Creswell Post Acute

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.

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OAR 411-086-0160 Nursing Services: Discharge Summary

Refer to F661
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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.

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.

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."

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.

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.

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.

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.

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.

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.

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.
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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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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OAR 411-085-0360 Abuse

Refer to F600
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F677, F684, and F760
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OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care

Refer to F690
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OAR 411-086-0100 Nursing Services: Staffing

Refer to F725
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OAR 411-086-0240 Social Services

Refer to F744
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Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 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.