three and a half 12-ounce beers in total. Upon return to the facility Staff 26 and Staff 25 stated Resident 43's nurse was not notified of her/his consumption of more than the physician ordered limit of 12-ounces of beer. Resident 43 went back to her/his room, staff noticed her/his change of condition and called the EMTs. Resident 43 was back to baseline when the EMTs arrived and she/he declined to go to the hospital. On 8/29/24 at 11:53 AM Staff 25 stated Resident 43 asked her a week before they went to the river to go rock hunting she/he wanted a beer. Orders for the beer were obtained by Staff 2 (DNS). Staff 25 stated when they arrived at the river Resident 43 was given a beer, which spilled, and Staff 26 gave her/him another one. Staff 25 stated she and Staff 26 went into the river to rock hunt and Resident 43 stayed on the riverbank. Staff 25 stated she and Staff 26 were supervising Resident 43, but she was unaware Resident 43 drank more than the beer Staff 26 gave her/him, and she was unaware her son brought the rest of the beers down to the river. Staff 25 stated her son was unaware how many beers Resident 43 could drink. Staff 25 stated they became aware of how many beers were consumed when they were cleaning up and heading back to the facility. Staff 25 stated Resident 43 consumed 2 to 3 beers, but she was unsure. Staff 25 stated Staff 26 brought Resident 43 into the facility. Staff 25 stated she did not inform anyone how many beers Resident 43 drank. On 8/28/24 at 12:07 PM Staff 26 stated she verified the order with Resident 43's provider prior to the outing at the river. Staff 26 stated the provider ordered for Resident 43 to have no more than 12 ounces of beer. Staff 26 stated she and Staff 25 were supervising Resident 43, but she was unaware Resident 43 consumed more beers than what was provided. Staff 26 stated she was unaware how many beers Resident 43 drank, but thought she/he had two 12-ounce beers and maybe a sip of another can. Staff 26 stated she brought Resident 43 back into the facility after the outing and informed the nurse Resident 43 would need a change of clothes, a shower, and a nap. Staff 26 stated she did not inform the nurse how many beers Resident 43 consumed. On 8/29/24 at 12:16 PM Staff 2 stated she received orders for Resident 43 to consume up to 12 ounces of beer on the outing to the river and both Staff 26 and Staff 25 were aware of the order. Staff 2 stated Staff 25's son gave Resident 43 more beers and Resident 43 consumed three and a half 12-ounce cans of beer. Staff 2 stated Staff 26 and Staff 25 did not inform anyone of how many beers Resident 43 consumed upon return to the facility. Staff 2 confirmed Resident 43 was supposed to have been supervised by Staff 26 and Staff 25, but they were unaware of how many beers Resident 43 drank.

Resident Cited Resident #43 remains in facility. MD was notified of resident drinking more than the prescribed amount of beer while on outing. Resident is at baseline. Residents at Risk House wide audit of all current residents to identify any other residents with orders for alcohol. Any concerns to be addressed as needed. Education Staff re-education has been completed regarding ensuring residents are being supervised appropriately while out of facility with staff to ensure MD orders are followed. Audits To ensure ongoing compliance, DNS/designee will conduct audits of residents who went out of facility with orders for alcohol to ensure that residents were appropriately supervised and MD orders followed weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than five percent. There were 2 errors in 39 opportunities resulting in a 5.13 percent error rate. This placed residents at risk for adverse medication side effects. Findings include: Resident 301 admitted to the facility in 8/2024 with diagnoses including chronic pancreatitis (difficulty with food digestion) and chronic obstructive pulmonary disease. Resident 310's 8/2024 Physician Orders included the following: - Creon Oral Capsule Delayed Release (releases food digesting enzymes) 6000-19000 unit, administer three times a day with meals at 8:00 AM, 12:00 PM, and 5:30 PM. - Advair Diskus Inhalation Aerosol Powder Breath Activated (prevents shortness of breath) 250-50mcg/act, administer twice a day at 8:00 AM and 5:00 PM. Resident 301 was to rinse mouth and spit after inhalation to prevent oral thrush. On 8/28/24 from 9:23 AM to 9:38 AM Staff 5 (CMA/CNA) administered Resident 301's medications after breakfast which included Creon and Advair Diskus Inhalation. During the medication administration observation Staff 5 did not have Resident 301 rinse her/his mouth and spit out the liquid. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated she expected staff to administer medications per physician order and at the physician ordered time. On 8/28/24 at 12:53 PM Staff 5 stated the Creon was not administered at the provider ordered time of 8:00 AM, and Resident 301 did not rinse and spit after her/his Advair Diskus inhalation.

Resident Cited Resident #301 no longer resides in facility. Residents at Risk House wide audit of all residents to ensure those who have orders for inhalers and medications to be given with meals are appropriately timed in EMAR and special instructions to rinse mouth attached. Education Staff re-education to be completed with Nurses and Med aides to ensure that they are administering medication with meals as ordered and that residents are being prompted to rinse mouth after use of inhalers. Audits To ensure ongoing compliance, DNS/designee will conduct audits of medication pass on a random sample of residents with orders for inhalers/medications with meals to ensure they are given appropriately and residents prompted to rinse mouth after use of inhaler. These audits will be completed weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation, interview and record review it was determined the facility failed to ensure proper storage and labeling of medication and biologicals for 1 of 2 treatment carts and 1 of 1 medication and biologicals refrigerator reviewed for biologicals and medication storage. This placed residents at risk for reduced efficacy of medication, inaccurate tuberculosis testing, and decreased vaccine efficacy. Findings include: During an audit of the South Hall treatment cart with Staff 8 (RN) on 8/28/24 at 3:50 PM, an open vial of Insulin Glargine dated 7/26/24 was observed in the cart. Staff 8 examined the vial and confirmed the date on the vial was over 28 days and it should have been discarded. While conducting an audit of the medication and biologicals refrigerator on 8/29/24 at 11:14 AM with Staff 9 (LPN) an open and undated multi-dose vial of tuberculin solution (a solution used in testing for Tuberculosis), and multiple closed vials of Spikevax (COVID - 19 vaccine) with an expiration date of 7/18/24 were found in a basket on a shelf. Staff 9 verified there was no open date on the tuberculin and placed it in the sharps container (plastic container designed to safely hold needles and other sharps). Staff 9 verified the vials of Spikevax were expired and stated the facility was waiting for the pharmacy to exchange them for viable vaccines. The tuberculin manufacturer package insert, revised 6/2010, indicated the tuberculin vial was to be discarded 30 days after opening. On 8/29/24 at 2:11 PM Staff 3 (RNCM) stated the expectation was for all medications to have an open date, the insulin and tuberculin to be put in the sharps container when expired, and for the Spikevax vaccines to be labeled as do not use and returned to the pharmacy.

Resident Cited No specific resident was cited. Expired SpikeVax vaccines were discarded. TB solution that was expired with no open date was discarded and Insulin Glargine vial that was discovered and expired was discarded. Residents at Risk House wide audit of all injectable medications audited to ensure none are expired and all have open dates on the vial. Education Staff re-education to be completed with nursing staff regarding ensuring that all injectable medications are not expired and open dates are written on vials when being opened. Audits To ensure ongoing compliance, DNS/designee to conduct audits of all injectable medications to ensure that all have open dates and that none are expired weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure a resident understood an arbitration agreement for 1 of 3 sampled residents (#47) reviewed for arbitration. This placed residents at risk for loss of legal rights. Findings include: Resident 47 admitted to the facility in 7/2024 with a diagnosis of diabetes. A 7/31/24 admission MDS revealed Resident 47 was cognitively intact. A Patient and Facility Arbitration Agreement revealed Resident 47 signed the agreement on 7/25/24. On 8/28/24 at 3:29 PM Resident 47 stated she/he did not recall signing anything regarding an arbitration agreement. The resident stated she/he "was so drugged up" and no one followed up with her/him regarding an arbitration agreement. On 8/29/24 at 10:43 AM Staff 3 (Social Service Director) stated she was responsible for all admission paperwork, including arbitration agreements. Staff 3 stated she explained the arbitration agreement, it's meaning, and the option to sign the arbitration agreement or not. Staff 3 stated she did not follow up with residents after they signed the arbitration agreement, considering it a one-time task. Staff 3 acknowledged she did not follow up with Resident 47 regarding the arbitration agreement.

Resident Cited Resident #47 no longer resides in this facility. Residents at Risk House-wide audits of residents who admitted in the last 30 days and signed the arbitration agreement completed to ensure that residents understood the arbitration agreement and documentation completed in the medical record. Education Staff reeducation to be completed with Social Services to ensure that they explain the arbitration agreement to residents before signing and ensure that resident understands what they are signing and documentation to be completed in the medical record. Audits To ensure ongoing compliance, DNS/designee to be completed to ensure that residents that were admitted and the arbitration agreement signed understood the agreement they signed and that resident understanding is documented in the medical record weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation and interview it was determined the facility's Qualified Entity Designee (certification to review and access staff criminal background information) was not current for 1 of 1 facility reviewed for criminal background checks. Findings include: On 8/28/24 at 3:30 PM Staff 25 (Human Resources) was observed to access the state data base for criminal background information. On 8/28/24 at 3:30 PM a request was made for Staff 25 to provide her QED certificate. Staff stated her certification ended in 2020.

Resident Cited No specific resident cited. Residents at Risk All residents are at potential risk for this deficient practice. HR background certification has been renewed. Education Education completed with staff responsible for background checks educated on keeping certification up to date. Audits To ensure ongoing compliance, DNS/designee will conduct audits of background check certifications monthly x 3 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing requirements were met for 20 of 56 days reviewed. This placed residents at risk for unmet care needs. Findings include: Review of Staff Care Daily Reports from 7/12/24 through 8/26/24 revealed the following days where minimum CNA staffing requirements were not met on one or more shifts: -7/4/24 night shift. -7/5/24 night shift. -7/13/24 day shift. -7/16/24 evening shift. -7/19/24 evening shift. -7/20/24 evening shift. -7/25/24 evening shift. -7/28/24 day and evening shift. -7/29/24 day shift. -7/30/24 evening shift. -7/31/24 night shift. -8/3/24 day and evening shift. -8/9/24 day shift. -8/10/24 evening shift. -8/11/24 evening shift. -8/12/24 evening shift. -8/20/24 evening shift. -8/22/24 day and evening shift. -8/24/24 evening and night shift. -8/25/24 day, evening , and night shift. On 8/29/24 at 1:07 PM Staff 2 (DNS) verified the above dates the facility was not staffed to meet minimum CNA staffing requirements.

Resident Cited No specific resident cited. Residents at Risk House-wide interviews completed with residents to ensure their needs are being met and concerns addressed as needed. Education Staff education with staffing coordinator to ensure that ratio is met for all shifts. Audits To ensure ongoing compliance, DNS/designee will conduct audits of staffing levels to ensure minimum ratio was met weekly x 4 months, monthly x 2 months. Results of audits will be brought to QAPI for review.

OAR 411-085-0310 Resident Rights: Generally

Refer to F550, F552, F583 and F585 **************************************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 **************************************** OAR 411-088-0050 Right to Return from Hospital Refer to F625 *************************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F660 **************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684, F685 and F759 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686, F688 and F689 **************************************** OAR 411-086-0040 Admission of Residents Refer to F655 *************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F761 ************************************ OAR 411-086-0010 Administrator Refer to F847 ************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to ensure residents were free from verbal abuse for 2 of 3 sampled residents (#s 4 and 5) reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. Resident 4 was admitted to the facility in 2020 with diagnoses including stroke. An 8/19/23 FRI indicated on 8/18/23 Resident 4 and Resident 5 were in the dining room having a conversation. Resident 5 suddenly started yelling at Resident 4, and called her/him and "asshole" and "mother fucker." Staff 11 (CNA) and Staff 12 (CNA) witnessed the incident and attempted to redirect Resident 5 but had a difficult time calming her/him down. An 8/19/23 Incident Investigation revealed Resident 4 and Resident 5 were in the dining room for dinner on 8/18/23 and were having a conversation while waiting for dinner. Resident 5 started to yell at Resident 4 and called her/him an "asshole" and a "mother fucker." The CNA attempted to redirect Resident 5 but had a difficult time calming her/him down. Neither resident wanted to leave the dining room table at which they were both seated. The investigation concluded the verbal resident to resident altercation occurred between Resident 5 to Resident 4. On 9/15/23 at 10:10 AM Staff 12 stated she observed the incident on 8/18/23 and both Resident 4 and Resident 5 were waiting for dinner. Resident 5 became inpatient waiting for her/his meal and called Resident 4 a "mother fucker." Neither resident wanted to move from their table. On 9/15/23 at 10:54 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated verbal abuse by Resident 5 to Resident 4 was substantiated during the facility investigation. 2. Resident 5 admitted to the facility in 2022 with delusional disorders and dementia. An 8/30/23 Incident Investigation revealed Resident 7 and Resident 5 were sitting in the dining room and Resident 5 was joking with a CNA. The CNA stated to Resident 7 "what are you looking at?" and in a joking tone Resident 7 stated "I am looking at you." Resident 5 thought Resident 7 was looking at her/him and stated, "Why are you looking at me?" Resident 7 stated "[Resident 5] if you don't shut the fuck up, I'm going to beat you up." A CNA intervened immediately and was able to redirect Resident 5 away from the table. The facility substantiated the verbal altercation between Resident 7 to Resident 5. An 8/31/23 FRI revealed Resident 7 told Resident 5 she/he was going to beat her/him up if she/he did not "shut the fuck up." Resident 5 was upset after the incident and told staff that Resident 7 hurt her/his feelings. On 9/13/23 at 10:50 AM Staff 6 (CNA) stated she was in the dining room on 8/30/23 and Resident 7 and Resident 5 were sitting by each other. Resident 7 was chatting and then she/he became upset and told Resident 5 she/he was going to beat her/him up. On 9/15/23 at 10:06 AM Resident 7 stated nothing happened between Resident 5 and her/him. Resident 5 and Resident 7 got in a "bit" of an argument and Resident 5 had an attitude. On 9/15/23 at 10:55 AM Staff 2 (DNS) and Staff 24 (LPN-RCM) stated verbal abuse by Resident 7 to Resident 5 was substantiated during the facility investigation.

Resident Cited Resident #4 - Resident was assessed for s/sx of psychological distress and none was found. Resident stated he feels safe at the facility. Resident #5 - this resident is no longer in the facility. Resident #7 - Resident's care plan updated to reflect redirecting resident when agitated. Resident was assessed for s/sx of psychological distress, and none was found. Resident stated he feels safe at the facility. Residents at Risk Residents who reside in the facility are at potential risk for this deficient practice. Resident interviews to determine if there are any resident-to-resident conflicts that need to be investigated. Education Staff education completed regarding resident-to-resident altercations and strategies to prevent an altercation when possible. Audits To ensure ongoing compliance, DNS/designee will perform resident interviews weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 3 sampled residents (#s 3, 5 and 6) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: 1. Resident 3 admitted to the facility on 6/12/23 with diagnoses including chronic pain. A 6/18/23 Admission MDS indicated Resident 3's BIMS score was 13 indicating she/he was cognitively intact. Resident 3 required one-person physical assist with showers. A 6/2023 Documentation Survey Report indicated from 6/14/23 through 6/30/23 the following: -Page 12 ADL-Bathing Shower Sunday and Wednesday evenings: NA (Not applicable) was documented five times. 6/14/23, 6/18/23, 6/21/23, 6/25/23 and 6/28/23. -Page 16 ADL-Bathing Shower Sunday and Wednesday evenings; RR (resident refused) was documented on 6/18/23 and 6/21/23, no documentation on 6/25/23, and it was documented Resident 3 had a shower on 6/28/23 (18 days without bathing). A 6/19/23 Health Status Note indicated Resident 3 refused a shower on 6/18/23 and requested a sponge bath on 6/19/23. Resident 3 was added to the day shift shower list. No documentation was found in clinical records Resident 3 received a sponge bath on 6/19/23. A 6/23/23 Health Status Note indicated Resident 3 refused a shower on 6/22/23 and stated she/he took one on 6/21/23. Resident 3 was added to the shower list. A public complaint was received on 7/20/23 which indicated staff reported Resident 3 got bathed twice per week, but in actuality was only occasionally bathed once per week. On 9/12/23 at 8:13 AM Resident 3 stated she/he wanted to take a shower and the staff refused to provide one. The staff told her/him they would only provide bathing two times a week and that was it. Resident 3 did not remember refusing any type of bathing while she/he was at the facility. On 9/15/23 at 10:39 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated they were unsure why staff kept documenting "NA" on charting when showers should occur. 2. Resident 5 admitted to the facility in 2022 with delusional disorders and dementia. An 4/5/23 Annual MDS revealed Resident 5's BIMS score was seven, which indicated severe cognitive impact. Resident 5 required physical assistance by one person for bathing. 8/2023 and 9/2023 Documentation Survey Reports revealed from 8/25/23 until 9/13/23 Resident 5 did not receive any type of bathing. It was documented on 8/28/23, 8/31/23 and 9/4/23 the bathing activity did not occur. On 9/7/23 no documentation was completed (20 days without bathing). An 8/31/23 Administration Note indicated Resident 5 refused her/his shower. On 9/15/23 at 11:01 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated staff should document refusals and the facility policy was for residents to receive bathing two times a week. 3. Resident 6 was admitted to the facility in 2023 with diagnoses including paraplegia and anxiety disorder. An 8/8/23 care plan indicated Resident 6 had ADL self-care performance deficit and required two person assistance with a mechanical lift for transfers. An 8/9/23 Admission MDS revealed Resident 6's BIMS score was 15 which indicated she/he was cognitively intact and she/he required extensive two-person physical assist for transfers. An 8/20/23 Health Care Log completed by Witness 3 (Family Member) indicated the following: -8/11/23 Resident 6 called Witness 3 at noon and reported she/he was still in bed waiting for a bed bath. Resident 6 requested to get up, get dressed and transferred to her/his chair. Resident 6 ended up eating lunch in bed and was still in bed at 3:00 PM. -8/15/23 Resident 6 left a phone message for Witness 3 at 1:15 PM and indicated she/he was still in bed. -8/18/23 Resident 6 called Witness 3 and stated it was unlikely she/he would be up and dressed by 1:00 PM. Witness 3 arrived at 11:00 AM, Resident 6 ate breakfast in bed and was still in bed. A public complaint was received on 8/21/23 which indicated Resident 6 was left in bed all morning into the afternoon and no one assisted her/him out of the bed. On 9/11/23 at 11:26 AM Witness 3 stated she had concerns for Resident 6's care from the first day of admission and so she decided to keep a log of what occurred. On 9/13/23 at 9:30 AM Staff 5 (CNA) stated Resident 6 liked to get up in the morning and there were two times in 8/2023 she came onto her shift for evening shift at 2:00 PM and Resident 6 was still in bed. It was the same CNA scheduled on day shift each time and Staff 5 was frustrated as she had to work harder during her shift to get Resident 6 up as well as complete her other tasks. On 9/13/23 at 10:19 AM Staff 16 (CNA) stated there were times she could not transfer Resident 6 out of bed when she/he wanted to get up. Staff 16 stated she believed it happened two times. On 9/15/23 at 11:01 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated it was expected of staff to document resident refusals.

Resident Cited Resident #3 - This resident no longer resides in the facility. Resident #5 - This resident no longer resides in the facility. Resident #6 - This resident no longer resides in the facility. Residents at Risk Residents who reside in the facility are at potential risk for this deficient practice. House-wide audit to ensure residents showers are scheduled correctly in the POC charting for CNA. Education Staff education completed regarding facility policy of residents being offered 2 showers per week and how to correctly chart refusals. Audits To ensure ongoing compliance, DNS/designee will perform audits of showers completed/documentation weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to follow physician's orders for 1 of 3 sampled residents (#6) reviewed for catheter. This placed residents at risk for ineffective treatment of her/his infection. Findings include: When Vancomycin (an antibiotic medication used to treat several bacterial infections) was used in the treatment of infections, drug monitoring (a Vancomycin trough) is required to establish the concentration of medication in the blood just prior to administration of the next dose. This allows for adjustments to the prescribed dosage by the physician or pharmacist. If Vancomycin concentration in the blood is below therapeutic levels, the result is an ineffective treatment of infection with serious potential consequences. If the concentration is above therapeutic levels it can result in Vancomycin toxicity which can lead to serious consequences including acute renal (kidney) failure. Resident 6 was admitted to the facility in 2023 with diagnoses including methicillin resistant staphylococcus aureus (MRSA a bacterium which is resistant to certain antibiotics) infection. a. An 8/8/23 hospital Discharge Orders Report instructed staff to administer Vancomycin oral solution by mouth daily for 15 days. The report also instructed staff to administer IV medication Vancomycin every 12 hours and for the pharmacy to keep trough levels between 15 and 20 and to send the lab results to the physician. An 8/8/23 Pharmacist Communication Pharmacy Monitoring CPA on File Ongoing Vancomycin Monitoring form indicated Resident 6's Vancomycin trough was 16.8 as of 8/8/23. The target goal was ten to 15. The form indicated to continue the current Vancomycin order with the next Vancomycin trough and basic metabolic panel (BMP, a test which measures eight different substances in the blood) was due on 8/11/23 thirty minutes prior to the Vancomycin dose time. An 8/11/23 Internal medicine Nurse Practitioner Progress Notes indicated the plan was to stop antibiotics on 8/23/23, okay to draw Vancomycin trough as "stat" (immediately), and weekly labs as ordered. Resident 6 was placed on IV Vancomycin, oral ciprofloxacin (an antibiotic medication used to treat several bacterial infections) and oral Vancomycin due to her/his history of clostridioides difficile (C. diff., an infection of the large intestine). It was recommended Resident 6 receive daily oral Vancomycin for the duration of her/his systemic antibiotics and to prevent another episode of C-diff. The Nurse Practitioner Progress Notes also indicated "Nursing issues- lab is here. Vancomycin trough was drawn at incorrect time. Need orders clarified for new draw." An 8/15/23 Pharmacist Communication Pharmacy Monitoring CPA on File Ongoing Vancomycin Monitoring form indicated Resident 6's Vancomycin trough was 12.8 as of 8/15/23 at 8:50 AM and the Vancomycin level was drawn late. The form also indicated to continue the Vancomycin order with the next Vancomycin trough and BMP due on 8/17/23 thirty minutes prior to the dose time. On 8/18/23 faxes from the pharmacy indicated the following: -2:03 PM the pharmacy was refaxing the most recent request for Vancomycin trough and BMP as it was supposed to be completed on 8/17/23. The fax also indicated to please attempt to complete labs as soon as possible and fax results to pharmacy right away. -4:03 PM Resident 6's labs were due and to send them to the pharmacy as soon as available. On 9/15/23 at 11:07 AM Staff 2 and Staff 24 (RCM-LPN) stated they wanted to review the information. Staff 2 stated one day the nurse drew Resident 6's blood for the Vancomycin trough early. No additional information was provided. b. An 8/8/23 hospital Discharge Orders Report instructed staff to administer Vancomycin oral solution by mouth daily for 15 days. The report also instructed staff to administer IV Vancomycin every 12 hours. An 8/11/23 Internal medicine Nurse Practitioner Progress Notes indicated Resident 6 was placed on IV Vancomycin and oral Vancomycin due to her/his history of clostridioides difficile (C. diff., an infection of the large intestine). It was recommended Resident 6 receive daily oral Vancomycin for the duration of her/his systemic antibiotics and to prevent another episode of C-diff. An 8/2023 MAR instructed staff to administer Vancomycin Oral by mouth one time a day for 14 days. On 8/13/23, 8/14/23, 8/15/23, 8/16/23, 8/20/23, 8/21/23 and 8/22/23 the MAR instructed the reader to see progress notes. Administration Notes indicated to administer Vancomycin oral suspension one time a day for 14 days notes as follows: -8/13/23 IV medication administered and physician notified. -8/14/23 no additional information documented. -8/15/23 "PICC line in place." -8/16/23 "PICC line in place." -8/20/23 no additional information documented. -8/21/23 "Do not have medication." -8/22/23 "Don't have." On 9/15/23 at 11:04 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated since Resident 6's IV line dislodged some of the nurses believed she/he was administered the oral during the time she/he could not receive IV Vancomycin. Staff 2 stated Resident 6's physician ordered the resident to receive both oral and IV Vancomycin.

Resident Cited Resident #6 - This resident no longer resides in the facility. Residents at Risk Residents who reside in facility and receive vancomycin are at potential risk for this deficient practice. All residents in the facility who receive vancomycin will be audited to ensure vancomycin troughs are completed per order and oral vancomycin medication is being administered per MD order. Education Education completed with nursing staff regarding ensuring vancomycin troughs are completed per orders and oral vancomycin is administered to residents per MD order. Audits To ensure ongoing compliance, DNS/designee will perform audits of residents who receive vancomycin to ensure that troughs are obtained per order and oral medication is administered per MD order weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation, interview and record review it was determined the facility failed to provide adequate catheter care for 2 of 3 residents reviewed for catheterization (#s 3 and 6) reviewed for catheter. This placed residents at risk for unmet catheter needs. Findings include: A revised facility In-dwelling Urinary Catheter Policy and Procedure indicated a care plan development would address the catheter use which may include management of the catheter, bag and tubing changes, prevention of drag on the catheter tubing, maintenance of the catheter bag below the level of the resident's pelvis, routine catheter care, fluid intake, preserving resident dignity and monitoring for signs of complications. Resident 3 was admitted to the facility in 2023 with diagnoses including obstructive and reflux uropathy (a blockage of the normal flow of contents of the urinary tract). A 6/13/23 care plan indicated Resident 3 had a urinary catheter and would remain free of catheter related trauma with interventions including position bag and tubing below level of bladder, ensure tubing was free of kinks, monitor for signs and symptoms of UTI, see MAR and TAR for current medical interventions, and urinary catheter care "(SPECIFY) (*AR*)". No specific catheter care was documented. A 6/17/23 Alert Note indicated Resident 3 was complaining of a full bladder and there was no urine in her/his catheter urine collection bag. Staff 13 (RN) noted the tubing was twisted and after unwinding the tubing the bag collected 750 ml of urine. A 6/18/23 Admission MDS indicated Resident 3's BIMS score was 13 which indicated she/he was cognitively intact. Resident 3 had an indwelling catheter. The Urinary Incontinence and Indwelling Catheter CAA indicated Staff were to provide catheter care every shift and as needed and conduct a weekly skin audit. Resident 3 was at risk for skin impairment, pressure ulcers and dehydration. On 7/20/23 a public complaint was received which indicated Resident 3's catheter insertion area was not cleaned daily and the tape to secure the tubing on her/his leg was only changed one time from 6/14/23 through 7/9/23. The skin under the tape had a rash. On 9/12/23 at 8:13 AM Resident 3 stated staff did not change the tape that secured the catheter tubing to her/his leg. Resident 3 stated toward the end of her/his stay they started to provide catheter care but she/he went a couple of weeks without being cleaned. They were emptying her/his catheter bag but not cleaning the catheter insertion site. No documentation was found in clinical records for the monitoring or changing of the tape securing Resident 3's catheter tubing to her/his leg. On 9/13/23 at 8:38 AM Staff 13 stated the device which secures the catheter tubing to the leg should be changed if it was soiled or dislodged, staff should change the location of the tubing, and the industry standard of care was once per week. Staff 13 stated he did not know if the nurse or the CNA completed the care related to the catheter tubing tape, that it depended on facility policy. Staff 13 stated on 6/17/23 he remembered the CNA coming to him and letting him know Resident 3 did not have urine coming out of her/his catheter. He examined the tubing and it was kinked which blocked urine flow. Staff 13 stated he was surprised 750 ml came out as average standard output was about 30 ml per hour. Staff 13 stated it was best practice for a resident with a catheter to have input and output documented each shift. On 9/15/23 at 9:07 AM Staff 22 (CNA) stated changing of the tape to secure the tubing to the leg was normally completed by the nurse. On 9/15/23 at 10:48 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated the CNAs were responsible to change the tape for the catheter tubing and, if the tape was soiled or lifting up, CNAs were to move the tape to another place. If the catheter bag was changed the tape was changed. It was expected for staff to generally write a note for patency and the monitoring for UTI was in nursing tasks, size of catheter and balloon size should be on the TAR for changing. 2. Resident 6 was admitted to the facility in 2023 with diagnoses including osteomyelitis (infection of the bone). An 8/8/23 care plan indicated Resident 6 had a urinary catheter with interventions including "see MAR and TAR for current medical interventions." Resident 6 had a supra pubic (a flexible tube to drain urine from the bladder inserted into the bladder through the abdomen) catheter. An 8/8/23 through 8/31/23 Documentation Survey Report revealed urinary catheter care per protocol. On day shift it was documented no catheter care was provided nine times during day shift. On night shift there was no documentation catheter care was provided four times. No output of Resident 6's urine was documented on the report. An 8/9/23 Admission MDS and Dehydration Fluid Intake CAA indicated Resident 6 had osteomyelitis and dehydration. Resident 6 received IV fluids in the hospital and was at risk for dehydration, infection and sepsis. A 8/20/23 Health Care Log completed by Witness 3 (Family Member) indicated on 8/20/23 Resident 6 reported Staff 22 (CNA) commented to her/him that her/his urine "smelled really bad"/ and that Resident 6's catheter hygiene was "questionable" since her/his admission. Resident 6 developed a yeast infection in the abdomen crease where her/his catheter exited her/his body as well as in her/his groin. An 8/20/23 Alert Note indicated Resident 6 had a red "yeasty looking" rash to her/his pannus (fold of excess skin and fat that hangs down from the abdomen) and right side of her/his groin. A fax was sent to the physician requesting an order for treatment of the rash. On 9/11/23 at 11:26 AM Witness 3 stated she had concerns for Resident 6's care from the first day of admission and so she decided to keep a log of what occurred. On 9/15/23 at 9:07 AM Staff 22 (CNA) stated she did not remember documenting catheter care was not completed in 8/2023. On 9/15/23 at 11:19 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated the facility typically did not document output for a resident with a catheter. Resident 6 did not have any signs of dehydration. Staff 2 and Staff 24 were informed catheter care was not provided was documented in clinical records for Resident 6.

Resident Cited Resident #3 - This resident no longer resides in the facility. Resident #6 - This resident no longer resides in the facility. Residents at Risk Residents who reside at facility who have catheters are at potential risk for this deficient practice. House-wide audits will be completed on residents who have catheters to ensure catheter care is scheduled in POC for each shift and catheter tubing is not twisted. Education Staff education to be completed regarding completing catheter care and documenting correctly when catheter care is completed/or refused by resident and that catheter tubing is not twisted. Audits To ensure ongoing compliance DNS/designee will complete audits on residents who have catheters to ensure catheter care is being completed and catheter tubing is not twisted weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation, interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 4 sampled residents (#s 6, 8 and 9) and 1 of 3 halls (North) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 6 was admitted to the facility in 2023 with diagnoses including paraplegia and anxiety disorder. An 8/30/20 care plan indicated Resident 6 was at risk for falls with interventions which included to remind Resident 6 to use her/his call light for assistance and for staff to promptly respond to all requests for assistance. An 8/9/23 Admission MDS indicated Resident 6's BIMS score was 15 which indicated she/he was cognitively intact. Resident 6 required extensive two-person assistance with bed mobility and transfers. A Page Report (call light time log) from 8/9/23 through 8/30/23 revealed the following call light wait times for Resident 6: -8/11/23: 6:58 AM, 38 minutes; 5:40 PM, 57 minutes -8/12/23: 7:59 AM, 35 minutes -8/15/23: 8:33 AM, 29 minutes; 9:32 AM, 55 minutes; 12:32 PM, 37 minutes; and 8:25 PM, 24 minutes -8/16/23: 7:54 AM, 40 minutes; 9:54 AM, 44 minutes; 8:12 PM, 29 minutes -8/17/23: 6:59 AM, 42 minutes; 9:05 AM, 32 minutes -8/18/23: 7:06 PM, 24 minutes -8/19/23: 7:02 PM, 24 minutes -8/20/23: 9:06 AM, 28 minutes; 4:03 PM, 23 minutes -8/22/23: 6:53 AM, 24 minutes; 8:54 AM, 25 minutes -8/23/23: 10:00 AM, 43 minutes -8/24/23: 3:38 AM, 25 minutes -8/26/23: 1:12 PM, 27 minutes -8/28/23: 11:00 AM, 35 minutes; 6:02 PM, 64 minutes; 8:20 PM, 25 minutes; 9:35 PM, 30 minutes -8/29/23: 7:03 AM, 57 minutes A review of the DCSDRs (Direct Care Staff Daily Reports) from 8/11/23 through 8/31/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA to resident staffing ratios for six of 21 days. An 8/20/23 Health Care Log completed by Witness 3 (Family Member) indicated the following: -8/11/23 Resident 6 called Witness 3 at noon and reported she/he was still in bed waiting for a bed bath. Resident 6 was still in bed at 3:00 PM when she/he wanted to get out of bed in the morning. -8/15/23 Resident 6 called Witness 3 and left message to report she/he was still in bed at 1:15 PM On 9/11/23 at 11:26 AM Witness 3 confirmed the information on the 8/20/23 Health Care log she completed. On 9/15/23 at 9:41 AM Staff 23 (CNA) stated residents complained of long call light wait times, and if she was "stuck" in a room assisting another resident or on lunch break the hall partner did not always answer her call lights. On 9/15/23 at 11:13 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated the expectation for call light wait times was 20 minutes or less and if staff were having difficulty with answering timely to text another staff member to assist. 2. Resident 8 admitted to the facility in 2020 with diagnoses including pressure ulcers. A 5/26/20 care plan indicated Resident 8 was a fall risk with interventions to have her/his call light in reach, and encourage the resident to use the call light for assistance as needed. Resident 8 required prompt response to all requests for assistance. An 8/5/23 Quarterly MDS indicated Resident 8's BIMS score was 14 indicating she/he was cognitively intact. Resident 8 required extensive two-person assistance with bed mobility and was totally dependent on two-persons to assist with toilet use. A Page Report (call light time log) from 9/1/23 through 9/11/23 revealed the following call light wait times for Resident 8: -9/1/23 8:38 PM, 29 minutes -9/2/23 5:52 PM 28 minutes -9/3/23 12:48 PM, 36 minutes; 3:09 PM, 64 minutes; 5:43 PM, 73 minutes; 7:09 PM, 43 minutes; 8:55 PM, 24 minutes -9/5/23 10:51 AM, 33 minutes; 12:35 PM, 64 minutes -9/6/23 11:06 AM, 44 minutes; 12:49 PM, 52 minutes; 2:26 PM, 28 minutes -9/7/23 12:54 PM, 80 minutes; 7:41 PM, 28 minutes -9/8/23 9:26 AM, 25 minutes; 12:29 PM, 81 minutes; 3:50 PM, 28 minutes -9/9/23 3:47 PM, 42 minutes -9/10/23 6:43 AM, 25 minutes; 11:29 AM, 37 minutes; 3:32 PM, 25 minutes -9/11/23 8:29 AM, 31 minutes; 9:45 AM, 40 minutes On 9/11/23 the following occurred: -10:22 AM the nurses' call light monitor indicated Resident 8's call light was activated since 9:45 AM. -10:24 AM Resident 8 was in her/his room in bed and Staff 18 (NA) came into the room and stated she needed to find another staff member to assist. At 11:04 AM staff returned and assisted Resident 8 (40 minutes). -10:31 AM Resident 8 stated call light wait times over 20 minutes were "standard procedure", mealtimes were the worst as well as the night shift when there was only one staff for 50 residents. Resident 8 stated she/he got "pissed off" when she/he had to wait an extended period of time. On 9/13/23 at 9:58 AM Staff 18 stated the reason Resident 8's call light wait time was long on 9/11/23 was because she had to complete two full bed changes because other residents had upset stomachs. On 9/15/23 at 11:13 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated the expectation for call light wait times was 20 minutes or less and if staff were having difficulty with answering timely to text another staff member to assist. 3. Resident 9 was admitted to the facility in 2020 with diagnoses including diabetes and anxiety disorder. A 11/13/20 care plan indicated Resident 9 was at risk for falls with interventions including to remind Resident 9 to use the call light for assistance. A 7/15/23 Quarterly MDS indicated Resident 9's BIMS score was 14 indicating she/he was cognitively intact. Resident 9 required extensive one-person assistance with bed mobility and toileting. A review of the DCSDRs (Direct Care Staff Daily Reports) from 8/11/23 through 9/11/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA to resident staffing ratios for eight of 32 days. A Page Report (call light time log) from 9/1/23 through 9/11/23 revealed the following call light wait times for Resident 6's: -9/7/23 12:50 PM, 49 minutes -9/11/23 10:03 AM, 24 minutes On 9/11/23 the following occurred: -10:22 AM the call light time log was observed in the Central Hall and Resident 9's call light was activated at 10:03 AM. At 10:27 AM Staff 18 (NA) entered the room and assisted Resident 9 (24 minutes). -10:36 AM Resident 9 stated call light wait times were usually the worst during the mornings and call light wait times were more than 20 to 30 minutes. On 9/13/23 at 9:58 AM Staff 18 stated the reason Resident 9's call light wait time was long on 9/11/23 was because she had to complete two full bed changes because other residents had upset stomachs. On 9/15/23 at 11:13 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated the expectation for call light wait times was 20 minutes or less and if staff were having difficulty with answering timely to text another staff member to assist. 4. On 9/13/23 during random observations the following occurred: -11:37 AM observed call light monitors in the Central Hall, Room 6's call light was initiated at 10:42 AM. At 11:43 AM Staff 21 (CNA) entered Room 6 to assist the resident (61 minutes). -11:45 AM Staff 21 stated she did not know what happened as she just finished taking her lunch and Staff 22 (CNA) was supposed to answer her assigned residents' call lights for her while she was at lunch and "apparently" Staff 22 did not get to Room 6. On 9/15/23 at 11:13 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) stated the expectation for call light wait times was 20 minutes or less and if staff were having difficulty with answering timely to text another staff member to assist.

Resident Cited Resident # 6 - This resident no longer resides in the facility. Resident # 8 - Resident was assessed for any needs. Resident #9 - Resident was assessed for any needs. Residents at Risk Residents who use call lights are at potential risk for this deficient practice. Interviews completed with a sample of residents to identify call light response time and residents needs being met. Concerns identified addressed accordingly. Education Education completed with staff regarding call light response times. Audits To ensure ongoing compliance, DNS/designee will complete audits of call light times on a sample of residents weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to monitor behaviors related to dementia for 1 of 3 sampled residents (#5) reviewed for abuse. This placed residents at risk for unmet dementia care needs. Findings include: Resident 5 admitted to the facility in 2022 with delusional disorders and dementia. An 4/5/23 Annual MDS and Psychotropic CAA revealed Resident 5 had behaviors which included impulsiveness, yelling, swinging at staff, refusal of care, and arguing with other residents. Resident 5 also made "disturbing" sexual comments and stated she/he wanted to commit rape. Resident 5 was scheduled to visit with psychiatry and her/his mood was better. Staff were to administer medication as ordered, ensure pharmacist review per protocol, and engage psychiatry as needed. An 4/9/22 care plan indicated Resident 5 had a history of resident-to-resident incidents with interventions including monitor for changes in behavior and the effectiveness of interventions, and attempt to redirect and monitor for signs and symptoms of psychological distress. If Resident 5 became agitated and wanted out of bed she/he thought she/he needed to get up to go home, and staff were to attempt to calm her/him and assist her/him into her/his chair as needed. A 7/6/23 Quarterly MDS indicated Resident 5's BIMS score was seven indicating severe cognitive impairment, and she/he exhibited no behaviors. A review of 8/2023 and 9/2023 TARs, LN tasks (nursing tasks) and Documentation Survey Reports (CNA tasks) revealed no observed behaviors documented for Resident 5. An 8/16/23 Health Status Note indicated Resident 5 displayed more sexual behaviors in the common areas making inappropriate comments to and about other residents and staff members. Resident 5 was redirected without issue by staff. An 8/19/23 FRI indicated on 8/18/23 Resident 4 and Resident 5 were in the dining room having a conversation. Resident 5 suddenly started yelling at Resident 4 and called her/him an "asshole" and a "mother fucker." Staff 11 (CNA) and Staff 12 (CNA) witnessed the incident and attempted to redirect Resident 5 and had a difficult time calming her/him down. On 9/13/23 Staff 6 (CNA) stated she observed Resident 5 with behaviors. Staff 6 stated Resident 5 became fixated on sexual behaviors and became upset about her/his diet and became very angry. Staff 6 stated if Resident 5 made a sexual statement to her she did not document it and ignored it. Staff 6 did not want other staff to refuse to work with Resident 5 because of her/his behaviors. On 9/15/23 at 10:10 AM Staff 12 stated she observed Resident 5 with sexual behaviors. Staff 12 stated Resident 5's sexual behaviors were directed toward her often, and she ignored them or told Resident 5 they were inappropriate. If Resident 5 was safe she left. If there was an incident, she notified the nurse or Staff 2 (DNS). Staff 12 stated she observed the incident on 8/18/23 and both Resident 4 and Resident 5 were waiting for dinner. Resident 5 became impatient waiting for her/his meal and called Resident 4 a "mother fucker." Neither resident wanted to move. On 9/15/23 at 10:57 AM Staff 2 and Staff 24 (RCM-LPN) confirmed Resident 5's behaviors and indicated interventions should be documented.

Resident Cited Resident #5 - Resident no longer resides in facility. Residents at Risk Residents who reside in facilities with diagnosis of Dementia are at potential risk for this deficient practice. House-wide audit of residents with dementia completed to ensure behavior monitors are in place with interventions listed. Education Education completed with staff regarding documenting on residents behaviors and appropriate interventions. Audits To ensure ongoing compliance, DNS/designee will complete audits on behavior monitors of residents with dementia to ensure that documentation is complete weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to administer medications as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#2) reviewed for safe medication system. This placed residents at risk for adverse medication consequences. Findings include: Resident 2 admitted to the facility in 2022 with diagnoses including malnutrition, cirrhosis (degenerative disease of the liver resulting in scarring and liver failure) of the liver. A 11/9/22 care plan indicated Resident 2 was on Hospice services. A 11/17/22 Alert Note indicated family was contacted by phone and notified Resident 2 was declining and if family wanted to visit they should come. The Chaplin was with Resident 2 in her/his room. A 11/18/22 Incident Note indicated Staff 3 (RN) administered sorbitol (to treat constipation), senna (to treat constipation), and Pepsi (to break up obstructions in tubing) through Resident 2's PICC (peripherally inserted central catheter, a long line inserted in a vein to be passed through to larger vein near heart) instead of the J-tube (tube inserted directly through the wall of the intestine to provide necessary medications and nutrition). Hospice was notified and the PICC line was flushed with sterile saline per verbal orders. Resident 2 was monitored for indication of pain and discomfort. The Incident Investigation Report for the 11/18/22 incident indicated liquid medications were administered through Resident 2's PICC line instead of her/his J-tube. Staff 3 reported to a supervisor and notified Hospice of the medication error. Resident 2 was actively transitioning before medication administration. The report indicated Staff 3 administered liquid sorbitol, senna and diazepam (used to treat anxiety, muscle spasms, and alcohol withdrawal) into the PICC line. Staff 2 indicated he pulled up the flush of Pepsi which was meant to go into the J-tube and started administering this as well into the PICC line and realized he was administering the medication in the wrong route and stopped administering the Pepsi. Because Resident 2 was on Hospice it was determined to keep her/him at the facility. The physician did not feel any immediate harm would come to the resident and gave orders to flush the PICC line. The facility submitted a FRI on 11/22/22 which revealed Resident 2 received liquid medication through a PICC line instead of the G-tube (a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration and or medicine). On 9/11/23 Staff 3 confirmed the medication error on 11/18/22 and stated he was educated on medication administration. On 9/15/23 at 10:31 AM Staff 2 (DNS) and Staff 24 (RCM-LPN) confirmed on 11/18/22 Staff 3 administered medication through the wrong route and a medication error occurred. Staff 24 stated Resident 2 had a PICC line, G-tube and a J-tube. The incident met the criteria for past non-compliance as follows: 1. The incident indicated non-compliance for F760. 2. There was sufficient evidence the facility corrected the non-compliance and was in substantial compliance with F760 as evidenced by: -No deficient practice was found at F760 with additional sampled residents. -The deficient practice was identified by the facility and the facility took immediate action to provide one on one counseling with the staff responsible for the medication error. -Medication Pass Observations were implemented for four weeks then went monthly for two months. -All licensed nurses completed competencies on 1/11/23.

**************************************** OAR 411-085-0360 Abuse Refer to F600 *************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684, and F760 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F690 **************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 *************************************** OAR 411-086-0240 Social Services Refer to F744 ***************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/21/2023 and 08/27/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/17/2023 and 07/23/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to treat residents with respect and dignity for 2 of 9 sampled residents (#s 13 and 55) reviewed for abuse and hospice. This placed residents at risk for lack of dignity. Findings include: 1. Resident 55 was admitted to the facility in 7/2020 with diagnoses including depression. Review of an undated incident investigation revealed on 3/30/23 Resident 55 turned on her/his call light for assistance while getting ready for a resident outing. When the resident did not receive assistance, after some time, the resident started to ring a silver desk bell to get the staff's attention. Resident 55 was worried she/he would miss the outing. Staff 6 (CMA) entered the resident's room and told the resident to stop ringing the silver desk bell. The investigation indicated Staff 6 said she was going to take away her/his silver desk bell and attempted to take it from the resident. Resident 55 moved the desk bell away from Staff 6 and Staff 6 walked out of the room and closed the resident's door. The investigation concluded Staff 6 tried to take Resident 55's silver desk bell away from him/her and isolated the resident by closing the resident's room door. In an interview on 5/2/23 at 9:35 AM Resident 55 stated on 3/30/23 she/he wanted to go on a resident outing and turned on her/his call light for assistance with dressing. Resident 55 stated after an hour no staff came in to the room so she/he started to ring a silver desk bell for help. Resident 55 stated the room door was open and Staff 6 came in to the room and told her/his to stop ringing the bell. Resident 55 stated Staff 6 tried to take her/his bell away and then left the room shutting the door. Resident 55 stated after she/he returned from the outing her/his desk bell was missing. Resident 55 stated Staff 6 did not offer her/him assistance to get out of bed. In an interview on 5/2/23 at 11:51 AM Staff 2 (DNS) stated Staff 6 isolated the resident and was unprofessional telling the resident to stop ringing her/his desk bell. In an interview on 5/3/23 at 7:58 AM Resident 33 (Resident 55's roommate) stated on 3/30/23 Resident 55 needed assistance with getting dressed to go on an outing. Resident 33 stated Resident 55 started ringing a desk bell for help. Staff 6 entered the room and told Resident 5 to "stop it" and did not ask Resident 55 what the resident needed. Resident 33 also indicated Staff 6 threatened to take Resident 55's desk bell away if she/he did not stop ringing the desk bell. Resident 33 stated Staff 6 was aggressive and tone of voice was "mean". Staff 6 then left the room and shut the room door. In an interview on 5/3/23 at 8:11 AM Staff 6 stated on 3/30/23 she entered Resident 55's room to ask what the resident needed and why she/he was ringing the desk bell. Resident 55 told her she/he needed to get ready for an outing. Staff 6 stated she attempted to take the desk bell from Resident 55 but was unable. , 2. Resident 13 was admitted to the facility in 2023 with diagnoses including dysphagia (difficulty in swallowing food or liquid) following a stroke. A 1/16/23 Admission MDS indicated Resident 13 had a terminal prognosis and received hospice care. A hospice Meeting Review with certification period 3/19/23 through 5/17/23 instructed staff to approach Resident 13 with a calm and receptive demeanor and allow Resident 13 to vent. On 5/4/23 at 11:28 AM Witness 5 (Hospice RN) was in Resident 13's room. Resident 13 stated she/he would like to receive her/his shower after lunch. Witness 6 (Hospice CNA) entered Resident 13's room with a shower chair and asked Resident 13 if she/he was ready for her/his shower. Resident 13 stated she/he wanted to eat lunch first. Witness 6 stated she did not have enough time as "they" only gave her an hour. Witness 6's tone of voice was curt. Resident 13 was visibly upset and stated she/he did not want the shower then as she/he wanted to eat. Witness 6 stated she could come in on 5/5/23 and provide a shower at 7:00 AM. The time of the shower was discussed, and Witness 6 then stated it was earlier than she thought so she could provide the shower after Resident 13 ate lunch. Resident 13 became confused on the changes of times for her/his shower and became upset and stated Witness 6 should know how to treat her/him as she was from hospice. On 5/5/23 at 7:45 AM Staff 15 (CNA) stated Resident 13 received her/his shower at 7:00 AM because on 5/4/23 Resident 13 did not eat her/his lunch quick enough and Witness 6 kept stating she only had an hour and then left without providing Resident 13's shower. Staff 15 stated she did not want Resident 13 to hurry with eating lunch as she/he could choke. In an interview on 5/5/23 at 9:58 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) stated they would speak to hospice regarding to Witness 6.

F 557 Respect, Dignity/Right to Have Personal Property Resident Cited Resident #55 Rick Meade- Staff member involved in incident no longer employed at facility. Resident with no s/sx of psychological distress and at baseline. Resident # 13 Gary Reigel- Hospice informed of incident and no longer coming to facility. Resident with no s/sx of psychological distress and at baseline. Residents at Risk All residents that are in facility are at potential risk for this deficient practice. House-wide audit will be completed with all residents to determine if there are any other concerns regarding dignity. Education Education to be completed with all staff regarding expectations on how residents are treated. Meeting with Hospice company to be set to discuss survey tags and expectation of resident treatment. Audits To ensure ongoing compliance, DNA/designee will conduct audits through resident interviews regarding residents being treated with dignity weekly x 4 weeks, Monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of advance beneficiary information for 1 of 4 sampled residents (#51) reviewed for required advanced beneficiary notices. This placed residents at risk for not being informed of financial liabilities. Findings include: Resident 51 admitted to the facility with Medicare Part A services on 1/12/22. On 4/8/22 a Notice of Medicare Non-coverage was provided for discontinuation of Medicare Part A services on 4/10/22. According to the Skilled Nursing Facility Beneficiary Protection Notification document provided by the facility, the resident remained in the facility after 4/10/22 under a different payer status. No evidence of written notification of financial responsibility was provided upon surveyor request. On 5/5/23 at 9:16 AM Staff 17 (Social Services) stated changes in coverage were discussed with residents, representatives and family members when Medicare coverage ended, but the facility did not put financial liability information in writing for the resident or the representative.

F582 Medicaid/Medicare Coverage/Liability Notice Resident Cited Resident #51 Ardith Anell- Written notice to be given to resident regarding Financial responsibility. Residents at Risk All residents who reside in facility are at potential risk for this deficient practice. Residents who changed coverage and remained in facility in the past 30 days will be audited to ensure written notification of financial responsibility was given. Education Education to be completed with Social Services regarding when to issue written notification of financial responsibility. Audits To ensure ongoing compliance Administrator/Designee will audit residents with payor changes for appropriate notice of financial responsibility was completed weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 8 sampled residents (#21) reviewed for abuse. This placed residents at risk for abuse. Findings include: The deficient practice was determined to be Past Noncompliance. On 2/18/22 the facility completed a root cause analysis of the incident and moved Resident 57 to another room by herself/himself. The Plan of Correction included: 1. Staff were educated on resident-to-resident altercations on 1/23/22 and 2/18/23 and general abuse and neglect training occurred on 2/10/22 including review of policies and procedures; 2. multiple audits were completed in 1/2022 and 2/2022. Resident 21 was admitted to the facility in 2020 with diagnoses including stroke. A 1/5/22 Incident report revealed on 1/5/22 Staff 6 (CMA) entered the room of Resident 21 and Resident 57 and observed Resident 57 hitting Resident 21's leg with her/his front wheel walker. Staff 6 intervened and moved Resident 57 away from Resident 21. Resident 57 indicated Resident 21 stole her/his two TV remotes and called Resident 21 a "liar" when she/he denied the allegation. Resident 57 then stood up and walked to Resident 21's bed and hit her/him on the leg. No injuries were identified. The facility substantiated abuse. On 5/1/23 at 2:24 PM Resident 21 stated she/he remembered the incident and confirmed Resident 57 hit her/him on the legs with a front wheel walker. On 5/3/23 at 9:49 AM Staff 6 stated Resident 21 was yelling when she went into the room and Resident 57 was "beating" Resident 21 with her/his walker and stated to her that Resident 21 stole her/his TV remote. Staff 6 stated Resident 21 hit another resident in 12/2021 in a different room. On 5/5/23 at 9:16 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) confirmed the incident occurred and the facility substantiated abuse.

Based on observation, interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident (#202) reviewed for unnecessary medication. This placed residents at risk for unmet needs. Findings include: Resident 202 was admitted to the facility in 2023 with diagnoses including atrial fibrillation (abnormal heart rhythm), COPD (chronic obstructive pulmonary disease) and high blood pressure. Resident 202's 4/2023 MAR indicated the resident received an anticoagulant for atrial fibrillation, multiple inhalers for COPD and multiple blood pressure medications. Resident 202's care plan dated 3/7/23 did not include safety interventions and monitoring for bruising or bleeding related to anticoagulant use, or safety interventions and monitoring for multiple medications for COPD and high blood pressure placing the resident at risk for adverse side effects. On 5/4/23 at 9:36 AM Staff 3 (LPN Resident Care Manager) acknowledged Resident 202 received an anticoagulant medication which placed the resident at risk for bruising and bleeding, and multiple COPD and blood pressure medications placing the resident at risk for adverse side effects.

F656 Develop/Implement Comprehensive Care Plan Resident Cited: Resident # 202 Monika Keyes- Resident is no longer in facility. Residents at Risk All residents who reside in facility on anti-coagulants and medications for COPD and HTN are at potential risk for this deficient practice. Audit of all residents on Anti-coagulant therapy, medications for COPD, and medications for HTN will be completed to ensure safety interventions and monitoring are documented on careplan. Education Education with Nurse Management to be completed to ensure careplans are comprehensive and include safety interventions and monitoring related to anti-coagulant use, and multiple medications used to treat respiratory/blood pressure concerns. Audits To ensure ongoing compliance, DNS/designee will complete random audits on residents with anti-coagulant medication, respiratory medications, and anti-hypertensives to ensure careplan in place weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed ensure physician orders were followed for 3 of 6 sampled residents (#s 33, 42 and 54) reviewed for ADLs, nutrition and dialysis. This placed residents at risk for unmet needs. Findings include: 1. Resident 33 was admitted to the facility in 2022 with diagnoses including diabetes. An 8/29/22 care plan revealed Resident 33 attended dialysis three days a week on Tuesday, Thursday and Saturday. The care plan also indicated Resident 33 had diabetes with interventions including providing diabetes medication as ordered by the physician. An 4/2023 TAR instructed staff to inject Lispro insulin before meals on a sliding scale if blood sugar levels were between 90 and 180 and to administer eight units of insulin. If blood sugar levels were over 161 to inject 10 units of insulin. Staff were to hold insulin if blood sugar levels were below 90 or if Resident 33 was not eating. A review during the lunch time insulin administration revealed the following: -4/4/23 indicated Resident 33 was out of facility without her/his medications, and the administration note indicated Resident 33 was at dialysis. Resident 33's blood sugar level was 148. -4/6/23 indicated Resident 33 was out of the facility without her/his medications. No blood sugar level was documented. No administration notes were found . -4/11/23 indicated Resident 33 was out of the facility without her/his medications with "not applicable" documented for blood sugar level. No administration notes were found. -4/18/23 indicated Resident 33's blood sugar level was 132 and documented as "no insulin indicated." Administration notes indicated Resident 33 was at dialysis. -4/20/23 indicated Resident 33 was out of the facility without her/his medications; no blood sugar level documented. No administration notes were found. -4/25/23 indicated Resident 33 was out of the facility without her/his medications and her/his blood sugar level was 151. Administration notes indicated Resident 33 was at dialysis. -4/27/23 indicated Resident 33 was out of the facility without her/his medications with no blood sugar level documented. No administration notes were found. In an interview on 5/5/23 at 9:30 AM Staff 1 (Administrator) Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) stated the facility did not receive orders to hold Resident 33's insulin. Resident 33 received lunch at dialysis and arrived back at the facility in the afternoon. Staff 2 stated they expected documentation, or the timing would have to be different on Resident 33's administration of insulin. , 2. Resident 42 was admitted to the facility in 2023 with diagnoses including heart disease. An 4/27/23 Physician order revealed Resident 42 was to be administered Lasix (removes excess fluids) PRN for a weight gain of two pounds in 24 hours, a weight gain of three pounds in three days or a weight gain of five pounds in one week. Resident 42's 4/2023 and 5/2023 weights revealed the following: -4/27/23 150 pounds -4/28/23 149 pounds -4/29/23 no weight was obtained -4/30/23 152.4 pounds -5/1/23 152.4 pounds -5/2/3 151 pounds -5/3/23 155 pounds An 4/2023 MAR revealed the resident did not receive PRN Lasix despite a weight gain of over three pounds in two days from 4/28/23 to 4/30/23. A 5/2023 MAR revealed the resident did not receive PRN Lasix despite a weight gain of more than two pounds from 5/2/23 to 5/3/23. On 5/4/23 at 10:14 AM Staff 4 (RNCM) acknowledged the staff did not obtain a weight on 4/29/23 and could not determine if PRN Lasix was needed, and the resident had two missed doses of PRN Lasix when the resident gained weight. , 3. Resident 54 was admitted to the facility in 2022 with diagnoses including lower extremity venous stasis ulcers (skin defect that fails to heal). A 12/7/22 physician order indicated Resident 54 was to receive Coban Two (multi-layer compression bandages) to legs weekly and as needed. A public complaint dated 1/24/23 indicated Resident 54 was sent to the emergency room for a headache. Witness 8 (Hospital Care Management Team) reported Resident 54's lower extremities were purple and wrapped tight with regular Coban (self-adhering bandage) and not Coban Two. On 5/4/23 at 9:22 AM Staff 3 (LPN Resident Care Manager) acknowledged she received a call from the nurse in the emergency room who stated Resident 54 had Coban wrapped tight around her/his legs. Staff 3 stated Staff 28 (RN) placed the wrong Coban wraps on Resident 54 and acknowledged the physician orders were not followed.

F 684 Quality of Care Resident Cited: Resident # 33 Roger Crowder- Insulin order has been changed to be given BID on dialysis days and TID on non-dialysis days. Residnet # 42 Pauline Robinson- Re-education completed with Licensed Nurses regarding residents need for following PRN Lasix orders. Added an order to MAR for Licensed nurses to check weight to determine if PRN Lasix needs to be administered. Resident # 54 Holmes- No longer resides in facility. Residents at Risk All residents residing in facility with Dialysis and receiving Insulin, PRN Lasix, and Two-Flex orders are at potential risk for this citation. Last 30 days of MARS will be audited for residents still in house to identify any additional concerns. Education Education to be completed with Licensed nurses/CMAs regarding following physician orders. Audits To ensure ongoing compliance, DNS/designee will conduct audits on residents receiving Dialysis and Insulin, PRN Lasix, and Two-flex to ensure they are being completed as ordered. Audits will be completed three times a week x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

1.

Based on interview and record review it was determined the facility failed to ensure fall investigations were thorough for 3 of 5 sampled residents (#s 15, 41 and 42) reviewed for accidents and care planning. This placed residents at risk for continued falls and neglect of care. Findings include: a. Resident 15 was admitted to the facility in 2022 with diagnoses including an unspecified brain disorder. A 2/3/23 Annual MDS and associated CAAs indicated Resident 15 required extensive assistance with ADLs, had falls in the facility and was at risk for continued falls. A care plan was to be developed to provide interventions to minimize the risk of falls. Resident 15's care plan initiated 1/27/22 revealed the resident was at risk for falls related to impaired balance. The care plan had multiple interventions and revisions including the resident was to have frequent checks to ensure the resident was safe and her/his needs were met. An 4/9/23 Fall investigation indicated Resident 15 fell on 4/9/23 at 1:45 PM. The investigation did not indicate the last time the resident was last assisted or visualized to ensure the resident was safe and/or her/his needs were met. On 5/4/23 at 10:01 AM Staff 4 (RNCM) stated Resident 15 shared her/his room with two additional residents and staff were frequently in the room. When staff assisted with one of the residents they visualized the other two residents to ensure the residents' needs were met. Staff 4 acknowledged the 4/9/23 Fall investigation did not indicate the last time staff assisted or visualized Resident 15. b. Resident 42 was admitted to the facility in 2023 with diagnoses including heart disease. A 2/8/23 Admission MDS and associated CAAs indicated Resident 42 was weak, required extensive assistance with ADLs and was at risk for falls. A care plan was to be developed to decrease the risk of falls. A care plan initiated 1/23/23 revealed the resident was at risk for falls due to impaired cognition and poor mobility. The resident had multiple interventions and revisions including staff were to make frequent checks every shift. An 4/5/23 Fall investigation and witness statements indicated Resident 42 fell on 4/5/23 at 9:52 PM. Witness statements indicated the resident was last seen at approximately 6:40 PM, over three hours prior to the fall. On 5/3/23 at 7:42 AM Staff 16 (CNA) stated "frequent checks" meant staff were to check on a resident more than the standard of every two hours. Staff 16 also indicated staff were to look in the resident's room every time they walked by the room. On 5/3/23 at 2:20 PM Staff 10 (CNA) stated if a resident was on "frequent checks" it meant the resident was to be visualized every time staff walked by the room and, at a minimum, every hour. On 5/4/23 at 10:12 AM and 12:50 PM Staff 4 (RNCM) indicated the 4/5/23 investigation did not have the last time the resident was visualized and the documents indicated the last time the resident was assisted was approximately three hours prior to the fall. Staff 4 stated the investigation did not include the call light times or when the medication staff were in the room and saw the resident less than one hour before the fall. , c. Resident 41 was admitted to the facility in 2022 with diagnoses including hypothyroidism (a disorder in which the thyroid does not produce enough hormone). A Care Plan revised 12/20/22 revealed Resident 41 was at risk for falls. A 1/6/23 Health Status Note revealed Resident 41 was found on the floor, was confused, had no signs of injury and was helped back to her/his room. On 5/2/23 at 3:00 PM Staff 5 (LPN Resident Care Manager) reviewed Resident 41's 1/6/23 fall and stated there was no investigation of the fall but she expected one to be completed. On 5/3/23 Staff 2 (DNS) reviewed Resident 41's fall, stated she expected the nurse on duty to complete a fall investigation and notify the physician and resident's family. Staff 2 stated she found witness statements for the 1/6/23 fall but no investigation was completed. , 2. Based on observation, interview and record review it was determined the facility failed to ensure the environment remained free from accident hazards for 1 of 1 sampled resident (#13) reviewed for hospice. This placed residents at risk for accidents. Findings include: a. Resident 13 was admitted to the facility in 2023 with diagnoses including dysphagia (difficulty in swallowing food or liquid) following a stroke. A 1/16/23 Admission MDS indicated Resident 13 had loss of liquids or solids from her/his mouth when eating or drinking and received hospice care. A 1/10/23 care plan indicated Resident 13 had a nutritional problem. Interventions included a preference to dine in the main dining room and in the resident's room when eating independently. Staff were to monitor, document and report any signs of dysphagia such as pocketing of food, choking, coughing, drooling, holding food in mouth, or several attempts at swallowing, refusing to eat, and if she/he appeared to be concerned during meals. A hospice Meeting Review with a certification period of 1/18/23 through 3/18/23 revealed safety measures of Resident 13 included aspiration precautions with a regular diet. On 5/2/23 the following was observed: -12:02 PM Staff 15 (CNA) and Staff 26 (CNA) delivered Resident 13's food tray. -12:05 PM Staff 26 stayed in her/his room and attempted to cut Resident 13's pork with a fork and could not so used a knife to cut into the pork into approximately one-inch squares. Resident 13 stated she/he was hungry all the time but could not chew her/his food. -12:08 PM Staff 27 (CMA) entered Resident 13's room to administer pain medication and Resident 13 stated a pain level of seven out of 10. -12:11 PM Staff 27 continued to be in Resident 13's room as Resident 13 started choking. Resident 13 reached into her/his mouth and pulled out a slice of pork which was still whole. Staff 27 stated she thought Resident 13 was going to vomit. Resident 13 stated she/he could not eat the pork. -12:18 PM Staff 4 (RNCM) stated she would speak to the kitchen about Resident 13's food and she/he was scheduled for a swallow test on 5/3/23. A 5/3/23 Alert Note indicated a CNA reported Resident 13 was "coughing" more with meals. Resident 13 was currently on a general regular diet. Resident 13's diet would be downgraded to soft and bite sized and hospice would be notified. No documentation was found in the clinical records Resident 13 choked on 5/2/23. On 5/3/23 the following was observed: -8:23 AM Resident 13 was observed eating pancakes and one slice of uncut bacon was on her/his plate. -8:24 AM Staff 27 entered the room and confirmed the bacon was not considered a soft texture. Staff 27 asked Resident 13 if she/he was going to eat the bacon and she/he stated she/he was not. Staff 27 left the bacon on Resident 13's plate. -8:31 AM Staff 14 (Nutrition and Services Manager) stated Resident 13 was on a regular texture diet and was not on an easy to chew diet. -9:03 AM Resident 13 stated she/he did eat her/his bacon for her/his breakfast, and she/he almost choked on it but did not. -12:02 PM Staff 26 delivered Resident 13's food tray. Resident 13 received chopped up meatloaf in a gravy. Resident 13 stated the meatloaf was tough and difficult to chew. A 5/4/23 Kardex (instructions for CNAs) revealed Resident 13's diet was a regular diet with regular texture. Nutrition and eating included "dining preference-main dining room", "dining preference-Resident's room", "Eating-Independent." On 5/4/23 at 10:14 AM Witness 5 (Hospice RN) stated Resident 13 was an aspiration risk, should be sitting up when eating, and for 30 minutes after a meal. Witness 5 stated Resident 13 should be supervised while eating and "ideally" should have someone with her/him while she/he eats. Witness 5 stated the facility did not report Resident 13's choking incident on 5/2/23. On 5/4/23 at 11:24 AM Resident 13 stated she/he did not understand why her/his food was cut up into small pieces but was still difficult to chew. Resident 13 stated she/he would like food which was easy to chew. In an interview on 5/5/23 at 9:49 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) stated all resident's beds were to be placed in an upright position before eating and Staff 27 was a CMA and did not enter progress notes such as regarding Resident 13 choking.

F 689 Free of Accident Hazards/Supervision/Devices Resident Cited Resident # 15 Helen Kivisto: Incident investigation to be re-opened for fall on 4/9/23 to write a more thorough summary of investigation including time when resident was last checked on if possible. Resident # 42 Pauline Robinson: Incident investigation for fall on 4/5/23 to be re-opened to write a more thorough summary of investigation including time when resident was last checked on if possible. Resident # 41 John Carsner: Incident report and investigation to be completed for fall on 1/6/23. Resident # 13 Gary Reigel: Residents diet has been downgraded to a Soft and Bite Sized Texture. Careplan to be updated to reflect encouraging resident to get up into chair when eating with supervision in dining room as he allows. Notification sent to Hospice regarding resident choking with pork on 5/2/23 that he was able to clear by pulling out food himself. Careplan updated with aspiration risk precautions. Request ST eval for diet texture. Residents at Risk All residents with falls/dysphagia are at potential risk for this deficient practice. Tray audit will be completed for residents who have dysphagia and are aspiration risks to ensure appropriate diet texture is being served. Careplans of residents who are an aspiration risk to be audited to ensure interventions are in place. Falls for the last 30 days will be reviewed for thoroughness of investigations. Education Education to be completed with Nurse Management on completing a thorough investigation. Education completed with Licensed Nurses to ensure every fall has an incident report completed. Education to be completed with all nursing staff regarding reporting/documenting residents that have trouble eating/coughing with meals/choking and implementation of interventions. Audits To ensure ongoing compliance DNS/Designee will conduct random tray audits on residents with dysphagia to ensure safe texture is being served/careplanned interventions are in place weekly x 4 weeks, monthly x 2 months. DNS/designee will conduct audits on incident investigations completed weekly x 4 weeks, monthly x 2 months to ensure a thorough investigation was completed. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to provide adequate incontinent care for 1 of 1 sampled resident (#54) reviewed for incontinence care. This placed residents at risk for skin breakdown. Findings Include: Resident 54 was admitted to the facility in 2022 with diagnoses including UTI. The care plan initiated on 9/7/2022 indicated resident 54 had bladder incontinence related to decreased mobility. Resident 54 was at risk for UTI and staff were to assist the resident with incontinence care. On 1/25/23 a public complaint was received which indicated Witness 8 (Hospital Care Management Team) reported Resident 54 was sent to the hospital on 1/24/23 from the facility to rule out a stroke. Resident 54 arrived in the ER wearing two pull-up type incontinence briefs which were saturated with urine. On 5/3/23 at 7:08 PM Staff 19 (CNA) stated resident 54 wore pull-ups or briefs. Staff 19 stated the resident called for assistance most of the time but was occasionally incontinent. Staff 19 stated she was not aware of any staff who placed two briefs on any residents. On 5/3/23 at 8:04 PM Staff 20 (CNA) stated Resident 54 used the commode but became more incontinent the more sick she/he became. Staff 20 stated she was not aware of any staff who placed two briefs on a resident. On 5/4/23 at 9:22 AM Staff 3 (LPN Resident Care Manager) acknowledged Resident 54 was sent to the hospital wearing two briefs.

F 690 Bowel/Bladder Incontinence, Catheter, UTI Resident Cited Resident # 54 James Holmes: Resident no longer in facility. Residents at Risk All residents who are incontinent are at potential risk for this deficient practice. House-wide audit will be conducted on residents who are incontinent to ensure that adequate incontinence care is being provided and residents only have one brief on. Education Education to be completed with nursing staff regarding providing adequate incontinence care and not using two briefs on residents. Audits To ensure ongoing compliance, DNS/designee will complete random audits on residents who are incontinent to ensure incontinence care provided and appropriate amount of briefs on resident weekly x 4 weeks, then monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 7 of 9 sampled residents (#s 6, 13, 15, 18, 25, 58 and 202) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 6 was admitted to the facility in 3/2023 with diagnoses including femur fracture. An 4/4/23 Admission MDS revealed Resident 6 had a BIMS of 14 indicating she/he was cognitively intact. On 5/3/23 at 8:34 AM Resident 6 stated she/he had to wait for the call light to be answered at times and it resulted in incontinence. The 3/30/23 through 4/5/23 call light response log for Resident 6's room revealed the following call light wait times over 20 minutes: - 3/30/23 at 10:09 AM: 42 minutes - 3/30/23 at 4:16 PM: 40 minutes - 3/30/23 at 8:42 PM: 40 minutes - 3/31/23 at 12:32 PM: 38 minutes - 4/1/23 at 6:18 AM: 29 minutes - 4/1/23 at 12:07 PM: 21 minutes - 4/2/23 at 8:07 AM: 22 minutes - 4/2/23 at 8:45 AM: 24 minutes - 4/3/23 at 7:43 AM: 46 minutes - 4/3/23 at 9:24 AM: 25 minutes - 4/3/23 at 12:24 PM: 33 minutes - 4/4/23 at 8:01 AM: 1 hour and 8 minutes - 4/4/23 at 9:50 AM: 57 minutes - 4/5/23 at 8:57 AM: 22 minutes - 4/5/23 at 9:55 AM: 1 hour and 45 minutes On 5/3/23 at 10:02 AM Staff 13 (CNA) stated Resident 6 was continent during the day. Staff 13 stated call lights took longer to answer at times because the hall had two CNAs on shift and there were many residents who required extensive assistance of two staff. Staff 13 also stated when CNAs were on break the call lights took longer due to only one staff being available to provide care. On 5/3/23 at 11:23 AM Staff 12 (CNA) stated the facility staffed according to the census, but for the level of acuity of the residents the facility was short-staffed. Staff 12 stated the facility had many residents who were two person care so at times it resulted in a longer wait time. Staff 12 also stated it was possible for residents to wait an hour for care due to acuity. On 5/3/23 at 2:11 PM Staff 1 (DNS) stated she expected call wait times to be less than 20 minutes. On 5/4/23 at 2:45 PM Staff 23 (CNA) stated the facility could use additional staff and there were times a call light was on when she went on break and it was still on when she returned from break. , 2. Resident 13 was admitted to the facility in 2023 with diagnoses including stroke and dysphagia (difficulty swallowing). A care plan dated 1/25/23 indicated Resident 13 was at risk for falls. Interventions included to encourage Resident 13 to use the call light for assistance and provide prompt responses to all requests for assistance. A Page Report (call light time log) from 4/15/23 through 4/27/23 revealed Resident 13's call light wait times exceeded 20 minutes on several occasions: -4/15/23: 8:42 AM-38 minutes -4/16/23: 11:09 AM-26 minutes -4/17/23: 8:58 AM-28 minutes -4/18/23: 8:11 AM-one hour 21 minutes; and at 11:20 AM-39 minutes -4/19/23: 6:57 AM-52 minutes -4/21/23: 3:43 PM-26 minutes -4/25/23: 11:23-AM 21 minutes -4/26/23: 9:35 AM-29 minutes A review of the DCSDRs (Direct Care Staff Daily Reports) from 4/1/23 through 4/30/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA-to-resident staffing ratio for six of 34 days. The DCSDRs revealed the facility also exceeded the state maximum CNA to NA ratio of 25 percent for six of 34 days. On 5/1/23 at 12:48 PM Resident 13 stated the call light wait times were often over an hour when staff were passing out food trays. Resident 13 also stated at night if she/he fell asleep while waiting for her/his call light to be answered, the staff turned off her/his call light and walked away without assisting. On 5/3/23 at 10:58 AM Staff 16 (CNA) stated newer staff did not assist with answering all call lights but only attended to their assigned residents. On 5/4/23 at 6:53 AM Staff 15 (CNA) stated she was usually responsible for eight residents on day shift. Staff 15 also stated it was "impossible" to get all tasks done each day. In an interview on 5/5/23 at 9:36 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) stated the acuity of residents' needs increased due to behavioral and health issues. The facility was overstaffing to compensate for staff who called off work and then sending the extra staff home if not needed. Staff 1 stated they did not feel the facility was understaffed. 3. Resident 15 was admitted to the facility in 2022 with diagnoses including a disorder of the brain. A 2/11/22 care plan indicated Resident 15 fell due to balance and weakness issues. Interventions included keeping Resident 15's call light within reach, encouraging the resident to use the call light for assistance and providing prompt responses to all requests for assistance. A Page Report (call light time log) from 4/8/23 through 4/13/23 revealed Resident 15's call light wait times exceeded 20 minutes on several occasions: -4/12/23: 10:10 PM-39 minutes -4/13/23: 4:26 AM-23 minutes; 7:30 AM-47 minutes; and 2:11 PM-58 minutes. A review of the DCSDRs (Direct Care Staff Daily Reports) from 4/1/23 through 4/30/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA to resident staffing ratios for six of 34 days. The DCSDRs revealed the facility also exceeded the state 25 percent maximum ratio of NAs to CNAs for six of 34 shifts. On 5/1/23 at 11:38 AM Resident 15 stated the call light wait times were "well over" 10 minutes and staff came in and turned off the lights. Resident 15 also stated long call light wait times were a concern on all shifts. In an interview on 5/5/23 at 9:36 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) stated the acuity of residents' needs had increased due to behavioral and health issues. The facility was overstaffing to compensate for staff who called off work and then sending the extra staff home if not needed. Staff 1 stated they did not feel the facility was understaffed. 4. Resident 18 was admitted to the facility in 2019 with diagnoses including respiratory failure. An 4/24/20 care plan indicated Resident 18 was at risk for falls. Interventions included keeping Resident 18's call light within reach, encourage the resident to use the call light for assistance and providing prompt responses to all requests for assistance. A Page Report (call light time log) from 4/1/23 through 4/7/23 revealed Resident 18's call light wait times exceeded 20 minutes on several occasions: -4/1/23: 5:54 AM-one hour 13 minutes; 7:28 AM-34 minutes; 1:59 PM-42 minutes; 5:24 PM-25 minutes -4/2/23: 7:41 AM-50 minutes; 1:54 PM-35 minutes; 10:24 AM-38 minutes; 11:44 AM-38 minutes; 12:45 PM-28 minutes; 5:05 PM-24 minutes; 6:19 PM-31 minutes; and 7:29 PM-34 minutes -4/3/23: 11:47 AM-22 minutes; 12:53 PM-23 minutes; 7:22 PM-23 minutes; and 8:11 PM-25 minutes -4/4/23: 11:54 AM-21 minutes -4/5/23: 5:20 AM-36 minutes; 6:46 AM-52 minutes; 9:50 AM-23 minutes; 4:38 PM-26 minutes; 5:21 PM-55 minutes; 7:16 PM-24 minutes; 7:51 PM-47 minutes; 9:25 PM-51 minutes; and 10:38 PM-45 minutes -4/6/23: 7:35 AM-31 minutes; 12:34 PM-one hour 15 minutes; 3:57 PM-28 minutes; and 9:57 PM-32 minutes -4/7/23: 12:48 AM-35 minutes; 6:19 AM-31 minutes; 11:40 AM-25 minutes; 12:18 PM-29 minutes; 3:55 PM-37 minutes; 4:35 PM-one hour 30 minutes; 6:33 PM-23 minutes; 8:38 PM-36 minutes; 9:21 PM-55 minutes; and 10:41 PM-42 minutes A review of the DCSDRs (Direct Care Staff Daily Reports) from 4/1/23 through 4/30/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA to resident staffing ratios for six of 34 days. The DCSDRs revealed the facility exceeded the state 25 percent maximum ratio of NAs to CNAs for six of 34 shifts. On 5/1/23 at 10:28 AM and 5/3/23 at 11:53 AM Resident 18 stated in the last month call light wait times were around 45 minutes to get assistance. Resident 18 stated about 75 percent of the time it was due to staff members not answering the call lights in a timely manner and about 25 percent of the time there were issues with the call light system. In an interview on 5/5/23 at 9:36 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) stated the acuity of residents' needs had increased due to behavioral and health issues. The facility was overstaffing to compensate for staff who called off work and then sending the extra staff home if not needed. Staff 1 stated they did not feel the facility was understaffed. 5. Resident 25 was admitted to the facility in 2020 with diagnoses including infection in the spine. A 5/26/20 care plan indicated Resident 25 was at risk for falls. Interventions included to encourage Resident 25 to use the call light for assistance and for staff to promptly respond to all requests for assistance. A 2/4/23 Quarterly MDS indicated Resident 25's BIMS score was 15 indicating she/he was cognitively intact. Resident 25 required extensive one-person assistance with toileting, bed mobility and transfers. A Page Report (call light time log) from 4/8/23 through 4/14/23 revealed Resident 25's call light wait times exceeded 20 minutes on several occasions: -4/8/23: 1:54 PM-one hour 20 minutes; 5:32 PM-41 minutes; and 7:48 PM-23 minutes -4/9/23: 8:15 AM-51 minutes; and 9:47 PM-one hour 12 minutes -4/10/23: 1:25 PM-one hour 19 minutes; 5:35 PM-20 minutes; and 9:45 PM-54 minutes -4/11/23: 10:24 AM-27 minutes; 3:11 PM-one hour eight minutes; and 6:34 PM-31 minutes -4/12/23: 10:09 AM-22 minutes -4/13/23: 2:12 PM-55 minutes; 5:43 PM-28 minutes; and 6:49 PM-22 minutes A review of the DCSDRs (Direct Care Staff Daily Reports) from 4/1/23 through 4/30/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA to resident staffing ratios for six of 34 days. The DCSDRs revealed the facility exceeded the state 25 percent maximum ratio of NAs to CNAs for six of 34 shifts. On 5/1/23 at 10:31 AM Resident 25 stated the call light wait times could be as long as two hours. Resident 25 stated one night there was one staff member for 50 residents and the facility was short staffed most nights as staff called off work. In an interview on 5/5/23 at 9:36 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) stated the acuity of residents' needs had increased due to behavioral and health issues. The facility was overstaffing to compensate for staff who called off work and then sending the extra staff home if not needed. Staff 1 stated they did not feel the facility was understaffed. 6. Resident 58 was admitted to the facility in 2022 with diagnoses including morbid obesity and osteoarthritis of the knee. A 5/27/22 care plan indicated Resident 58 was continent of bladder and needed a female urinal. A 6/2/22 Admission MDS indicated Resident 58's BIMS score was 13 indicating she/he was cognitively intact. Resident 58 required extensive one-person assistance with toileting. A 6/2/22 Grievance Concern report revealed Resident 58 reported concerns for waiting a long time for her/his call light to be answered. A review of the Direct Care Staff Daily Reports from 5/27/22 through 5/30/22 revealed the facility did not have enough CNA staff to meet the state minimum CNA to resident staffing ratios for three out of the four days reviewed. On 5/3/23 at 9:24 AM Resident 58 stated the call lights were "useless" the majority of the time. Resident 58 stated call light wait times were about a half an hour and one instance she/he had to wait over two hours and she/he had an incontinent episode because of the long wait. In an interview on 5/5/23 at 9:16 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) confirmed there were staff shortages in 5/2022. , 7. Resident 202 was admitted to the facility in 2023 with diagnoses including foot fracture. A 3/7/23 care plan indicated Resident 202 was at risk for falls. Interventions included encouraging Resident 202 to use the call light for assistance and provide prompt response to all requests for assistance. A Page Report (call light time log) from 4/15/23 through 4/21/23 revealed Resident 202's call light wait times exceeded 20 minutes on several occasions: -4/16/23: 7:35 AM-29 minutes -4/16/23: 1:38 PM-52 minutes -4/17/23: 10:39 AM-25 minutes -4/17/23: 11:14 AM-one hour 17 minutes -4/17/23: 2:34 PM-39 minutes -4/18/23: 5:40 AM-29 minutes -4/18/23: 1:14-PM 35 minutes -4/18/23: 2:56 PM-44 minutes -4/19/23: 2:36 PM-32 minutes -4/19/23: :15 PM-32- minutes -4/19/23: 9:25 PM-22 minutes -4/20/23: 3:13 PM-one hour 19 minutes -4/20/23: 7:38 PM-29 minutes On 5/1/23 at 12:55 PM Resident 202 stated evening shift was the worst and she/he had to wait 30 minutes or more for staff to answer the call light. Resident 202 stated she/he was left on the commode for an hour and could hear the staff in the hall talking and laughing while she/he had her/his call light on. Resident 202 stated she/he had five incontinent episodes due to waiting too long for staff to answer her/his call light. Resident 202 stated she/he had to wait over an hour for pain medication because staff took too long to answer her/his call light. On 5/2/23 at 2:00 PM Staff 12 (CNA) stated the facility was short staffed on weekends. Staff 12 stated the acuity of the residents increased and staff had a difficult time responding to all of the call lights. On 5/3/23 at 8:04 PM Staff 20 (CNA) stated the facility seemed to have enough staff except on the weekends. Staff 20 stated the acuity of care had increased. On 5/4/23 at 9:56 AM Staff 3 (LPN Resident Care Manager) stated staff told her some staff were not answering their call lights. Staff 3 stated the acuity in the facility was high and staff did not have the appropriate training for the high acuity.

F 725 Sufficient Nursing Staff Resident Cited Resident #6, 13, 15, 18, 25, 58 and 202 were assessed for any needs. Residents at Risk All residents who use call lights are at potential risk for this deficient practice. The facility Administrator or designee completed interviews with a sample of residents to identify call light response time and residents' needs being met. Concerns identified were addressed accordingly. Education DNS provided re-education to the CNAs, around call light response times. DNS provided re-education to the LNs, around assisting CNAs with call lights and residents needs to ensure needs are addressed timely. Audits Administrator or designee will check 2 residents a week for 4 weeks and 1 resident for 1 month to validate call light response time is adequate. The results of the audit and any corrective action will be reported to the monthly QAPI committee for 3 months or until the deficiencies are resolved.

Based on interview and record review it was determined the facility failed to ensure routine medication was obtained timely for 2 of 6 sampled residents (#s 11 and 41) reviewed for pain and medications. This placed residents at risk for medication withdrawal symptoms. Findings include: 1. Resident 11 was admitted to the facility in 9/2022 with diagnoses including ankylosing spondylitis (inflammatory arthritis). Resident 11's 9/22/22 MDS and associated CAAs indicated she/he was alert and oriented. A 1/2023 MAR revealed Resident 11 was to be administered Methadone (narcotic pain medication) four times a day at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM. On 1/14/23, a Saturday, Resident 11 did not receive her/his 5:00 PM and 9:00 PM doses. The resident also did not receive the 1/15/23 9:00 AM dose. The 1/14/23 at 4:53 PM Progress Notes indicated the Methadone was "on order" and the 8:29 PM note indicated the pharmacy was called and the prescription was not authorized to be filled until 1/15/23. There were no additional notes in the resident's record to indicate the physician was called to refill the prescription sooner to prevent missed routine pain medication administrations. A 3/2023 MAR revealed the resident was to be administered Methadone four times a day at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM. Resident 11 did not receive her/his Methadone on 3/12/23, a Sunday, at 9:00 AM, 12:00 PM and 5:00 PM. The MAR also indicated Resident 11 did not receive her/his 5:00 PM and 9:00 PM Methadone doses on 3/13/23, or her/his 9:00 AM and 12:00 PM doses on 3/14/23. The 3/12/23 at 6:26 PM Progress Note indicated "awaiting [Methadone] delivery from pharmacy." The 8:00 PM note indicated the resident's physician authorized a one time order for Methadone to be administered at 8:00 PM and for 3/12/23 at midnight until the pharmacy delivered the refills. The 3/13/23 at 5:53 PM Progress Note indicated the provider was aware the Methadone was not available and "was working on this." The 3/13/23 notes also indicated the physician authorized 12 doses of Methadone but the pharmacy did not deliver the medication. The resident declined to be sent to the emergency room for pain management. The 3/14/23 Progress Note indicated staff called the pharmacy at 8:00 AM, 10:00 AM and 11:00 AM but had to leave messages. When the pharmacy returned the call they indicated the methadone "should" arrive "today." On 5/4/23 at 10:59 AM Witness 7 (Pharmacy Technician) indicated if the facility knew a narcotic was going to run out on the weekend and the prescription could not be refilled sooner, the facility was to call the pharmacy before the weekend. This could prevent the resident from running out of medication and a late delivery. Witness 7 indicated delivery of a medication could take at least four hours so it was important for the facility to call the pharmacy the day before the medication ran out. On 5/2/23 at 12:03 PM Resident 11 stated she/he was admitted to the facility in 9/2022 and the facility ran out of his medication on more than one occasion. There were problems with the delivery service or the pharmacy. Resident 11 indicated she/he took Methadone for the past 22 years for ankylosing spondylitis. Resident 11 indicated it was a very painful disease. Resident 11 indicated if she/he missed one dose of Methadone she/he started to feel withdrawal symptoms which included chills and the sensation that her/his skin was crawling. On 5/2/23 at 3:19 PM and 5/3/23 at 9:37 AM Staff 4 (RNCM) stated Resident 11 was on a strict pain management regimen and managed by a specific physician. At times the prescription ran out on the weekend and pharmacy was not able to deliver the medication on time. In 3/2023, the pharmacy system was down and the pharmacy was not able to fill the prescription and the physician had to send a new prescription to the pharmacy. , 2. Resident 41 was admitted to the facility in 2022 with diagnoses including hypothyroidism (a disorder in which the thyroid does not produce enough hormone). Resident 41's Physician's Orders revealed an order for levothyroxine sodium (a thyroid medication) to be administered every morning. Resident 41's 4/2023 MAR revealed levothyroxine was not administered on 4/22/23, 4/23/23, 4/24/23, 4/25/23, 4/26/23, 4/28/23 and 4/29/23. A review of Resident 41's progress notes revealed levothyroxine was not administered because the pharmacy did not send the medication due to the refill being too soon. There was no documentation of Resident 41's physician being notified of the medication errors and no documentation of communication with the pharmacy. On 5/3/23 at 3:32 PM Staff 24 (LPN) stated when medications were not available the staff were to notify the physician to see what they wanted to do, which could include a medication change and labs. On 5/4/23 at 11:39 AM Staff 2 (DNS) reviewed Resident 41's medication record and confirmed the levothyroxine sodium was not administered and the physician was not notified as she expected. Staff 2 stated if the medication was not available due to insurance not paying for it she would sign a form to have the facility pay for the medication but she was not aware of this medication issue.

F 755 Pharmacy Services Resident Cited Resident # 11 Dawayne Hurst: Methadone in stock for resident. Nurses educated on procedure when medication is not available. Resident # 41 John Carsner: Levothyroxine in stock for resident. Nurses educated on procedure when medication is not available. Residents at Risk All residents who reside in facility are at potential risk for this deficient practice. House-wide audit to be completed on medication not available in past week to ensure all medication in house and administered per order. Education Education to be completed with Licensed Nurses/CMAs regarding obtaining medications in a timely manner and procedure in place for what to do when medication is not available. Audits To ensure ongoing compliance, DNS/designee will complete audits of medication administration for medication not available weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure pharmacy review recommendations were addressed by the physician for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for subtherapeutic medication levels. Findings include: Resident 15 was admitted to the facility in 2022 with diagnoses including depression. Resident 15's current medications last reviewed 4/25/23 revealed the resident was to be administered sertraline (treats depression) 25 mg daily. A Recommendation Summary for Medical Director and DON (Director of Nursing) form dated 2/20/23 indicated Resident 15's current dose of sertraline was 25 mg daily. The dose was noted to be very low and the pharmacist indicated the resident could benefit from a dose of 50 mg or higher. On 5/3/23 at 9:16 AM Staff 4 (RNCM) stated she did not find a response from the 2/20/23 pharmacy recommendation for Resident 15.

F 756 Drug Regimen Review Resident Cited Resident # 15 Helen Kivisto: Pharmacy recommendation from February was sent to residents PCP for response. Response returned that PCP did not want to increase Sertraline dose as pharmacist suggested. Residents at Risk All residents who reside in facility are at potential risk for this deficient practice. Audit to be completed of the past 30 days of pharmacy recommendations to ensure follow up completed. Education Education completed with Nurse Management and Medical Records regarding timely follow up of Pharmacy recommendations. Audits To ensure ongoing compliance, DNS/Designee will complete audits of pharmacy recommendations for completion monthly x 3 months. Results of audits will be brought to QAPI for review.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from a medication error rate less than 5 percent. There were 3 errors in 31 opportunities resulting in a medication error rate of 9.7 percent. This placed residents at risk for adverse medication consequences. Findings include: Resident 18 was admitted to the facility in 2020 with diagnoses including diabetes. On 5/2/23 at 4:15 PM Staff 25 (CMA) was observed to prepare and deliver, lactulose (treats constipation), bupropione (treats depression), metformin (treats diabetes), diclofenac (decreases inflammation) and Tylenol (treats pain) to Resident 18. Staff 25 left the medications at the bedside and stated Resident 18 was assessed and staff were allowed to leave medications at the bedside. Review of the resident's record revealed there was a Self Administration of Medication Evaluation form dated 9/3/21 for staff to leave medications at the bedside. The assessment indicated the medication to be left at the bedside included bupropione and Tylenol. The form did not indicate the resident could self administer lactulose, metformin or diclofenac. On 5/3/23 at 9:40 AM Staff 4 (RNCM) stated residents were to be assessed to self administer specific medications which could be left at the bedside. On 5/3/23 at 10:43 AM Staff 2 (DNS) acknowledged medications left at the bedside during medication administration without an assessment were considered a medication error.

F 759 Free of Medication Error Rate 5 % or More Resident Cited Resident # 18 Kathleen Albrethsen: Self-Administration Assessment form updated to reflect current medications that are okay to leave a bedside per MD. Residents at Risk All residents who reside in facility and administer own medications are at potential risk for this deficient practice. All residents who self-administer medications audited to ensure assessment forms are updated as needed to reflect current orders. Education Education to be completed with nursing staff regarding ensuring self-administration medication forms are completed with all medications that resident self-administers. Audits To ensure ongoing compliance, DNS/designee will complete random audits on residents who self-administer medications to ensure self-administration forms are up to date with correct medications weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

Based on observation, interview and record review it was determined the facility failed to ensure residents received coordination for end-of-life care for 1 of 1 sampled resident (#13) reviewed for hospice. This placed residents at risk for a lack of coordination of care. Findings include: Resident 13 was admitted to the facility in 2023 with diagnoses including dysphagia (difficulty in swallowing food or liquid) following a stroke. The facility's 1/30/23 signed Hospice Contract with the facility agreed to observe, and record on a regular basis, the resident's response to treatment and the facility agreed to notify hospice "immediately" of any change in condition of the hospice resident. A hospice care plan with a certification period of 1/18/23 through 3/18/23 revealed safety measures of Resident 13 included aspiration precautions with a regular diet. On 5/1/23 at 10:34 AM and at 1:01 PM Resident 13 stated she/he had difficulty eating as she/he could not chew the food. Resident 13 revealed the inside of her/his mouth; no teeth were visible. Resident 13 stated she/he did not like the current wheelchair as it was uncomfortable for her/his legs, and she/he felt like she/he was going to fall out. Staff 15 (CNA) stated Resident 13's wheelchair was not appropriate, and she/he would benefit from a wheelchair which tilted back. Staff 15 attempted to talk Resident 13 in transferring out of bed into her/his wheelchair to reduce her/his pain level to get into an alternate position besides her/his bed and she/he declined. On 5/4/23 at 11:02 AM Witness 5 (Hospice RN) provided a hospice meeting review form (care plan) with a certification period of 3/19/23 through 5/17/23. On 5/4/23 at 12:30 PM the facility provided a hospice meeting review form with a certification period of 1/18/23 through 3/18/23. The updated hospice care plan was not found in Resident 13's clinical records at the facility. On 5/4/23 at 11:24 AM Resident 13 stated she/he did not understand why her/his food was cut up into small pieces but was still difficult to chew. Resident 13 stated she/he would like food which was easy to chew. On 5/4/23 at 10:14 AM Witness 5 (Hospice RN) stated a 5/2/23 choking incident was not reported to her. Witness 5 also stated it was not communicated to her that Resident 13 reported she/he was uncomfortable in her/his wheelchair and was concerned she/he would fall out. In an interview on 5/5/23 at 9:49 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN Resident Care Manager) stated there were multiple staff who communicated with hospice, and it was usually verbal. Staff 2 stated there was only one documented communication which was sent to hospice. No documentation of communications from the facility to hospice were provided. Refer to F557 and F689

F 849 Hospice Services Resident Cited Resident # 13 Gary Reigel: Incident on 5/2/23 in which resident was choking was reported to Hospice RN. Resident's statement that his wheelchair was uncomfortable was reported to Hospice RN. Residents at Risk All residents who are on Hospice are at potential risk for this deficient practice. All residents on Hospice to be reviewed to ensure care concerns have been communicated to Hospice personnel. Discussion with Hospice personnel regarding communication with facility for residents care needs. Education Education completed with Licensed Nurses regarding end of life coordination of care with Hospice personnel/notification to Hospice of any changes in condition of resident. Audits To ensure ongoing compliance, DNS/designee will complete audits of changes in condition of Hospice residents/communication to Hospice personnel weekly x 4 weeks, monthly x 3 months. Results of audits will be brought to QAPI for review.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing requirements were maintained for 12 of 102 shifts and exceeded the 25 percent maximum CNA to NA ratio for 5 of 102 shifts. This placed residents at risk of not receiving care in a timely manner. Findings include: A review of the DCSDRs (Direct Care Staff Daily Reports) from 4/1/23 through 4/30/23 and 5/27/22 through 5/30/22 revealed the facility did not have sufficient CNA staff to meet the minimum CNA to resident staffing ratio for 12 of 102 shifts, and the facility exceeded the 25 percent maximum ratio of NAs for 5 of 102 shifts. In an interview on 5/5/23 at 9:36 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (RCM/LPN) stated the acuity of residents' needs increased due to behavioral and health issues. The facility was overstaffing to compensate for staff who called off work and then sending the extra staff home if not needed. Staff 1 stated they did not feel the facility was understaffed.

M183 OAR Nursing Services Resident Cited No specific resident was cited. Residents at Risk All residents who reside in facility are at potential risk for this citation. Education Regional support provided re-education to the Administration and Staffing Coordinator, around ensuring significant staffing is provided and the 25% NA ratio per shift is not exceeded to meet residents needs. Audits Administrator or designee will review the Direct Care Staff Daily Reports 2 times a week for 4 weeks and once a month for one month to ensure the 25% NA maximum ratio of NAs to CNAs per shift is not exceeded. The results of the audit and any corrective action will be reported to the monthly QAPI committee for 3 months or until the deficiencies are resolved.

************************************ OAR 411-085-0310 Resident Rights: Generally Refer to F557 ************************************* OAR 411-085-0320 Residents' Rights: Charges and Rates Refer to F582 ************************************* OAR 411-085-0360 Abuse Refer to F600 ************************************* OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 ************************************ OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 and F759 ************************************ OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 and F690 ************************************ OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ************************************ OAR 411-086-0260 Pharmacy Services: Pharmaceutical Services Refer to F755 and F756 ************************************ OAR 411-086-0010 Administrator Refer to F849 ************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/31/2022 and 11/06/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate bowel care was provided for 1 of 5 sampled residents (#31) reviewed for medications. This placed residents at risk for unmet bowel care needs. Findings include: Resident 31 was admitted to the facility in 2021 with diagnoses including chronic bilateral lower extremity skin ulcers and acute kidney failure. The resident's 2/18/21 care plan indicated she/he was at risk for constipation, ileus (slowing or stopping of intestinal movement) and impaction (hard stool in the colon that will not pass). The 1/2022 MAR indicated Resident 31 began receiving Miralax (laxative) twice daily on 11/20/21 when it was ordered. A 1/2/22 PN (Progress Note) revealed Resident 31 complained of constipation and pain and felt like she/he could not pass stool. The PN further revealed MOM (Milk of Magnesia - laxative) was administered, fluids were encouraged and the physician was notified. On 1/2/22 the physician was notified of Resident 31's complaint of feeling constipated and pain when trying to pass stool. The physician responded with an order to decrease the dose of Miralax to once daily. The resident's 4/2022 MAR indicated she/he had the following bowel care medications available for administration: - Senna Plus (laxative) BID routinely, - Miralax every morning routinely, - Bisacodyl suppository daily (laxative) PRN for constipation, and - MOM every PRN constipation or no BM in 48 hours. On 4/8/22 the following occurred: - 11:29 AM Resident 31 told the surveyor she/he was having a difficult time trying to pass some hard stool. The resident stated it was "very painful" and she/he wanted something to help with the BM (bowel movement) but she/he was given nothing. - 11:35 AM Staff 5 (Agency LPN) stated she would tell the CMA to give the resident a stool softener. Resident 31 continued calling out for assistance and did not use the call light. - The 4/2022 MAR revealed MOM was administered to Resident 31 at 11:46 AM by Staff 4 (CMA). The result was documented as "unknown." - 11:50 AM, after administration of the MOM to Resident 31, Staff 4 stated she attempted to reposition the resident but the resident declined. - 11:53 AM Staff 4 stated the resident had pain related to constipation and took two bowel care medications. Staff 4 stated Resident 31's inability to reposition while in bed did not help with the constipation. - 12:00 PM Staff 3 (CNA) took Resident 31's lunch tray to her/his room. Staff 3 stated the resident reported she/he had constipation issues and was unable to eat. - 12:26 PM on 4/8/22 the surveyor heard Resident 31 calling out for help. According to the resident's medical record Resident 31 had no documented BMs from 4/6/22 at 1:59 PM through 4/9/22 at 12:33 PM. The 4/2022 MAR indicated Resident 31 was administered MOM on 4/10/22 at 9:59 AM and the result was documented as "ineffective." On 4/10/22 at 5:31 PM Resident 31 was heard by the surveyor repeatedly calling out "help" from her/his room. At 5:41 PM on 4/10/22 the surveyor visited Resident 31 who was agitated and calling out to staff for help because she/he was unable to locate the call light. The resident stated she/he was trying to have a BM, but it was too hard and painful to pass. The resident's medical record revealed no documented BMs for Resident 31 on 4/10/22. On 4/11/22 at 12:56 AM the resident's medical record indicated a medium BM was documented. On 4/11/22 at 12:05 PM Resident 31 was observed lying in bed and there was a strong smell of BM. The resident stated she/he had been trying to have a BM but it was too painful. The resident further stated the problem with having BMs had been "going on for awhile." The resident received MOM at 3:12 PM on 4/11/22 and the result was documented as "ineffective." During an interview on 4/12/22 at 10:06 AM Staff 2 (DNS) revealed the bowel protocol followed by the facility was to provide MOM after three days without a BM, if the MOM was ineffective a suppository was administered and if there were no results an enema was administered. Staff 2 acknowledged Resident 31 was not provided appropriate bowel care.

Resident # 31 remains in facility ICF. Resident # 31’s medications were reviewed with MD to ensure appropriate bowel care ordered to prevent constipation. Residents currently residing in the facility may be at risk related to this citation. Residents orders are reviewed to ensure standing bowel care orders are in place as appropriate. Staff education will be completed with Licensed Nurses and CMAs regarding following the bowel care protocol and notifying MD if bowel care protocol is not working or resident complains of hard stool/being constipated. To ensure on-going compliance, the Director of Nursing/designee will complete audits of the bowel care list to ensure medications are given appropriately as ordered and physician notified if not effective. These audits will be daily (Monday through Friday) for two weeks, then weekly for four weeks, then monthly until substantial compliance is maintained. Audit outcomes will be reported to monthly quality assurance meeting.

****************************** 411-085-0110 Nursing Services: Resident Care Refer to F684

Based on interview and record review it was determined the facility failed to ensure residents were free from verbal abuse for 2 of 8 sampled residents (#s 2 and 9) reviewed for abuse. This placed resident at risk for abuse. Findings include: 1. Resident 2 was admitted to the facility in 3/2018 with diagnoses including dementia and depression. A significant change MDS dated 10/22/21 revealed Resident 2 was rarely understood and she/he required a one or two-person extensive assistance with all her/his ADL care needs. A 6/26/20 Incident Investigation revealed the following: -Resident 2 was heard yelling and screaming "somebody help me!" Witness 15 (Former-CNA) was heard yelling and cursing telling Resident 2 "you need to shut the fuck up right now. People are trying to sleep." -Staff 10 (LPN) heard the noise and entered Resident 2's room to find Witness 15 at the foot of the bed and the bed was waist high. Resident 2 was holding onto the side rail yelling and appeared scared. -Witness 15 had stepped away from the bed and the cord to the remote was stretched all the way out in Witness 15's hand and she was standing away from the bed just staring at Resident 2. -Resident 2's blankets were all the way off, her/his clothes were at Resident 2's feet and her/his shirt was up around her/his neck. -Staff 10 told Witness 15 to leave the room and she would provide ADL care for Resident 2. -Staff 24 (CNA) stated she heard Witness 15 cursing and screaming from Resident 2's room when Staff 10 entered the room to see what was going on. Staff 15 left Resident 2's room yelling, cursing and slamming doors and then went outside to smoke. -Staff 10 stated she was charting at the nurse's station when she heard the cursing and screaming coming from Resident 2's room. She entered the room and took over ADL cares for Resident 2 and had Witness 15 exit the room. -Staff 15 (Former-CNA) stated Resident 2 was screaming and Witness 15 was trying to change her/him and get Resident 2 up. Witness 15 stated that she probably sounded loud because she was by Resident 2's door and talking over Resident 2 screaming. Witness 15 further stated she knows she should not raise her voice but does at times and becomes impatient with residents because residents were impatient with their ADL care needs and it stressed her out. -Five residents were interviewed regarding Witness 15 and they indicated she was perturbed easily, slammed items around, used foul language and was short tempered at times. -Resident 2 when interviewed did not recall the event that occurred on 6/26/20 -It was determined Witness 15 was verbally abusive towards Resident 2 and Witness 15 was terminated. Attempts were made to contact Witness 15 and Staff 24 but were unsuccessful. On 12/23/21 at 10:32 AM Staff 10 stated she recalled the incident on 6/26/20, heard Resident 2 yelling for help and heard Witness 15 cursing at the resident. Staff 10 stated she entered the room to find Witness 15 standing away from the bed with the remote control to the bed in her hand and the bed was waist high. Staff 10 stated Witness 15 was speaking rudely to Resident 2 who appeared scared. Staff 10 took the remote control to the bed from Witness 15 and told her to leave the room. Staff 10 stated she completed ADL care for Resident 2. Staff 10 further stated this was reported to the DNS and Witness 15 was terminated. On 12/29/21 at 10:44 AM Staff 2 (DNS) stated she was informed of the 6/26/20 incident from Staff 10, initiated an investigation. Witness 15 was determined to be verbally abusive towards Resident 2 and additional residents reported Witness 15 had unprofessional and inappropriate behaviors when she assisted them with care needs. Witness 15 was terminated. 2. Resident 9 was admitted to the facility in 3/2010 with diagnoses including dementia and a brain tumor. A quarterly MDS dated 11/14/21 revealed Resident 9 had a BIMs score of 11 indicating moderate cognitive impairment. Resident 9 required one or two-person extensive assistance with all her/his ADL care needs. A 6/26/20 Incident Investigation revealed the following: -Witness 15 (Former-CNA) was overheard by Witness 16 (Former-LPN) telling Resident 9 she would not get her/him up to use the toilet because Witness 15 had just changed her/him. Witness 15 stated to Resident 9 "you never pee when you are placed on the toilet." Witness 16 spoke with Witness 15 and let her know that was not appropriate and that Witness 15 needed to place Resident 9 on the toilet. -Witness 15 had been observed over the last couple of weeks be impatient with Resident 9 by yelling at her/him loudly. -Five residents were interviewed regarding Witness 15 and they indicated she was perturbed easily, slammed items around, used foul language and short tempered at times. -Resident 9 stated she recalled a staff member would not take her/him to the bathroom but another CNA assisted her/him to the toilet. Resident 9 could not recall specific details regarding Witness 15. -Witness 15 stated Resident 9 needed to utilize the bathroom and had no patience. Witness 15 stated she had raised her voice towards Resident 9 saying "You need to wait. You are going to hurt yourself." Witness 15 stated she raised her voice to get other staff members to come in and help her. Witness 15 further stated she knows she should not raise her voice but does and becomes impatient with residents at times because residents were impatient with their ADL care needs and it stressed her out. -It was determined Witness 15 displayed unprofessional behaviors towards Resident 9 and other resident in the facility and Witness 15 was terminated. Attempts were made to reach Staff 15 (Former-CNA), Staff 16 (Former-LPN) and Staff 24 (CNA) but were unsuccessful. On 12/29/21 at 10:44 AM Staff 2 (DNS) stated she was informed of the 6/26/20 incident from Staff 10 and initiated her investigation and based off her finding Witness 15 had unprofessional and inappropriate behaviors towards Resident 9 and other residents when assisting them with care needs. Staff 2 stated Witness 15 was terminated.

Resident#2 Discharged from the facility on 01/07/2022. Resident #9 remains in the facility as an ICF resident. Both residents were placed on alert for psychological harm following incident. Staff Member #15 mentioned in this citation was terminated immediately following the incident. Residents currently residing in facility may be at risk related to this citation. Interviews conducted with Residents to identify any abuse that was not reported. Staff to be re-educated regarding policies on abuse and neglect. To ensure on-going compliance, the Director of Nursing/ designee will complete audits and resident interviews to ensure no abuse or neglect are occurring and take appropriate action as needed. These audits will be daily(Monday through Friday) for two weeks, then weekly for four weeks, then monthly until substantial compliance is maintained. Audit outcomes will be reported to monthly quality assurance meeting.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#4) reviewed for discharge planning. This placed residents at risk for an unsafe discharge. Findings include: Resident 4 was admitted to the facility in 1/2021 for rehabilitation and wound care following surgery. A 1/14/21 care plan revealed Resident 4's discharge plan was to return home. Facility staff were to establish a pre-discharge plan with the resident, family and caregivers and evaluate progress and revise the care plan as needed. Facility staff were to make arrangements with required community resources to support independence post-discharge including home health, occupational therapy, physical therapy, and nursing services. The care plan was not updated at any point during the resident's stay to reflect her/his specific discharge needs. A physician visit dated 3/16/21 indicated Resident 4 admitted to the facility following surgery. Resident 4 was at the facility for therapy services as well as wound care management of wound drains. Resident 4 was to discharge home on 3/17/21 and the physician discharge instructions included the following: - Resident 4's wound to her/his left foot was to be cleansed with normal saline and apply a foam dressing; this was to be changed every three days and PRN. -Resident 4's left flank wound was to be cleansed with normal saline or wound cleanser, apply skin prep to peri wound as needed for skin breakdown, apply Hydro-fiber (a soft, sterile, non-woven pad to absorb a large amount of wound fluid) with Silverlon (an absorbent rayon pad covered with a film transparent layer and an adhesive border) and cover with silicone border foam. A 3/17/21 Physician Discharge Order indicated home health services were required at the time of discharge, a wound care consult was required and wound care orders were reviewed with Resident 4 on 3/16/21. A 3/17/21 Discharge Summary Plan of Care revealed Resident 4 was alert and oriented and able to communicate her/his needs. While at the facility Resident 4 received physical therapy, occupational therapy and wound care. Resident 4 discharged home on 3/17/21 with a home health referral. The resident needed a wheelchair, mechanical lift and a bedside commode. The Discharge Summary Plan indicated Resident 4 had a pressure wound to her/his left lateral foot and a surgical wound to her/his iliac crest. Medications were reviewed with Resident 4 and wound care treatment instructions were marked as not applicable. The facility did not provide wound care supplies upon her/his discharge. A 3/18/21 Social Service note revealed Witness 9 (Complainant) called and stated the home health agency did not receive Resident 4's referral for home health services. Staff 5 (Social Service Director) re-faxed the order to the home health office and received a confirmation via fax on 3/18/21. On 12/20/21 at 2:31 PM Witness 9 stated Resident 4 was discharged home on 3/17/21 with no wound care supplies and she had no knowledge of how to care for the wounds. Witness 9 stated she called EMTs (emergency medical technicians) to care for Resident 4's wounds. Witness 9 spoke with Staff 5 regarding lack of home health services for Resident 4 or any wound supplies to care for Resident 4's wounds. Witness 9 stated home health services did not receive a referral until after Resident 4 arrived home. Due to lack of communication and planning from the nursing facility Resident 4 was not assessed by home health services until approximately six or seven days after discharge from the facility. Witness 9 stated it was stressful for her and Resident 4. On 12/21/21 at 11:07 AM Staff 5 and Staff 6 (Social Service Assistant) stated they initiated home health services on 3/16/21 but the referral was sent to the wrong county and home health did not alert them of this. Staff 5 stated Witness 9 informed them on 3/18/21 she had not yet heard from home health care services. Staff 5 and Staff 6 stated they re-submitted/faxed the referral for home health on 3/18/21 to the correct county. Staff 5 and Staff 6 further stated nursing staff were to review the discharge information with family and residents regarding medications and any other nursing services required at the time of discharge. On 12/21/21 at 12:17 PM Witness 14 (Home Health Medical Records) stated they received a home health referral via fax from the nursing facility on 3/18/21, the referral was approved by Resident 4's insurance on 3/19/21 and services were not started until 3/24/21 (seven days after Resident 4 discharged from the facility). On 12/21/21 at 12:28 PM Witness 13 (Home Health Clinical Manager) stated she did not assess Resident 4 until 3/24/21. Resident 4 had an unstageable (depth of the ulcer is obscured by slough in the wound bed) pressure ulcer to her/his left foot and a surgical wound to the left upper hip area. Witness 13 stated she supplied and delivered all products for the wounds and initiated wound care orders. On 12/23/21 at 11:21 AM Staff 3 (LPN/RCM) stated when Resident 4 discharged, the nurses were responsible to review the discharge paperwork with the resident and family. Staff 3 stated she recalled they had an issue with Resident 4's original referral for home health services but expected home health services to begin within a day or two after Resident 4 discharged. Staff 3 stated she could not verify wound care instructions were reviewed with Resident 4 or Witness 9 but wound care supplies should have been sent home with Resident 4.

Resident# 4 discharged from the facility on 3/17/2021 Residents currently residing in the facility that plan to discharge for the facility to home may be at risk related to this citation. Residents that have discharged from the facility in the last 30 days were reviewed to identify any issues with discharge plans. Staff to be reeducated regarding policies surrounding discharge and set-up home health services, including sending to correct county and following up with a phone call to ensure referral was received. Nursing staff education completed regarding completing education of wound care orders with resident and family prior to discharge and sending wound care supplies home when appropriate upon discharge from facility. To ensure ongoing compliance the Director of Nursing/ Designee will complete audits to ensure Home Health was set up appropriately upon discharge and necessary education completed/ supplies sent home with resident. These audits will be daily (Monday through Friday) for two weeks, then weekly for four weeks, then monthly until substantial compliance is maintained. Audit outcomes will be reported to monthly quality assurance meeting.

Based on interview and record review the facility failed to ensure showers and adequate hygiene were provided for 1 of 3 sampled residents (#5) reviewed for ADL care. This placed residents at risk for poor hygiene. Findings include: Resident 5 admitted to the facility during 3/2021 with diagnoses including traumatic brain injury and anxiety disorder. A 3/12/21 care plan revealed Resident 5 required one-person extensive assistance with grooming her/his hair and shaving. A 3/19/21 admission MDS revealed Resident 5's BIMS score was a nine indicating moderate cognitive impairment. A review of the 3/12/21 through 3/30/21 Documentation Survey report revealed the following: -Resident 5 had 37 opportunities for personal hygiene on day, evening and night shift. -Eight times Resident 5 had supervision (oversight or cueing) and set-up only. -Seven times Resident 5 had limited assistance and one-person physical assistance. -Three times Resident 5 was independent with set-up only. -One time Resident 5 was independent with set-up only and no physical help from staff. -Two times Resident 5 had the number eight which indicated the activity did not occur. -On 2/20/21 evening shift the column was left blank. On 12/20/21 at 2:43 PM Witness 10 (Complainant) stated she picked up Resident 5 for medical appointments and Resident 5 was not well groomed with messy hair and she/he had what appeared to be "feces" around her/his fingernails. On 12/23/21 at 9:10 AM Staff 20 (CNA/CMA) stated she recalled Resident 5 being "very" confused and needed one-person extensive assistance with her/his ADL care needs because of her/his confusion. On 12/23/21 at 11:03 AM Staff 10 (LPN) stated she recalled Resident 5 was "impulsive" and confused. Staff 10 stated Resident 5 needed one-person extensive assistance with her/his ADL care needs due to her/his confusion. On 12/23/21 at 12:02 PM and 1/4/22 at 11:51 AM Staff 3 (LPN/RCM) stated she recalled Resident 5 and her/his confusion. Staff 3 stated Resident 5 needed assistance with her/his ADL care needs because of her/his confusion. Staff 3 stated she expected staff to follow the care plan to ensure Resident 5's ADL care needs were met appropriately.

Resident #5 discharged from the facility on 03/30/2021. Resident currently residing in facility requiring assistance with ADLs may be at risk related to this citation Care plans reviewed for current residents in facility to ensure accuracy of the assistance required for ADL care. Review of POC charting completed to identify any discrepancies between what is care planned and what care is being provided. Staff to be re-educated regarding policies surrounding providing the care that a resident is care planned for and reporting any discrepancies to charge nurse/ nurse management. To ensure ongoing compliance the Director of Nursing/ Designee will complete audits to ensure POC charting matches what residents are care planned for and repeat staff education as needed. These audits will be daily (Monday through Friday) for two weeks, then weekly for four weeks, then monthly until substantial compliance is maintained. Audit outcomes will be reported to monthly quality assurance meeting.

Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety for 1 of 3 sampled residents (# 1) reviewed for accidents. Resident 1 fell and sustained a right hip fracture. Findings include: A public complaint was received on 7/13/20 that alleged the facility failed to provide appropriate care and services related to resident's fall. Resident 1 admitted to the facility in 2018 with diagnoses including stroke, abnormal gait and lack of coordination. A comprehensive care plan dated 1/17/20 indicated Resident 1 was a high fall risk and to keep call light in reach, floor free of clutter and Resident 1 was to wear non-skid socks with ambulation. Resident 1 was a one-person extensive assist for toileting and required the use of a gait belt when transferring and using her/his FWW (front wheeled walker). An incident report initiated on 7/12/2020 revealed the following: -Staff 14 (CNA) assisted Resident 1 to the bathroom using her/his FWW and as Resident 1 made her/his way to the bathroom Staff 14 followed behind her/him. Resident 1's FWW got caught on her/his roommates walker and caused Resident 1 to lose her/his balance and fall to the ground landing on her/his right hip. Staff 14 was unable to get from behind her/him and catch her/him in time. Resident 1 did not have a gait belt on during the time of the transfer. -Staff 14 alerted Staff 22 (RN) who entered the room and Resident 1 was on the ground, complaining of right hip pain. Staff 22 assessed the resident and directed staff to transfer her/him to bed by use of a mechanical lift. -Staff 22 notified the on-call physician and an in-house x-ray was completed and results showed a fracture to the right hip that appeared to be subacute to chronic in nature. -On 7/13/20 Resident 1 had increased pain in the morning and was sent to the hospital for evaluation. It was confirmed Resident 1 did fracture her/his right hip and was admitted for possible surgery. -Staff 14 indicated she got report from her fellow CNAs that Resident 1 took herself/himself to the bathroom with the use of an FWW. Staff 14 stated she approached Resident 1 and asked the resident if she/he had been using a gait belt during ambulation and she/he stated she/he did not need a gait belt and did fine without one. Staff 14 stated based on what Resident 1 said she did not utilize a gait belt. -It was determined Staff 14 failed to utilize a gait belt during Resident 1's ambulation and the policy stated all residents had gait belts used with transfers/ambulation unless it was medically contraindicated. A 7/12/20 Plan of Correction revealed the following: -An incident report for the right hip fracture was completed, MD and family were notified. The resident was sent to the hospital for possible surgical interventions. Education was completed with Staff 14 regarding the use of gait belts with all transfers and ambulation unless medically contraindicated and were specified on resident's care plan. -All residents that required assistance with transfers/ambulation were at risk for the deficient practice. Nurse management identified other residents that required assistance with transfers and ensured care plans were accurate -Nursing staff was re-educated on the use of gait belts with all residents that required assistance with transfers and ambulation. -Licensed nurses were educated regarding reviewing care plan and standards of care after each incident in which resident falls during ambulation, or transfers with staff present, to ensure a gait belt was used. -To ensure ongoing compliance Staff 2 DNS or designee will complete audits weekly times four weeks, then monthly times two months to validate that transfers and ambulation were being conducted with the use of a gait belt. -The results of the audits completed were brought to Quality Assurance and Performance Improvement and further audits would be completed as directed by the committee. A 7/16/20 Hospital Discharge Summary indicated Resident 1 had a ground level fall at her/his nursing facility resulting in a right hip fracture that required right hip surgery with no intraoperative complications. Resident 1 was discharged back to her/his nursing facility. Attempts were made to reach Witness 5 (Complainant) but were unsuccessful. On 12/21/21 at 12:50 PM Staff 18 (CNA) stated she was not present on 7/12/20 when Resident 1 broke her/his hip but stated she/he was a fall risk. Staff 18 stated Resident 1 used a FWW and required a one-person extensive assist with transfers and ambulation and required a gait belt for safety. Attempts were made to reach Staff 22 but were unsuccessful. On 12/22/21 at 12:55 PM Staff 14 stated she recalled the incident on 7/12/20 when Resident 1 fell. Staff 14 stated Resident 1 was a one-person extensive assist with the use a gait belt. Staff 14 stated Resident 1 needed assistance to the bathroom and she did not place a gait belt on Resident 1. When the resident ambulated with her/his FWW she/he fell which resulted in a fractured hip. Staff 14 stated Resident 1 was complaining of pain to her/his hip. Staff 14 stated she called for backup, a nurse entered the room and assessed Resident 1 and they placed her/him back into bed. Staff 14 stated she thought Resident 1 was not sent out to the hospital until the following day. Staff 14 further stated she should have reviewed the care plan. On 12/23/21 at 10:28 AM Resident 1 stated she/he recalled the fall on 7/12/20. Resident 1 stated a CNA helped her/him while using her/his FWW. Resident 1 stated the FWW got caught up on something and caused her/him to fall to the ground and she/he broke her/his right hip. Resident 1 stated she/he could not recall if a gait belt was used but stated the break was "painful". Resident 1 stated she/he thought she/he was sent out later that evening to the hospital but could not recall. On 12/22/21 at 4:00 PM and 12/29/21 at 10:37 AM Staff 2 (DNS) acknowledged the 7/12/20 fall incident which resulted in Resident 1 sustaining a right hip fracture. Staff 2 stated she expected Staff 14 (CNA) to review the care plan and utilize the gait belt when transferring Resident 1.

Based on interview and record review it was determined the facility failed to ensure medically related social services were provided related to discharge for 1 of 3 sampled residents (#4) reviewed for discharge. This placed residents at risk for unsafe discharge. Findings include: Resident 4 was admitted to the facility in 1/2021 for rehabilitation and wound care following surgery. A 1/14/21 care plan revealed Resident 4's discharge plan was to return home. Facility staff were to establish a pre-discharge plan with the resident, family and caregivers and evaluate progress and revise the care plan as needed. Facility staff were to make arrangements with required community resources to support independence post-discharge including home health, occupational therapy, physical therapy, and nursing services. The care plan was not updated at any point during the resident's stay to reflect her/his specific discharge needs. A 3/17/21 Physician Discharge Order indicated home health services were required at the time of discharge, a wound care consult was required and wound care orders were reviewed on 3/16/21. A 3/17/21 Discharge Summary Plan of Care revealed Resident 4 was alert and oriented and able to communicate her/his needs. Resident 4 discharged home on 3/17/21 with a home health referral. The resident needed a wheelchair, mechanical lift, bedside commode, and wound care. A 3/18/21 Social Service note revealed Witness 9 (Complainant) called and stated the home health agency did not receive Resident 4's referral for home health services. Staff 5 (Social Service Director) re-faxed the order to the home health office and received a confirmation via fax on 3/18/21. On 12/20/21 at 2:31 PM Witness 9 stated Resident 4 was discharged home on 3/17/21 with no wound care supplies and she had no knowledge of how to care for the wounds. Witness 9 stated she called EMTs (emergency medical technicians) to care for Resident 4's wounds. Witness 9 spoke with Staff 5 regarding not having home health services in place for Resident 4. Witness 9 stated home health services did not receive a referral until after Resident 4 had arrived home. Due to lack a of communication and planning Resident 4 was not assessed by home health services until approximately six or seven days later. On 12/21/21 at 11:07 AM Staff 5 and Staff 6 (Social Service Assistant) stated they initiated home health services but the referral was sent to the wrong county. Staff 5 stated Witness 9 informed them on 3/18/21 she had not yet heard from home health services. Staff 5 and Staff 6 stated they re-submitted/faxed the referral for home health on 3/18/21 but did not speak to any staff at home health regarding Resident 4's home health services.

Resident# 4 discharged from the facility on 3/17/2021 Residents currently residing in the facility that plan to discharge for the facility to home may be at risk related to this citation. Residents that have discharged from the facility in the last 30 days were reviewed to identify any issues with discharge plans. Staff to be reeducated regarding policies surrounding discharge and set-up home health services, including sending to correct county and following up with a phone call to ensure referral was received. Nursing staff education completed regarding completing education of wound care orders with resident and family prior to discharge and sending wound care supplies home when appropriate upon discharge from facility. To ensure ongoing compliance the Director of Nursing/ Designee will complete audits to ensure Home Health was set up appropriately upon discharge and necessary education completed/ supplies sent home with resident. These audits will be daily (Monday through Friday) for two weeks, then weekly for four weeks, then monthly until substantial compliance is maintained. Audit outcomes will be reported to monthly quality assurance meeting.

OAR-411-085-0360 Abuse

Refer to F600 ***** OAR-411-086-0060 Comprehensive Assessment and Care Plan Refer to F660 ***** OAR-411-086-0110 Nursing Services: Resident Care Refer to F677 ***** OAR-411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 ***** OAR 411-086-0240 Social Services Refer to F745