Avamere Riverpark of Eugene

Based on interview and record review, it was determined the facility failed to ensure resident care equipment was monitored as recommended for 1 of 3 sampled residents (#12) reviewed for accidents. Resident 12 experienced a fall from a broken shower chair, sustained rib fractures, and a closed head injury. Findings include:

Resident 12 was admitted to the facility in 9/2024 with diagnoses including stroke.

A 5/14/25 Fall investigation revealed Staff 12 (CNA) was providing Resident 12 with a shower. Resident 12's shower chair broke and Resident 12 fell onto the shower room floor, complaining of head and right rib pain. Resident 12 was sent to the hospital.

A 5/14/25 hospital After Visit Summary revealed Resident 12 was diagnosed with a rib fracture, a closed head injury, and a bruise.

A review of the undated shower chair owner's manual revealed the chair was to be checked at least monthly for glued fittings by attempting to pull the polyvinyl chloride (type of plastic) out of the fittings. The pipes on the shower chair needed to be checked for cracking, fractures, or other damage at least monthly.

A Work History Report printed on 7/9/25 revealed no inspections of shower chairs were completed in 2024 or 2025.

On 7/8/25 at 12:35 PM, Resident 12 stated on 5/11/25 the shower chair came apart and two CNAs put the chair back together. On 5/14/25 she/he received a shower and the chair collapsed causing fractured ribs.

On 7/8/25 at 2:03 PM, Staff 11 (CNA) stated on 5/11/25 Resident 12 was in the shower chair and Staff 10 (CNA) noticed a piece was coming apart on the chair. Staff 11 stated they transferred Resident 12 to her/his wheelchair and Staff 10 took the shower chair to the maintenance room.

Attempts to reach Staff 10 on 7/8/25 and 7/9/25 were unsuccessful.

On 7/8/25 at 2:24 PM, Staff 8 (Maintenance Lead) stated on 5/12/25, there was a shower chair in the boiler room. Staff 8 stated there was no note on the chair and no work order was received for the chair. Staff 8 stated he did a visual inspection and figured a work order would come in. The shower chair was gone from the boiler room on 5/13/25. Staff 8 stated he did not do anything with the chair.

On 7/9/25 at 10:37 AM, Staff 12 stated she obtained the shower chair from the shower room on 5/14/25 and placed Resident 12 in the shower chair. Staff 12 did not hear any cracking noises when setting Resident 12 into the chair or while taking her/him to the shower room. After the shower was completed, Staff 12 rolled the chair toward her so she could dry Resident 12's feet and the shower chair collapsed.

On 7/9/25 at 11:09 AM, Staff 1 (Administrator) stated during the investigation they identified the process for broken equipment needed to be more "streamlined."

The deficient practice was identified as Past Noncompliance based on the following:

On 5/16/25, the deficient practice was identified by the facility and was corrected when the facility completed an investigation and identified system failures of using the same equipment which previously was broken. The Plan of Correction included:

-Broken shower chair was removed and discarded.

-A facility wide audit and inspection of all shower chairs was completed. A new process was implemented for logging equipment inspections as well as a new tagging process for equipment requiring maintenance.

-Facility wide education was provided to staff on equipment safety checks, the process for when equipment needed maintenance, and the new tagging process for equipment requiring maintenance.

-Audits were completed for random staff knowledge on equipment not functioning properly and audits of shower chairs' functional status were completed on the following dates: 5/23/25, 5/30/25, 6/6/25, 6/7/25, 6/13/25, 6/20/25, 6/27/25, and 7/3/25.

2. Resident 16 was admitted to the facility in 7/2022 with diagnoses which included stroke.

A 5/5/25 Bowel and Bladder Evaluation indicated Resident 16 was a candidate for scheduled toileting (timed voiding).

A 5/5/25 quarterly MDS indicated Resident 16 was cognitively intact.

A 6/3/25 care plan revealed Resident 16 was incontinent of bowel and bladder. Resident 16 had a history of urgency incontinence. Interventions included assisting with using the bathroom before breakfast and after lunch per preference to anticipate needs, resident used briefs, provide incontinentence care as needed, and provide peri care (cleaning of the genital area) after an incontinent episode.

A public complaint was received on 6/23/25 alleging in 6/2025 Resident 16 was not cleaned properly after a bowel movement. The brief was clean, but Resident 16 had dried feces over groin area, buttocks and down her/his thighs.

On 7/8/25 at 9:16 AM, Witness 1 (Complainant) stated twice in 6/2025 she found Resident 16 with dried feces on her/him. Witness 1 stated the first instance involved dried feces on her/his back, causing skin irritation. Witness 1 stated Staff 6 (CNA) came in, saw the dried feces on Resident 16, and cleaned her/him. The second instance involved dried feces on Resident 16's groin area.

On 7/8/25 at 12:42 PM, Resident 16 stated staff would put her/him in a wheelchair and she/he would be in it all day with no incontinentence care unless she/he advocated for assistance.

On 7/8/25 at 1:23 PM, Staff 6 (CNA) stated in 6/2025 he came on shift and assisted Resident 16 because she/he had dried feces on her/him and some dry skin flakes on her/his buttocks. Staff 6 stated Resident 16 was not fully cleaned following the previous incontinent episode.

On 7/8/25 at 1:31 PM, Staff 5 (CNA) stated there was a day in 6/2025 when Resident 16 had "explosive diarrhea" and she was changing Resident 16's shirt and pants all day long.

On 7/9/25 at 8:32 AM, Staff 7 (CNA) stated Resident 16 was difficult to clean after a bowel movement. Staff 7 stated she did not leave Resident 16 unclean after incontinentence care and there were times when she could only get "90 percent" of Resident 16's feces off her/him because she/he would refuse additional cleaning. Staff 7 reported it to the nurse and let the next CNA know during the shift change.

On 7/9/25 at 11:04 AM and 12:25 PM, Staff 1 (Administrator) stated she would expect staff to clean a resident thoroughly unless a resident refused. If a resident refused, CNA staff were expected to report the refusal to the nurse. Staff 2 (DNS) stated she expected the nurse to document if the resident refused incontinentence care in case there was a skin issue.



, Based on interview and record review it was determined the facility failed to provide adequate incontinentence and catheter care for 2 of 3 sampled residents (#s 14 and 16) reviewed for catheter care. This placed residents at risk for unmet care needs, skin breakdown and loss of dignity. Findings include:

1. Resident 14 was admitted to the facility in 12/2022 with diagnoses including chronic venous hypertension with ulcer and inflammation of bilateral lower extremity.

A 12/2024 Annual MDS indicated Resident 14 was cognitively intact.

A 12/16/24 signed order instructed staff to provide catheter care each shift.

A 6/2025 TAR instructed staff to provide catheter care each shift. Catheter care was not completed during the night shift on 6/6/25.

A FRI received on 6/9/25 alleged on 6/6/25 Resident 14 was not provided incontinentence care.

On 7/8/25 at 9:05 AM, Resident 14 stated she/he notified staff she/he needed her/his brief changed on 6/6/25. Staff 14 (CNA) stated she could not provide care immediately and would return.

On 7/8/25 at 4:10 PM, Staff 13 (CNA) stated during night shift on 6/6/25 he went to check on Resident 14 around 11:00 PM. Resident 14 was not changed for nine hours. Resident 14's catheter bag was full and was not checked on night shift.

On 7/9/25 at 11:00 AM, Staff 10 (CNA) stated Resident 14 reported Staff 14 (CNA) answered her/his call light and stated she would return and never did on 6/6/25. Staff 10 and Staff 13 assisted Resident 14 with the brief change on the next shift. Staff 10 stated it was "evident" Resident 14 was not provided catheter or incontinentence care during the night shift on 6/6/25.

Messages were left with Staff 14 (CNA) twice on 7/8/25 and twice on 7/9/25. Calls were not returned.

On 7/9/25 at 11:32 AM, Staff 1 (Administrator) acknowledged Resident 14 was not provided incontinentence care and the expectation was to provide care each shift.

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OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care

Refer to F689 and F690
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Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 1 sampled resident (#39) reviewed for medication administration. This placed residents at risk for lack of dignity. Findings include:

Resident 39 admitted to the facility in 2/2024 with diagnoses including diabetes.

On 10/10/24 at 11:50 AM Staff 28 (RN) performed a CBG (blood sugar measurement) check on Resident 39 in the dining room without permission from the resident with multiple residents in the dining room. Resident 39 required an insulin injection, Staff 28 raised the resident's shirt and administered the insulin into her/his abdomen. Resident 39 asked Staff 28 to administer the injection in her/his arm multiple times. Another resident in proximity to Resident 39 looked away during her/his insulin administration.

On 10/10/24 at 12:05 PM Staff 3 (LPN-Resident Care Manager) and Staff 30 (LPN-Resident Care Manager) acknowledged Staff 28 failed to protect Resident 39's dignity by performing a CBG check in the dining room, and by lifting Resident 39's shirt in a populated common area to administer insulin.

Based on interview and record review it was determined the facility failed to ensure a resident's representative was included in the care planning process for 1 of 2 sampled residents (#77) reviewed for communication. This placed residents at risk for lack of input in the care planning process. Findings include:

Resident 77 admitted to the facility in 12/2023 with diagnoses including stroke and aphasia (language disorder).

An 4/18/24 Comprehensive Plan of Care Review indicated "N/A" (not applicable) related to the attendance of the responsible party.

A 7/22/24 Annual MDS indicated Resident 77's BIMS assessment could not be completed, she/he was rarely understood and she/he used nonverbal communication to express her/his needs.

A 7/23/24 Comprehensive Plan of Care Review indicated "N/A" related to the attendance of the responsible party.

An 10/7/24 resident profile for Resident 77 indicated Witness 1 (Family Member) was her/his main contact.

On 10/7/24 at 4:01 PM Witness 1 stated she did not receive invitations to Resident 77's care conferences and she was in the facility weekly.

On 10/10/24 at 9:27 AM Staff 7 (Business Office Manager) stated invitations sent to Witness 1 for Resident 77's care conferences were completed through the mail, the invitations were returned to the facility due to an out of date address and the last attempt to contact Witness 1 was nine months earlier. Staff 9 stated Staff 6 (Social Services Coordinator) was not informed the invitations to Witness 1 were returned.

On 10/10/24 at 9:39 AM Staff 6 stated family involvement at care conferences would benefit Resident 77. Staff 6 acknowledged there was no communication with Resident 77 or Witness 1 to ensure family contacts were included in the care planning process.

Based on interview and record review it was determined the facility failed to notify the physician regarding refusals and changes in condition for 3 of 9 sampled residents (#s 26, 42, and 442) reviewed for medications, and change of condition. This placed residents at risk for lack of physician involvement. Findings include:

The facilities 2/2021 Requesting, Refusing, and/or Discontinuing Care or Treatment Policy indicated;
-the healthcare practitioner must be notified of refusal of treatment.

1. Resident 26 admitted to the facility in 10/2017 with diagnoses including kidney failure.

A 9/25/24 physician order indicated staff were to complete daily weights, and call the physician for a weight gain of two to three pounds per day over a two-day period or five pounds in one week.

A review of the 9/2024 and 10/2024 TARs indicated Resident 26 refused daily weights from 9/25/24 through 10/9/24.

A 9/25/24 physician order indicated staff were to check Resident 26's CBG (blood sugar measurement) level four times a day and to notify the physician for a CBG level less than 70 or greater than 400 before meals and at bedtime.

No documentation was found in Resident 26's clinical record the physician was notified of the refusals of daily weights and CBG checks from 9/25/24 through 10/9/24.

On 10/9/24 at 3:44 PM Staff 2 (DNS) confirmed the physician was not notified at any time of refusals for daily weights or CBG checks from 9/25/24 through 10/9/24.

2. Resident 442 admitted to the facility in 4/2024 with diagnoses including stroke.

A 4/6/24 physician order indicated staff were to administer chlorpromazine (antipsychotic for mental disorder) PO, vitamin D3 PO, Protonix (treat reflux) PO, lithium ER (extended release for bipolar disorder) PO, and propranolol (for high blood pressure) PO.

On 10/10/24 Drugs.com indicated the above medications should not be crushed or chewed.

A public complaint was received on 5/30/24 which alleged on 5/29/24 at 7:30 AM Staff 28 (RN) administered Resident 442's morning medications, and within 30 minutes Witness 2 (Complainant) noticed the resident was not responding to staff when spoken to and "became out of it."

On 10/7/24 at 2:13 PM Witness 2 stated Resident 442 was brought to the dining room for breakfast but did not eat. Witness 2 stated the resident was lethargic. Witness 2 stated Staff 28 was notified of the change of condition but the resident was not assessed.

On 10/8/24 at 1:55 PM Staff 32 (CNA) stated on 5/29/24 Resident 442 was lethargic in the morning and was placed back in bed. Staff 32 stated Staff 28 was notified but the resident was not assessed. Staff 32 stated the resident was placed in her/his wheelchair for lunch but the resident was more lethargic and not responsive to stimuli. Staff 32 stated Staff 28 was again notified but the resident was not assessed. Staff 32 stated Staff 34 (CNA) was notified and requested Staff 3 (LPN-Resident Care Manager) to assess Resident 442.

On 10/8/24 at 1:06 PM Staff 3 stated Staff 32 and Staff 34 requested she assess Resident 442. Staff 3 stated the resident was lethargic and sent out and admitted to the hospital.

A 5/29/24 Progress Note indicated Resident 442 had a difficult time swallowing her/his morning medications, so the medications were crushed and placed in pudding for administration.

A 5/29/24 Hospital Summary Note indicated Resident 442 arrived to the emergency room with altered mental status, and mildly elevated lithium levels. Normal lithium levels were 1.2 millequivents per liter and the resident's level was 2.5 millequivents per liter. Resident 442 was transferred to the ICU (intensive care unit).

No documentation was found in Resident 442's clinical record the physician was notified of the change of condition the morning of 5/29/24.

On 10/9/24 at 12:11 PM Staff 28 stated Resident 442 took her/his medication whole in applesauce or pudding, but on the morning of 5/29/24 she/he could not swallow her/his medications and was lethargic. Staff 28 stated she crushed Resident 442's morning medications and placed them in pudding. Staff 28 acknowledged she crushed medications, which should not be crushed, and did not notify the physician of the resident's change of condition.

On 10/9/24 at 3:03 PM Staff 2 (DNS) acknowledged Staff 28 crushed Resident 442's morning medications, which were not to be crushed, and did not notify the physician of the resident's change of condition timely.
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3. Resident 42 admitted to the facility in 6/2024 with diagnoses including cellulitus (deep infection of the skin) and heart failure.

A 7/8/24 Alert Note indicated Resident 42 was observed with a reddened area above her/his left ankle and the resident requested to be sent to the emergency department. Resident 42 returned to the facility with a diagnoses of cellulitis and new orders for antibiotics. There was no indication Resident 42's physician was notified of the resident's change of condition.

A 9/12/24 progress note indicated Resident 42 complained of uncontrolled pain and an inability to move her/his leg which had copious amounts of drainage. Resident 42 was transported to the emergency department. There was no indication Resident 42's physician was notified of the resident's change of condition.

On 10/11/24 at 12:29 PM Staff 2 (DNS) acknowledged no physician was notified on 7/8/24 or 9/12/24 of the resident's change of condition.

Based on interview and record review it was determined the facility failed to ensure the required parties were notified of resident hospitalizations for 3 of 7 sampled residents (#s 42, 44, and 89) reviewed for hospitalization and change of condition. This placed residents at risk for lack of advocacy. Findings include:

1. Resident 42 admitted to the facility in 6/2024 with diagnoses including cellulitus (deep infection of the skin) and heart failure.

A 9/12/24 Progress Note indicated Resident 42 was transported to the emergency department due to complaints of uncontrolled pain.

A 9/12/24 MDS Discharge Assessment was completed with an anticipated return from the hospital.

Review of Resident 42's clinical record revealed no transfer notice was provided to Resident 42, her/his representative, or a representative of the Office of the State Long-Term Care Ombudsman.

On 10/11/24 at 12:29 PM Staff 2 (DNS) acknowledged a transfer notice was not provided to Resident 42, her/his representative, or a representative of the Office of the State Long-Term Care Ombudsman.

, 2. Resident 44 admitted to the facility in 2/2024 with diagnoses including seizures.

An 8/12/24 Progress Note revealed Resident 44 was transported to the hospital.

No evidence was found in Resident 44's health record to indicate a transfer notice was provided to Resident 44, her/his representative, or a representative of the Office of the State Long-Term Care Ombudsman.

On 10/10/24 at 3:57 PM Staff 1 (Administrator) reviewed the transfer to the hospital and stated the facility did not provide a transfer notice to Resident 44, her/his representative, or a representative of the Office of the State Long-Term Care Ombudsman.
, 3. Resident 89 admitted to the facility in 10/2024 with diagnoses including non-infective gastroenteritis (inflammation of the stomach) and colitis (inflammation of the colon).

A 9/7/24 Progress Note revealed Resident 89 discharged to the hospital on 9/7/24.

No evidence was found in Resident 89's health record to indicate a transfer notice with appeal rights was provided in writing to her/him or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital.

On 10/10/24 at Staff 1 (Administrator) acknowledged the facility did not provide transfer notices to residents, their representatives, or the Office of the State Long-Term Care Ombudsman.

Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 3 of 7 sampled residents (#s 42, 44, and 89) reviewed for hospitalization and change of condition. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include:

1. Resident 42 was admitted to the facility in 6/2024 with diagnoses including cellulitus (deep infection of the skin) and heart failure.

A 9/12/24 progress note indicated Resident 42 was transported to the emergency department due to complaints of uncontrolled pain.

A 9/12/24 MDS Discharge Assessment was completed with return anticipated.

A reviewed of Resident 42's clinical record revealed no documentation the resident or her/his representative was provided information regarding the facilty bed hold policy.

On 10/11/24 at 11:09 AM Staff 14 (LPN) stated she did not understand the process to provide bed hold information to Resident 42 when she/he was transferred to the hospital and did not receive training related to the expectations.

On 10/11/24 at 12:29 PM Staff 2 (DNS) acknowledged the requirement to provide bed hold information to Resident 42 was not met.
, 2. Resident 44 admitted to the facility in 2/2024 with diagnoses including seizures.

A 8/12/24 Progress Note revealed Resident 44 was transported to the hospital.

A review of the medical record revealed no documentation a bed hold policy was provided to Resident 44 or her/his resident representative.

On 10/10/2024 at 3:57 PM Staff 1 (Administrator) reviewed the transfer to the hospital and stated the facility did not provide the bed hold to Resident 44 or his/her resident representative at the time of or after her/his transfer to the hospital.
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3. Resident 89 was admitted to the facility on 10/2024 with a diagnosis of noninfective Gastroenteritis and Colitis

A review of Resident 89's 8/20/24 review 5-day MDS Assessment revealed she/he was cognitively intact.

A review of Resident 89's nursing progress notes revealed she/he was discharged to the hospital on 9/7/24 and was readmitted to the facility on 10/9/24.

No evidence was found in Resident 89's health record to indicate a transfer notice with appeal rights was provided in writing to her/him or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital.

On 10/11/24 at 12:51 PM Staff 27 (Guest Services Coordinator) stated she was not able to get a hold of resident 89 and documented late entry.

2. Resident 42 admitted to the facility in 6/2024 with diagnoses including heart failure and severe obesity.

The 6/14/24 Admission MDS indicated Resident 42 was occasionally incontinent of bladder and required substantial to maximum assistance with toileting hygiene.

An 10/3/24 revised care plan indicated staff were to provide intermittent supervision for Resident 42's personal hygiene including her/his perineum (genital area), and staff were to monitor for signs of heart failure including edema.

On 10/9/24 at 3:42 PM Resident 42 stated when staff entered her/his room they often left without asking if she/he need additional assistance. Resident 42 stated she/he did not ask for toileting hygiene from those who did not know her/him well because the request was embarrassing and she/he stated toileting hygiene should be offered. Resident 42 stated because of all her/his care needs, it was difficult to remember to request assistance to elevate her/his legs to reduce the swelling.

On 10/10/24 at 5:38 PM Staff 2 (DNS) and Staff 1 (Administrator) acknowledged Resident 42's care plan was not personalized to meet the needs of the resident related to personal hygiene and edema interventions and Resident 42's care needs increased since her/his 9/2024 hospitalization.





, Based on interview and record review it was determined the facility failed to complete comprehensive care plans within the required timelines and revise care plan interventions for 2 of 7 sampled residents (#s 38 and 42) reviewed for change of condition, ADL care and edema. This placed residents at risk for unmet needs. Findings include:

1. Resident 38 admitted to the facility in 8/2022 with diagnoses including kidney disease and UTI.

On 10/7/24 at 11:25 AM Resident 38 reported recurrent UTIs every three months, and also reported chronic bladder discomfort, burning with urination, and a sense of urinary urgency.

The 7/21/23 care plan documented Resident 38 was "at risk for UTIs with history of UTIs." There were no documented updates or revisions to the goals or interventions since the original date of care plan initiation on 7/21/23.

On 10/9/24 at 5:17 PM Staff 3 (LPN-Resident Care Manager) reported the 7/21/23 care plan included Resident 38's recurring UTIs however the interventions were not revised or updated since the date the care plan was initiated.

On 10/11/24 at 8:18 AM Staff 2 (DNS) reported Resident 38 was diagnosed with six UTI's in 2023. Staff 2 confirmed the 7/21/23 care plan was not revised to address Resident 38's recurring UTIs.

Based on observation, interview, and record review it was determined the facility failed to ensure professional standards were followed for 2 of 6 sampled residents (#s 39 and 442) for medication administration. This placed residents at risk for adverse side effects and cross contamination. Findings include:

Per OAR 851-045-0040 Scope of Practice Standards for All Licensed Nurses
(1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall:
(A) Adhere to professional practice and performance standards;
Per OAR 851-045-0070 Conduct Derogatory to the Standards of Nursing Defined:
Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to:
(2) Conduct related to achieving and maintaining clinical competency:
(a) Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established;
(3) Conduct related to the client's safety and integrity:

1. Resident 442 admitted to the facility in 4/2024 with diagnoses including bipolar disorder (mental health disorder).

A public complaint was received on 5/30/24 which alleged on 5/29/24 at 7:30 AM Staff 28 (RN) administered Resident 442's morning medications, and within 30 minutes Witness 2 (Complainant) noticed the resident was not responding to staff when spoken to and "became out of it."

An 4/6/24 physician order indicated staff were to administer chlorpromazine (antipsychotic for mental disorder) PO, vitamin D3 PO, Protonix (treat reflux) PO, lithium ER (extended release for bipolar disorder) PO, and propranolol (for high blood pressure) PO.

On 10/10/24 Drugs.com indicated lithium ER should not be crushed, chewed, or broken.

A 5/29/24 Progress Note indicated Resident 442 had a difficult time swallowing her/his medication in the morning, so Staff 28 (RN) crushed Resident 442's medication and administered the medication in pudding.

On 10/9/24 at 12:11 PM Staff 28 (RN) acknowledged she crushed Resident 442's lithium, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record.

On 10/9/24 at 3:03 PM Staff 2 (DNS) acknowledged Staff 28 crushed Resident 442's lithium medication, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record.

2. Resident 39 admitted to the facility in 2/2024 with diagnoses including diabetes.

On 10/9/24 at 11:50 AM Staff 28 (RN) was observed to check Resident 39's CBG (blood sugar measurement) level in the dining room. Staff 28 placed the glucometer on the North medication cart and cleaned the glucometer with small alcohol prep wipes.

On 10/9/24 at 12:10 PM Staff 28 stated she always used alcohol prep wipes to sanitize the glucometer, and she was not aware of another sanitizing wipe.

On 10/9/24 12:15 PM Staff 3 (LPN-Resident Care Manager) and Staff 30 (LPN-Resident Care Manager) stated the glucometer should be sanitized with the proper sanitizing wipes.

Based on observation, interview, and record review it was determined the facility failed to provide meaningful activities to dependent residents for 2 of 3 sampled residents (#s 21 and 37) reviewed for activities. This placed residents at risk for a diminished quality of life. Findings include:

1. Resident 37 admitted to the facility in 7/2023 with diagnoses including stroke.

The 7/15/24 Annual MDS revealed Resident 37's cognition was severely impaired, her/his family was involved in her/his care and indicated she/he enjoyed listening to music, spending time outside, and participating in religious activities.

Resident 37's comprehensive care plan revealed her/his activities of interests were gospel music, Christmas, and bible study. The care plan interventions included staff were to provide one on one time, help Resident 37 go to activities, remind her/him of the activities she/he enjoyed, and leave music on for Resident 37.

The 10/2024 Activities Calendar included weekly bible study social visits and weekly bible study.

Resident 37's medical record included no documentation of her/his participation in group activities or one on one activities for the last thirty days. There were no Activity Progress Notes for Resident 37.

On 10/7/24 at 10:59 AM Resident 37 was laying in bed.

On 10/8/24 at 1:03 PM bible study social visits were occurring in the activity room, but Resident 37 was not in the activity room. Staff 4 (Activity Director) stated the residents in the activity were praying with the bible studies ladies.

On 10/8/24 at 1:05 PM Resident 37 was laying in bed and the television was on, but the volume was off.

On 10/8/24 at 2:01 PM the facility had bible study in the activity room. Resident 37 was laying in bed with the television on, but the volume was off.

On 10/9/24 at 2:21 PM Resident 37 was laying in bed and the television was on, but the volume was off.

On 10/9/24 at 2:41 PM Staff 36 (CNA) stated she did not see Resident 37 participate in activities. Staff 36 stated after Resident 37 finished meals she/he was helped to bed and left with the television on. Staff 36 stated Resident 37's family wanted the television and volume on for her/him because that was what she/he did at home.

On 10/10/24 at 9:49 AM Staff 4 stated the activities department provided one on one visits for residents who did not attend group activities. Staff 4 stated Resident 37 was very religious, however the CNA staff did not assist her/him into the wheelchair so the activities staff could take Resident 37 to the religious activities she/he enjoyed. Staff 4 stated there was no documentation of group or one on one activities provided for Resident 37 in the last 30 days.

On 10/10/24 at 10:12 AM Staff 35 (CNA) stated she was unaware of any group activities in which Resident 37 was interested in attending. Staff 35 stated after meals she helped Resident 37 back to bed. Staff 35 stated activities of interest for residents should be on the care plan.

On 10/10/24 at 10:21 AM Resident 37 was laying in bed and the television was on, but the volume was off.

On 10/10/24 at 2:31 PM Staff 37 (CMA) stated Resident 37 did not go to activities at all. Staff 37 said there was a time when Resident 37 had the television on with the volume on but the roommate did not want the sound on.

On 10/10/24 at 2:35 PM Staff 19 (CNA) stated Resident 37 was generally lying down in bed in her/his in room watching television. Staff 19 stated Resident 37 was never in activities and she was not aware of any activities she/he should attend.

On 10/10/24 at 3:55 PM Staff 1 (Administrator) stated she had seen Resident 37 in the dining room and with the television and music on. Staff 1 stated she expected staff to know what activities in which residents wanted to participate, and for those to be listed on the care plan.

, 2. Resident 21 admitted to the facility in 2/2021 with diagnoses including depression.

On 10/7/24 at 11:18 AM Resident 21 stated she/he was not interested in group activities and staff did not provide in-room activities.

On 10/9/24 at 11:26 AM Staff 4 (Activities Director) stated Resident 21 preferred to stay in bed. Staff 4 stated Resident 21's in-room activities included use of electronics, television, music and one-to-one visits.

An 10/10/24 medical record review revealed Resident 21 had one-to-one activity once in the last 30 days.

On 10/10/23 at 11:07 AM Staff 1 (Administrator) stated she was unable to locate any other one-to-one activity documentation for Resident 21 in the last 30 days.

Based on observation, interview and record review it was determined the facility failed to properly assess pressure ulcers for 2 of 4 sampled residents (#s 13 and 62) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:

1. Resident 13 admitted to the facility in 7/2024 with diagnoses including muscle weakness.

The 7/28/24 Admission MDS indicated Resident 13 was at risk for pressure ulcers due to incontinence and decreased mobility.

The 7/25/24 care plan revised on 9/26/24 indicated Resident 13 had current skin concerns including pressure injuries to the bilateral buttocks.

A 9/24/24 incident report indicated Resident 13 was being monitored for redness and a CNA found two large blisters. There was no documentation which indicated where the pressure ulcers were located on the resident.

A 9/25/24 Weekly Skin assessment indicated the resident's skin was intact.

A 9/25/24 Wound Evaluation indicated the resident had a pressure ulcer to her/his sacrum (bone at the end of the lower back).

The 10/1/24 Wound Evaluation indicated the resident had a pressure ulcer to her/his sacrum.

The 10/8/24 Wound Evaluation indicated the resident had a pressure ulcer to her/his sacrum.

On 10/9/24 at 10:24 AM Resident 13 was observed with pressure ulcers on her/his bilateral buttocks not her/his sacrum.

On 10/9/24 at 4:51 PM Staff 29 (RN) stated the wounds were on Resident 13's bilateral buttocks not the sacrum and there was no documentation in Resident 13's medical record which identified blisters to the bilateral buttocks.

On 10/9/24 at 5:03 PM Staff 2 (DNS) acknowledged Resident 13's pressure ulcer investigation was not accurate or thorough.
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2. Resident 62 admitted to the facility in 12/2022 with diagnoses including a left below the knee amputation.

A 9/20/24 investigation indicated Resident 62 had a wound to her/his left knee. The wound was described as a 3 cm red area with a white area in the center. Resident 62 stated the wound was a pressure wound due to friction from her/his prosthetic leg rubbing on her/his knee. The investigation concluded the wound was an abrasion caused by the prosthetic leg rubbing on Resident 62's left knee. Resident 62 was encouraged to take breaks from wearing the prosthetic leg during the day.

A 9/20/24 Wound Evaluation indicated Resident 62 had a 1.27 cm by 1.02 cm abrasion to her/his left knee.

On 10/7/24 at 10:46 AM Resident 62 stated she/he had a pressure wound on her/his left knee.

On 10/10/24 at 10:59 AM Staff 18 (LPN) stated Resident 62 had some weight loss and due to the weight loss, Resident 62's prosthetic leg did not fit correctly which resulted in a wound on Resident 62's left knee.

On 10/11/24 at 9:20 AM Staff 3 (LPN-Resident Care Manager) stated Resident 62's wound on her/his left knee was caused by the prosthetic leg being too big, which caused friction between the knee and the prosthetic, and resulted in an abrasion to Resident 52's left knee.

On 10/11/24 at 9:23 AM Staff 20 (LPN-Resident Care Manager) stated Resident 62's prosthetic leg was adjusted twice and padding was added to help the prosthetic leg fit Resident 62 better.

On 10/11/24 at 9:30 AM Staff 3 acknowledged Resident 62's wound on her/his left knee was classified incorrectly, and the wound met the definition of a pressure wound.

Based on observation, interview, and record review it was determined the facility failed to supervise a resident while eating for 1 of 4 sampled residents (#292) reviewed for change of condition. This placed residents at risk for aspiration or choking. Findings include:

Resident 292 admitted to the facility in 2/2024 with diagnoses including dementia.

A 2/20/24 Admission MDS revealed Resident 292 had swallowing difficulties.

A review of Resident 292's 3/11/24 care plan revealed an intervention of close supervision while eating.

A 3/19/24 investigation revealed on 3/14/24 after 10:30 PM Staff 24 (former staff member) assisted Resident 292 into the Central Dining Room, gave her/him a peanut butter and jelly sandwich and then went to the Central Nursing Station to chart. Staff 24 stated she asked Staff 26 (LPN) to supervise Resident 292 while she/he ate. Staff 26 was charting at the Central Nursing Station and was not in the dining room.

On 10/10/24 at 11:09 AM Staff 22 (CNA) stated close supervision of a resident meant the staff were to remain within arm's length of the resident while eating.

On 10/10/24 at 2:45 PM Staff 3 (LPN-Resident Care Manager) stated close supervision of a resident meant the staff were to remain within arm's length of the resident while eating.

On 10/10/24 at 4:01 PM Staff 25 (ST-Rehab Manager) stated close supervision of residents when eating meant staff must sit at the same table or an adjoining table and the resident was not left unattended with the food tray.

On 10/10/24 at 7:56 PM Staff 26 stated he was unaware Resident 292 was eating a sandwich in the Central Dining Room, and he was not supervising Resident 292 while she/he was eating.

On 10/11/24 at 10:05 AM Staff 2 (DNS) stated close supervision required staff to sit at the same table or the next table with the resident. Staff 2 observed the Central Dining Room from the Central Nursing Station and acknowledged the dining room could not be observed from the Central Nursing Station. Staff 2 stated Resident 292 did not receive close supervision while eating on 3/14/24.

The deficient practice was identified as Past Noncompliance based on the following:

On 3/15/24 the deficient practice was identified by the facility and was corrected by 3/18/24 when the facility completed a root cause analysis of the incident and determined the facility failed to provide needed supervision for a resident when eating. The Plan of Correction included:
-A facility-wide audit to verify all aspiration risk-related documentation and care plans were current to orders and therapy recommendations.
-Educate staff on supervision levels.
-Spot audit residents during meals or snack time to verify they received the appropriate supervision level.
-Audit staff to quiz recall on different supervision levels.

2. Resident 42 admitted to the facility in 6/2024 with diagnoses including sleep apnea (a pause in breathing during sleep).

A 6/10/24 care plan indicated Resident 42's CPAP (Continuous Positive Airway Pressure) machine was to be worn as tolerated.

A 7/30/24 physician order directed staff to empty the water reservoir of Resident 42's CPAP machine daily and wash her/his CPAP mask each morning.

The 9/2024 and 10/2024 TARs indicated to refer to nursing notes on 9/4/24, 9/5/24, 9/26/24, 9/28/24, 10/2/24 and 10/3/24 related to the care of Resident 42's CPAP reservoir and mask by Staff 10 (LPN). No nursing notes were found.

On 10/9/24 at 3:42 PM Resident 42 was observed with her/his CPAP machine in use and stated the machine was rarely cleaned.

On 10/10/24 at 5:19 PM Staff 10 stated she was often unable to complete the task to clean and service Resident 42's CPAP machine due to the request by the resident to return at a later time during the day when the machine was not in use. Staff 10 indicated Resident 42 rarely removed her/his CPAP machine.

On 10/10/24 at 5:38 PM Staff 2 (DNS) acknowledged Resident 42's CPAP machine needed to be emptied and mask cleaned as ordered even if the resident's equipment was often in use.






, Based on observation, interview and record review it was determined the facility failed to thoroughly assess and monitor respiratory status and maintain respiratory equipment for 2 of 2 sampled residents (#s 17 and 42) reviewed for respiratory services. This placed residents at risk for worsening respiratory status. Findings include:

1. Resident 17 admitted to the facility in 7/2023 with diagnoses including chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe), congestive heart failure (a long-term condition that occurs when the heart is unable to pump enough blood to meet the body's needs) and pulmonary hypertension (a condition that affects the blood vessels in the lungs, making it harder for blood to flow to the lungs and causing the heart to work harder to pump blood).

A 9/22/24 Progress Note indicated Resident 17 had a wet productive cough, generalized body aches and tested negative for COVID 19.

A 9/23/24 Progress Note indicated Resident 17 had increased weakness, a moist cough, lethargy, nausea, coarse lungs sounds, COVID 19 negative and the provider was notified.

A 9/24/24 Progress Note indicated the provider saw Resident 17 and new antibiotics orders were received for an upper respiratory infection (a viral, contagious illness that affects the upper respiratory system).

A 9/25/24 Progress Note indicated Resident 17 had coarse lungs, a productive cough, oxygen saturation was at 91% without oxygen and was tired and weak.

No further documentation was found to indicate thorough respiratory assessments were completed for Resident 17 after 9/25/24.

An 10/1/24 Provider Progress Note indicated Resident 17 reported mild improvement in cough and pulmonary congestion. Resident 17 was noted to have normal respiratory effort and a mild cough. The note did not include evidence of a thorough respiratory assessment.

An 10/2/24 Progress Note indicated Resident 17 refused RA due to being sick.

A review of progress notes from 10/3/24 through 10/8/24 revealed no further documentation of Resident 17's respiratory status.

On 10/7/24 at 12:54 PM Resident 17 was observed in her/his bed with oxygen on at two liters per minute via nasal cannula. Resident 17 had a moist cough.

On 10/9/24 at 11:34 AM Staff 12 (CNA) stated Resident 17 had a moist cough for the last two to three weeks. Staff 12 stated Resident 17's cough worsened and she/he needed oxygen continuously since the resident started coughing.

On 10/10/24 at 10:56 AM Resident 17 was observed in bed, oxygen in place at two liters per minute via nasal cannula, and a moist cough was noted.

On 10/11/24 at 11:50 AM Staff 2 (DNS) stated she expected alert charting with respiratory symptoms to include assessment of lung sounds, cough, temperature, oxygen saturation and related respiratory symptoms until the respiratory symptoms resolved. Staff 2 agreed Resident 17 continued to experience respiratory symptoms and did not receive thorough respiratory assessments after 9/25/24.

Based on observation, interview, and record review it was determined the facility failed to provide sufficient staffing for 2 of 8 sampled residents (#s 42 and 76) reviewed for staffing. This placed residents at risk for unmet needs. Findings include:

1. Resident 42 admitted to the facility in 6/2024 with diagnoses including heart failure, diabetes and severe obesity.

A 6/14/24 Admission MDS indicated Resident 42 was occasionally incontinent of bladder and required substantial to maximum assistance with toileting hygiene.

A 9/26/24 through 10/9/24 CNA Task for Toileting Hygiene document identified Resident 42 required substantial assistance or was dependent on staff for toileting hygiene for 20 of 40 opportunities.

An 10/3/24 revised care plan indicated staff were to provide intermittent supervision for Resident 42's personal hygiene including her/his perineum (genital area) and care after incontinent episodes.

On 10/7/24 at 1:59 PM Resident 42 stated she/he urinated often due to her/his medication and frequently waited up to an hour for assistance with toileting hygiene. Resident 42 stated she/he complained to Staff 1 (Administrator) about her/his concerns of her/his inability to thoroughly complete toileting hygiene independently, but the lack of staffing assistance continued. Resident 42 stated it was difficult to get timely assistance due to her/his requirement for two person assistance.

On 10/9/24 at 10:32 AM Resident 42's call light was observed on and no staff were in her/his room. At 11:03 AM Staff 12 (CNA) entered Resident 42's room and shut off the call light before exiting the room to look for additional staff assistance.

On 10/9/24 at 11:04 AM Staff 12 (CNA) stated, when she entered Resident 42's room to address her/his call light, no other CNA was in the resident's room. Staff 12 was observed to leave Resident 42's room to obtain bed pad supplies and stated she also needed to look for another CNA due to the requirement for two person care for Resident 42. At 11:06 AM two staff were observed to enter Resident 42's room.

On 10/9/24 at 3:19 PM Staff 9 (CNA) stated over the last few weeks there were less staff assigned to Resident 42's hall than in prior months and stated she observed one 30 minute call light wait time for Resident 42 while Staff 9 was on her break.

On 10/10/24 at 2:35 PM Staff 19 (CNA) stated staffing was a concern especially on weekends due to staff absences. Staff 19 stated she did not believe the facility had a working system to address weekend staffing issues and posted schedules did not take into consideration the staffing needs for those residents with behaviors who required two-person assistance.

On 10/10/24 at 2:46 PM Staff 5 (CNA) stated the issues related to heavy care needs on Resident 42's hall were communicated to the Resident Care Manager, but there was no change. Light duty staff were added to the hall, but it was not effective because they could not assist with bariatric care needs.

On 10/10/24 at 5:19 PM Staff 10 (LPN) stated because of the lack of timely response for assistance, Resident 42 attempted to complete her/his personal hygiene care independently. Staff 10 confirmed Resident 42's hall had a high level of care needs and staff voiced their concerns to management.

On 10/11/24 at 12:29 PM Staff 1 (Administrator) and Staff 2 (DNS) were present when issues with Resident 42 were reviewed. Staff 2 stated there were times when staffing for Resident 42 related to two person care and bariatric needs were not met due to call offs and staffing challenges. Staff 1 acknowledged staffing needs based on acuity needed to be met.

, 2. Resident 76 admitted to the facility in 4/2024 with diagnoses including quadriplegia.

The comprehensive care plan for Resident 76 revealed she/he had a "sip and puff" call light (a call light activated by the mouth) to request help and staff were to ensure it was placed so Resident 76 could reach it with her/his mouth to activate it. The care plan also indicated Resident 76 was dependent on staff for all care due to quadriplegia and required two staff with a mechanical lift to transfer from chair to bed.

On 10/9/24 at 11:14 AM Resident 76 was in her/his wheelchair in front of the television in her/his room, and the call light was across the room at the bedside. A CMA was in the room and provided medications and, as she left, Resident 76 stated she/he wanted to go back to bed and asked the CMA to activate the call light. The call light was activated.

On 10/9/24 at 11:20 AM Staff 22 (CNA)was observed to enter Resident 76's room, turned off the call light, but did not provide care to Resident 76 and did not move the call light within her/his reach. Staff 22 then assisted another resident into the shower.

On 10/9/24 at 11:46 AM Staff 22 returned to Resident 76's room with Staff 21 (CNA) and stated they were going to assist Resident 76 back to bed.

On 10/10/24 at 2:31 PM Staff 37 (CMA) stated residents often complained about not receiving care timely.

On 10/10/24 at 2:35 PM Staff 19 (CNA) stated staff were mandated to work extra shifts and were often called in to work extra. Staff 19 also stated the facility had many residents who required two people for care due to transfer assistance and behavioral needs, but the facility did not take that into consideration when determining how many staff worked each shift.

On 10/10/24 at 3:43 PM Staff 2 (DNS) stated she expected staff to answer call lights within 12 to 15 minutes and the call light should be left on until staff were ready to provide care. Staff 2 stated she expected staff to ensure Resident 76 had her/his call light properly placed so she/he could call for assistance.

On 10/11/24 at 8:48 AM Staff 21 stated on 10/9/24 Resident 76's hall was very busy and acknowledged there was a delay in assisting her/him back to bed.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#442) reviewed for change of condition. This placed residents at risk for adverse side effects of medications. Findings include:

Resident 442 admitted to the facility in 4/2024 with diagnoses including bipolar disorder (mental health disorder).

An 4/6/24 physician order indicated staff were to administer lithium ER (extended release antipsychotic for bipolar disorder).

On 10/10/24 Drugs.com indicated lithium ER should not be crushed, chewed, or broken.

A 5/29/24 Progress Note indicated Resident 442 had a difficult time swallowing her/his medication in the morning, so Staff 28 (RN) crushed Resident 442's medication and administered the medication in pudding.

On 10/9/24 at 12:11 PM Staff 28 (RN) acknowledged she crushed Resident 442's lithium, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record.

On 10/9/24 at 3:03 PM Staff 2 (DNS) acknowledged Staff 28 crushed Resident 442's lithium medication, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record.

Refer to F658

Based on interview and record review it was determined the facility failed to ensure residents understood the meaning of an arbitration agreement (disputes resolved with a neutral party and not in court) for 2 of 5 sampled residents (#s 13 and 76) reviewed for arbitration. This placed residents at risk for being uninformed of their legal rights. Findings include:

1.Resident 13 admitted to the facility in 7/2024 with diagnoses including muscle weakness.

A 7/28/24 Medicare 5-Day MDS indicated Resident 13 was cognitively intact.

An 10/7/24 facility provided list of residents who signed a facility Arbitration Agreement indicated Resident 13 signed an Arbitration Agreement.

On 10/10/24 at 11:56 AM Resident 13 stated she/he was not aware of signing an arbitration agreement.

On 10/11/24 at 3:00 PM Witness 3 (Family Member) stated she did not recall speaking to anyone regarding arbitration agreements when the arbitration form was offered.

On 10/11/24 at 8:51 AM Staff 1 (Administrator) acknowledged they should ensure residents or their representatives understood the arbitration agreement.

2.Resident 76 admitted to the facility in 4/2024 with diagnoses including a pressure ulcer.

A 4/7/24 Admission MDS indicated Resident 76 was cognitively intact.

An 10/7/24 facility provided list of residents who signed a facility Arbitration Agreement indicated Resident 76 signed an Arbitration Agreement.

On 10/10/24 at 11:52 AM Resident 76 stated she/he did not remember signing an arbitration agreement and arbitration was not explained to her/him.

On 10/11/24 at 8:51 AM Staff 1 (Administrator) acknowledged they should ensure residents or their representatives understood the arbitration agreement.

Based on observation, interview and record review it was determined the facility failed to ensure the community use glucometer was properly sanitized between resident uses for 1 of 1 sampled resident (#39) reviewed during CBG checks. This placed all residents who required CBG checks at risk for bloodborne illness. Findings include:

Resident 39 admitted to the facility in 2/2024 with diagnoses including diabetes.

On 10/9/24 at 11:50 AM Staff 28 (RN) was observed to check Resident 39's CBG (blood sugar measurement) level in the dining room. Staff 28 placed the glucometer on the North medication cart and cleaned the glucometer with small alcohol prep wipes.

On 10/9/24 at 12:10 PM Staff 28 stated she always used alcohol prep wipes to sanitize the glucometer, and she was not aware of another sanitizing wipe.

On 10/9/24 12:15 PM Staff 3 (LPN-Resident Care Manager) and Staff 30 (LPN-Resident Care Manager) stated the glucometer should be sanitized with the proper sanitizing wipes.



, 3. Resident 42 admitted to the facility in 6/2024 with diagnoses including diabetes and bladder control dysfunction.

A 11/25/24 Progress Note indicated a Foley catheter (flexible tubing inserted into the body to aid in urination) was placed into Resident 42.

A 11/26/24 revised care plan indicated Resident 42 was on Enhanced Barrier Precautions (EBP) due to her/his catheter. Staff were to use gown and gloves for brief changes, toileting, linen changes, device care and other direct care procedures.

On 11/26/24 at 12:29 PM a sign on the outside or Resident 42's was observed which indicated staff were to use EBP during care. Staff 4 (CNA) was observed to exit her/his room with a bag of dirty linen. Staff 4 confirmed Resident 42 had a new catheter but she did not use a gown during the resident's incontinent brief and linen change.

On 11/26/24 at 2:06 PM Staff 3 (CNA) stated she was not aware Resident 42 required personal protective equipment on 11/25/24 when she cared for the resident during the evening shift.

On 11/27/24 at 11:13 Staff 2 (DNS) acknowledged with Resident 42's new catheter, EBP were not in place timely and staff were expected to wear a gown when providing close contact care.



,
Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 3 of 4 sampled residents (#s 21, 42, and 505) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Findings include:

1. Resident 21 admitted to the facility in 8/2020 with diagnoses including obesity.

An 4/8/24 Care Plan revealed Resident 21 was on enhanced barrier precautions due to chronic wounds.

On 11/26/24 at 11:41 AM Staff 6 (CNA) was observed exiting Resident 21's room with a bag of garbage. Staff 6 stated she changed Resident 21's brief. Staff 6 stated Resident 21 was on enhanced barrier precautions and stated staff were to wear a gown and gloves when providing care to a resident on enhanced barrier precautions. Staff 6 stated she did not wear a gown when she provided care to Resident 6.

On 11/26/24 at 4:11 PM Staff 2 (DNS) stated staff were expected to wear a gown when providing close contact care for a resident on enhanced barrier precautions.

2. Resident 505 admitted to the facility in 11/2024 with diagnoses including diabetes.

On 11/26/24 at 11:10 AM Staff 5 (LPN Resident Care Manager) was observed in the South dining room removing a dressing from Resident 505's right calf. Staff 5 brought Resident 505 into her office, completed hand hygiene and applied new gloves. Staff 5 was observed cleaning Resident 505's wound on her/his right calf and then, without removing dirty gloves and without completing hand hygiene, Staff 5 applied the new dressing to Resident 505's wound.

On 11/26/24 at 11:30 AM Staff 5 stated it was not best practice to complete wound care in the dining room and acknowledged she did not change her gloves or complete hand hygiene after cleaning Resident 505's wound.

On 11/26/24 at 11:42 AM Staff 7 (LPN IP) stated wound care should be completed in the resident's room or an area which is private and contained. Staff 7 stated wound care should not be completed in the dining room and stated Staff 5 should have removed her gloves and completed hand hygiene after cleaning Resident 505's wound and before applying a new dressing.




,
Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 2 of 4 sampled residents (#s 600 and 605) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Findings include:

1. Resident 600 admitted to the facility in 6/2012 with diagnoses including carrier or suspected carrier of MRSA (methicillin resistant staphylococcus aureus, an antibiotic resistant bacteria).

A 11/22/22 care plan revealed Resident 600 was on enhanced barrier precautions related to wounds and MRSA.

On 12/17/24 at 9:23 AM Staff 4 (CNA) was observed to enter Resident 600's room without a gown.

On 12/17/24 at 9:50 AM Staff 4 was observed to exit Resident 600's room without a gown. Staff 4 stated she did not wear a gown when providing care to Resident 600 because she was unaware Resident 600 was on enhanced barrier precautions. After reading the sign posted outside Resident 600's room, Staff 4 acknowledged Resident 600 was on enhanced barrier precautions and stated she should have worn a gown when providing Resident 600 care. Staff 4 stated she was a new employee and did not receive education on infection control.

On 12/17/24 at 11:02 AM Staff 5 (LPN Resident Care Manager, Former Infection Preventionist) stated staff were expected to follow precautions and to wear a gown when providing care to residents on enhanced barrier precautions.

On 12/17/24 at 11:21 AM Staff 2 (DNS) stated new staff were educated on infection control during new employee orientation. Staff 2 stated Staff 4 was a new employee and did not yet attend new employee orientation.

2. Resident 605 admitted to the facility in 8/2017 with diagnoses including dementia.

A 12/10/24 Progress Note revealed Resident 605 was placed on droplet precautions related to respiratory illness symptoms.

On 12/17/24 at 8:33 AM Staff 3 (LPN Resident Care Manager) was observed to enter Resident 605's room without a mask.

On 12/17/24 at 8:35 AM Staff 3 stated Resident 605 was on droplet precautions related to a diagnosis of pneumonia. Staff 3 stated she should have put on a mask before entering Resident 605's room.

On 12/17/24 at 11:02 AM Staff 5 (LPN Resident Care Manager, Former Infection Preventionist) stated staff were expected to follow precautions and to wear a mask prior to entering a room with a resident on droplet precautions.



,

Based on observation, interview, and record review it was determined the facility failed to ensure an antibiotic was indicated for use for 1 of 2 sampled residents (#17) reviewed for respiratory care. This placed residents at risk for antibiotic resistant organisms. Findings include:

Resident 17 admitted to the facility in 7/2023 with diagnoses including chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe), congestive heart failure (a long-term condition that occurs when the heart is unable to pump enough blood to meet the body's needs) and pulmonary hypertension (a condition that affects the blood vessels in the lungs, making it harder for blood to flow to the lungs and causing the heart to work harder to pump blood).

A 9/22/24 Progress Note indicated Resident 17 had a wet productive cough, generalized body aches and tested negative for COVID 19.

A 9/24/24 Progress Note indicated a provider visit with Resident 17 and a new antibiotic order was received for an upper respiratory infection (an illness that affects the upper respiratory system).

On 10/7/24 at 12:54 PM Resident 17 was observed in her/his bed with oxygen on at two liters per minute via nasal cannula. Resident 17 had an occasional moist cough.

On 10/11/24 at 10:28 AM Staff 17 (Infection Preventionist) stated Resident 17 tested negative for COVID 19 on 9/18/24 and 9/22/24 and Resident 17 was started on an antibiotic for an upper respiratory infection on 9/24/24. Staff 17 stated a chest x-ray was not completed and no other lab tests were completed to confirm Resident 17 had an upper respiratory infection or to confirm Resident 17 did not have complications from her/his respiratory diagnoses. Staff 17 stated the facility used the McGeer's Criteria for antibiotic stewardship to ensure residents were not treated unnecessarily with antibiotics. Staff 17 acknowledged Resident 17 did not meet the McGeer's Criteria for an upper respiratory infection, and Resident 17 required further diagnostic testing before starting an antibiotic.

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OAR 411-085-0310 Residents' Rights: Generally

Refer to F550 and F553
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OAR 411-086-0130 Nursing Services: Notification

Refer to F580
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OAR 411-088-0080 Notice Requirements

Refer to F623
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OAR 411-088-0050 Right to Return from Hospital

Refer to F625
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OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F657
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OAR 411-086-0230 Activity Services

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

Refer to F686 and F689
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F658, F695 and F760
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OAR 411-086-0100 Nursing Services: Staffing

Refer to F725
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OAR 411-086-0110 Administrator

Refer to F847
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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880 and F881
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OAR 411-086-0330 Infection Control and Universal Precautions

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



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OAR 411-086-0330 Infection Control and Universal Precautions

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

Based on observations, interview and record review it was determined the facility failed to follow physician orders and follow the care plan for 3 of 10 sampled residents (#s 3, 5 and 9) reviewed for medications and ADLs. This placed residents at risk for unmet care needs. Findings include:

1. Resident 9 was admitted to the facility in January 2023 with diagnoses including chronic pain syndrome.

Review of a physician order dated 1/5/23, revealed the resident was to receive Morphine (narcotic pain medication) 100 mg three times a day. The resident was to receive the Morphine at 8:00 AM, 2:00 PM and 9:00 PM.

Review of a progress note dated 10/11/23 at 5:12 AM, revealed the facility was out of the resident's Morphine and the resident was upset and cursing at the nurse.

Review of an October 2023 MAR revealed the resident was not administered Morphine on 10/11/23 at 8:00 AM.

Review of a progress note dated 12/11/23 at 4:59 AM, revealed the facility was out of the resident's Morphine and the resident was upset. At 11:11 AM, Resident 9 reported a pain level of 10/10 and was administered PRN pain medication.

Review of a December 2023 MAR revealed the resident was not administered Morphine on 12/11/23 at 8:00 AM.

Observation on 3/20/24 at 10:04 AM, revealed Resident 9 was in bed and appeared in no acute distress and did not appear to be in pain.

In an interview on 3/20/24 at 10:04 AM, Resident 9 said the facility did not administer 1-2 doses of Morphine. Resident 9 said the facility did not re-order the medication timely which caused the facility to run out of her/his medication. The resident indicated this caused her/him increased pain.

In an interview on 3/28/24 at 8:30 AM, Staff 1 (Administrator) and Staff 2 (DNS) both acknowledged the resident did not receive Morphine pain medication as ordered by the resident's physician.

2. Resident 3 was admitted to the facility in July 2023 with diagnoses including vascular dementia.

Review of a care plan dated 10/14/23, revealed the resident required assistance with ADLs due to dementia and a history of falls. Interventions included one person assist with bathing.

Review of a progress note dated 2/2/24 at 11:16 PM, revealed the resident was found unresponsive to commands and heart rate at 140. The note indicated the resident was removed from the bathtub, taken to the resident's room, dried and dressed. Staff would continue to monitor.

Review of an incident report/investigation dated 2/2/24, revealed the resident was left alone in the bathtub from 9:30 PM through 10:55 PM, and was found unresponsive. The resident was removed from the bathtub, returned to bed, placed on alert monitoring and the DNS was notified. The investigation revealed Resident 3 was on hospice care and had episodes of unresponsiveness and nonverbal. The resident care plan was reviewed and the care plan was not followed. Resident 3 was awake and responsive at 10:30 PM and back to baseline at 2:00 AM.

In an interview on 3/20/24 at 9:45 AM, Resident 3 said she/he was left in the shower by herself/himself but did not remember the date. Resident 3 said he felt "stuck" and was not harmed.

In an interview on 3/26/24 at 8:10 AM, Staff 3 (CNA) said on 2/2/24 the resident was taken to the shower by Staff 4 (CNA) and left in the bathtub from around 9:30-9:45 PM to around 11:00 PM. Staff 3 said the resident was removed from the bathtub by Staff 4 and the charge nurse and was awake but unresponsive and not talking. Staff 4 no longer worked at the facility.

In an interview on 3/26/24 at 9:32 AM, Staff 5 (CNA) said on 2/2/24 Staff 4 had checked on the resident in the shower and then took a 30 minute break. Staff 5 said Staff 4 had forgotten Resident 3 was in the bathtub. Staff 5 was aware the resident required one person assist with showers.

In an interview on 3/28/24 at 9:00 AM, Staff 2 (DNS) acknowledged the resident's care plan was not followed regarding bathing.

3. Resident 5 was admitted to the facility in January 2024 with diagnoses including fibromyalgia.

Review of a hospital physician order dated 1/6/24, revealed the resident was to receive colchicine (anti-inflamatory) by mouth daily.

Review of a January 2024 MAR revealed the resident did not receive colchicine from 1/7/24 through 1/18/24.

In an interview on 3/27/24 at 8:30 AM, Staff 2 (DNS) acknowledged the resident did not receive the colchicine as ordered by the resident's physician due to problems acquiring the medication from the pharmacy.

************************************
OAR 411-086-0110 - Nursing Services: Resident Care

Refer to F684
************************************

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 08/14/2023 and 08/20/2023, 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 ensure a resident was treated with respect for 1 of 1 sampled resident (#34) reviewed for dignity. This placed residents at risk for lack of respectful encounters. Findings include:

Resident 34 was admitted to the facility in 2020 with diagnoses including paraplegia (inability to voluntarily move the lower part of the body) and anxiety disorder.

A 1/13/23 revised care plan indicated Resident 34 had a history of receiving verbal aggression, staff were to stop activity if it was bothersome to her/him and monitor her/his emotional and physical distress. Staff were also to recognize Resident 34's experience and approach Resident 34 calmly.

An 4/13/23 Quarterly MDS indicated Resident 34 had no verbal aggression towards others and was cognitively intact.

A 5/1/23 FRI alleged on 4/29/23 Resident 34 was mistreated by Staff 6 (LPN) when Staff 6 came into Resident 34's room and yelled at her/him. Staff 6 was suspended pending investigation and Resident 34 requested Staff 6 no longer provide any of her/his care.

A 5/1/23 investigation of the 4/29/23 incident revealed Resident 34 asked for assistance for her/his roommate and Staff 6 "bust[ed] in the door and yelled at me and that she's running behind". Resident 34 did not feel threatened by Staff 6 but wanted Staff 6 to have a more professional attitude towards her/him.

On 6/27/23 at 9:44 AM Resident 34 stated she/he had to go outside to calm herself/himself down when Staff 6 was assigned to her/his room again that week.

On 6/28/23 at 1:39 PM and 6/29/23 at 2:42 PM Staff 5 (LPN-Resident Care Manager) stated based on observations Resident 34 was willing to approach Staff 6 after the 4/29/23 incident, and the facility began to reassign Staff 6 back to providing direct care for Resident 34. Staff 5 stated she should have discussed with Resident 34 the option of Staff 6's return to provide her/his care and did not.

On 6/29/23 at 11:26 AM Staff 6 stated on 4/29/23 she probably did not approach Resident 34 with the respect she/he wanted based on what she learned after reading her/his care plan. Staff 6 stated she repeated herself loudly and directly to Resident 34 to clarify a misunderstanding related to her/his roommate's care. Staff 6 confirmed she provided direct care for Resident 34 after the incident, believed those encounters felt awkward at times for both her and the resident but other nurses were unwilling to trade resident room assignments when Staff 6 requested.

On 6/30/23 at 9:02 AM Staff 20 (Social Services Director) stated during recent conversations with Resident 34 she/he confirmed she/he did not want Staff 6 to provide her/his care. Staff 20 stated it violated Resident 34's need for respect even more when the facility scheduled Staff 6 to work with her/him without her/his consent.

2. Resident 76 was admitted to the facility 6/1/23 with diagnoses including traumatic brain injury.

A Consent for use of Psychotropic Medication Therapy for trazodone (antidepressant) and fluoxetine (antidepressant) indicated the resident gave verbal consent for use of the medications on 6/2/23.

A 6/6/23 Admission MDS and associated CAAs indicated Resident 76 was unable to complete an interview for cognitive testing and demonstrated severe cognitive deficits.

On 6/28/23 at 10:23 AM Staff 1 (LPN-Resident Care Manager) indicated Resident 76's cognition was significantly impaired when she/he was admitted to the facility and likely did not understand the risk and benefits of the psychotropic medications. Staff 1 indicated the resident's family was involved with her/his care and staff should have reviewed the consents with the resident's family.



, Based on interview and record review it was determined the facility failed to ensure a cognitively impaired resident's representative was provided risk and benefits of a psychotropic medication prior to initiation and failed to ensure a resident's right to implement medication options was honored for 2 of 5 sampled residents (#s 63 and 76) reviewed for unnecessary medications. This placed residents at risk for lack of appropriate medical treatment decisions. Findings include:

1. Resident 63 was admitted to the facility in 2022 with diagnoses including major depressive disorder.

Resident 63's 12/2022 admission weight was 146.8 pounds and her/his weight on 6/23/23 was 172 pounds.

The 4/2023 through 6/2023 Behavior Monitoring Record and MAR indicated Resident 63 did not have
negative behaviors and received amitriptyline (an antidepressant medication) daily for depression.

A 6/11/23 Quarterly MDS revealed Resident 63 was cognitively intact.

A 7/2/23 Epocrates (a professional website that provides clinical references on drugs) reference revealed a common reaction to the use of amitriptyline was weight gain.

On 6/28/23 at 3:49 PM Resident 63 stated there was no recent discussion about any changes to her/his medications and her/his weight gain since admission. Resident 63 was concerned about her/his weight gain.

On 6/30/23 at 10:46 AM Staff 5 (LPN-Resident Care Manager) stated she had a discussion in 4/2023 with Resident 63 about the discontinuation of her/his amitriptyline and assumed Resident 63's physician would follow-up with this recommendation which was sent through an email. Staff 5 acknowledged there was no documentation about the discussion in Resident 63's clinical record or follow up with the physician to ensure Resident 63's request for the discontinuation of her/his medication was honored.

Based on interview and record review it was determined the facility failed to include a resident in the plan of care for 1 of 1 sampled resident (#34) reviewed for urinary catheter. This placed residents at risk for lack of inclusion in the care planning process. Findings include:

Resident 34 was admitted to the facility in 2020 with diagnoses including paraplegia (inability to voluntarily move the lower part of the body) and anxiety disorder.

An 4/13/21 revised care plan indicated to provide urinary catheter care each shift, empty the catheter as needed and Resident 34 preferred to perform her/his own catheter care.

An 4/13/23 Quarterly MDS indicated Resident 34 had an urinary catheter and was cognitively intact.

A 1/5/23 physician order indicated a Foley (flexible tube) urinary catheter was to be changed monthly.

The 6/2023 TAR indicated the urinary catheter was changed on 6/18/23 by Staff 6 (LPN).

A 6/25/23 progress note indicated Resident 34 requested a new urinary catheter and bag due to clogging and changed her/his urinary catheter independently with no difficulty.

On 6/27/23 at 10:03 AM Resident 34 stated over the last six months she/he started to replace her/his own urinary catheter although it was not her/his preference and it was difficult to do so. Resident 34 stated she/he was not aware of what was on her/his care plan.

On 6/29/23 at 11:26 AM Staff 6 stated she was verbally instructed to give Resident 34 the urinary catheter supplies and she/he preferred to replace her/his own urinary catheter although this was not a typical practice for nurses.

On 6/29/23 at 2:42 PM Staff 5 (LPN-Resident Care Manager) stated Resident 34 always changed her/his own urinary catheter and was not offered a copy of her/his care plan as a point of discussion about her/his care preferences. Staff 5 acknowledge Resident 34 was not always involved in the determination of her/his care.

Based on observation, interview and record review it was determined the facility failed to comprehensively assess residents' ability to self-administer medications for 1 of 1 sampled resident (#34) reviewed for non-pressure skin conditions. This placed resident at risk for adverse medication reactions. Findings include:

Resident 34 was admitted to the facility in 2020 with diagnoses including paraplegia (inability to voluntarily move the lower part of the body) and anxiety disorder.

An 4/13/23 Quarterly MDS revealed Resident 34 was cognitively intact and had no impairment to her/his upper extremities.

A 6/8/23 progress note revealed Resident 34 was seen by a NP because of a rash on her/his hand.

A 6/12/23 physician order indicated to apply hydrocortisone solution (medication use to treat skin irritation) to Resident 34's hand twice daily for two weeks.

On 6/28/23 at 12:01 PM Resident 34 was observed with a tube of hydrocortisone cream dated 6/8/23. Resident 34 stated the medication was in her/his possession since it was first ordered and she/he applied the medication as needed.

On 6/28/23 at 1:39 PM Staff 5 (LPN-Resident Care Manager) stated there was no conversation or assessment completed for Resident 34 to self-administer the cream. As a result a nurse should have administered the cream.

2. Resident 76 was admitted to the facility in 6/2023 with diagnoses including traumatic brain injury.

A 6/5/23 Admission MDS indicated the resident did not have dental issues.

On 6/28/23 at 8:55 AM Resident 76 was observed to have broken upper front teeth.

On 6/28/23 at 11:28 AM Staff 1 (LPN-Resident Care Manager) acknowledged the MDS was not coded correctly and staff therefore did not assess the resident for dental needs.


, Based on interview and record review it was determined the facility failed to accurately assess a resident's gradual dose reduction (GDR) status for 1 of 5 sampled residents (#14) and to accurately assess a resident's dental status for 1 of 1 sampled resident (#76) reviewed for unnecessary medications and dental status. This placed residents at risk for unassessed needs. Findings include:

1. Resident 14 was admitted to the facility in 1/2022 with diagnoses including depression and bipolar disorder.

The 5/2/23 Quarterly MDS indicated Resident 14 had a GDR on 2/17/23 for Abilify (antipsychotic), Trazodone (antidepressant) and Lexapro (antidepressant).

On 6/30/23 at 8:45 AM Staff 1 (LPN-Resident Care Manager), Staff 2 (DNS) and Staff 5 (LPN-Resident Care Manager) acknowledged Resident 14 did not have a GDR on 2/17/23 and Resident 14's Quarterly MDS dated 5/2/23 was coded incorrectly.

Based on observation, interview and record review it was determined the facility failed to update resident care plans to reflect edema, ROM and infection control precautions for 3 of 8 sampled resident (#s 49, 66 and 69) reviewed for edema, rehabilitation and unecessary medications. This placed residents at risk for lack of resident centered interventions. Findings include:

1. Resident 49 was admitted to the facility 5/23/23 with diagnoses including a fall and cervical neck fracture.

A 5/23/23 Nursing Admission Database indicated the resident did not have edema (swelling/fluid retention).

NP Progress Notes dated 6/8/23 indicated the resident was seen for hypertension follow-up and had newly identified edema to both legs and feet. The resident was assessed to not be short of breath and the NP ordered labs and additional medications.

Resident 49's Comprehensive Care Plan last updated 6/20/23 did not have an identified focus area of edema, with goals or interventions to prevent edema.

On 6/26/23 at 2:22 PM Resident 49 was observed to have edema to both legs and the resident's legs were not elevated.

On 6/29/23 at 12:21 PM Staff 1 (LPN-Resident Care Manager) acknowledged Resident 49 developed edema after the care plan was initiated and the NP initiated new medications. Staff 1 indicated the care plan was not updated to reflect a new condition which was being treated and there were no additional non-pharmacological interventions in place to assist the resident to decrease the edema such as elevating the legs and/or monitoring the resident's weights.

, 2. Resident 66 was admitted to the facility in 7/2022 with diagnoses including stroke.

A Progress Note dated 1/12/23 indicated Resident 66 had a cranioplasty (surgical repair of skull defects).

A care plan dated 1/18/23 indicated staff were to use enhanced barrier precautions related to her/his scalp wound due to Resident 66's viral infections. Staff were to don gloves and gowns for all cares.

On 6/29/23 at 9:08 AM Staff 7 (CNA), Staff 8 (CNA) and Staff 9 (CNA) stated they were unsure if Resident 66 was on enhanced barrier precautions. After looking in the resident's care plan, staff acknowledged Resident 66's care plan indicated she/he was on enhanced barrier precautions.

On 6/29/23 at 9:56 AM Staff 5 (LPN-Resident Care Manager) and Staff 22 (LPN-Infection Preventionest) confirmed Resident 66's head wound healed; the care plan should not include enhanced barrier precautions and should be updated.

, 3. Resident 69 was admitted to the facility in 2022 with diagnoses including stroke and hemiparalysis (weakness on one side of the body) of the left side.

A 5/30/23 revised care plan indicated to offer and place a bolster between Resident 69's left heel and gluteal (muscles of the buttock area). No additional information was found on the care plan related to ROM therapy.

The 6/2023 Tasks: ROM indicated Resident 69 was offered and accepted ROM exercises six times through 6/28/23.

A 6/9/23 OT Discharge Summary revealed staff were trained on the use of a left knee bolster for pain and contracture reduction and a ROM program was created to promote mobility in the left upper and lower extremities for Resident 69.

On 6/26/23 at 4:14 PM and 6/29/23 at 12:50 PM Resident 69 was observed in bed with her/his left knee bent and no pillow or bolster in place. Resident 69 stated her/his hip no longer worked properly and she/he often had pain.

On 6/29/23 at 12:43 PM Staff 14 (CNA) stated he believed Resident 69's bolster was used only for her/his hip pain. Staff 14 stated he did not inform nursing when Resident 69 refused the use of the bolster because the care plan did not indicate it was part of therapy.

On 6/29/23 at 1:50 PM Staff 2 (DNS) stated Resident 69's care plan should have been revised to include the details of her/his ROM therapy and indicate the pillow or bolster was used to assist with her/his contracture.

Based on interview and record review it was determined the facility failed to a ensure an order discrepancy related to pain medication was clarified and ensure a resident was assessed after falls for 2 of 7 sampled residents (#s 48 and 76) reviewed for pain and accidents. This placed residents at risk for increased pain and unidentified injuries. Findings include:

1. Resident 48 was admitted to the facility 6/15/23 with diagnoses including knee replacement.

Hospital Discharge Medications revealed tramadol was to be administered every six hours. The order was not PRN.

A hard copy of the prescription (required to be sent to the pharmacy in order for the medication to be filled), attached to the order form, was for tramadol PRN.

The resident's clinical record did not contain documentation to indicate the resident's physician was notified of the tramadol order discrepancy.

On 6/29/23 at 10:14 AM Staff 1 (LPN-Resident Care Manager) stated if the admission orders did not correlate with the hard copy of the prescription to be sent to the pharmacy, the staff were to call the physician for clarification. A request was made to Staff 1 to provide evidence the staff clarified the tramadol orders with the resident's physician. No additional information was provided.

2. Resident 76 was admitted to the facility in 2023 with diagnoses including brain injury.

Progress Notes revealed the following:
-6/8/23 at 9:40 AM Resident 76 fell
-6/8/23 at 11:43 PM the resident continued on neurological checks (assessment to rule out head injury)
-No note for 6/9/23
-6/10/23 at 5:56 PM the resident was noted to move her/his arms/legs, lungs were clear and the resident was alert but forgetful
-6/10/23 at 9:24 PM the resident fell from a recliner and then fell from the bed
-No notes for 6/11/23
-6/12/23 the resident was noted to not have injuries from the fall
-No notes for 6/13/23

A Neurological Flow Sheet initiated 6/8/23 revealed the following:
-vital signs were obtained every 15 minutes from 5:30 PM through 6:15 PM, every 30 from 6:45 PM through 8:15 PM and hourly from 8:15 PM through 11:15 PM. A total of 11 vital sets were obtained.
-nursing assessments to assess the resident's neurological condition were completed 2 of 11 opportunities, at 10:15 PM and 11:15 PM.

A Neurological Flow Sheet initiated 6/9/23 revealed the following:
-vital signs were obtained every four hours from 12:15 AM through 8:15 AM and every eight hours from 6/10/23 12:15 PM through 8:15 AM. A total of 11 vital sets were obtained.
-nursing assessments to assess the resident's neurological condition were not completed on two occasions and partially completed on two occasions. Only 3 of 7 assessments were complete.

A Neurological Flow Sheet initiated 6/10/23 revealed the following:
-vital signs were obtained every 15 minutes from 11:00 AM through 11:45 AM, every 30 minutes from 11:45 AM through 12:45 PM and every hour from 1:45 PM through 4:45 PM. A total of 11 vital sets were obtained.
-nursing assessments to assess the resident's neurological condition were not completed for the 11 opportunities.

On 6/28/23 at 10:23 AM Staff 1 (LPN-Resident Care Manager) stated after an unwitnessed fall, neurological assessments were to be completed, documented and the resident was to be monitored for injuries after the fall every shift for at least 72 hours. Staff 1 reviewed the resident's record and acknowledged the staff did not monitor the resident each shift.

On 6/28/23 at 2:37 PM Staff 2 (DNS) stated the nurses or CNAs initiated the neurological assessments sheets. The CNAs obtained all the required vital sign sets but the nurses did not always complete the required nursing assessments at the designated intervals.

Based on interview and record review it was determined the facility failed to assess and treat residents' pressure ulcers for 2 of 3 sampled residents (#s 16 and 79) reviewed for pressure ulcers. Resident 16 developed at Stage 3 pressure ulcer. This placed residents at risk for infections. Findings include:

1. Resident 79 was admitted to the facility 6/9/23 (Friday) with diagnoses including respiratory failure.

Hospital Discharge Orders Report dated 6/9/23 revealed Resident 79 had a pressure ulcer to the tailbone region. Wound care was to be provided every Monday, Wednesday and Friday.

A 6/9/23 Admission Nursing Database indicated the resident had a pressure ulcer to the tailbone. There were no measurements or descriptions of the ulcer on the form.

A 6/2023 TAR revealed no wound care was provided until 6/13/23. This was four days after admission to the facility.

Progress Notes revealed the following:
-6/10/23 wound care was not provided because the resident started to fall asleep and refused
-6/11/23 at 8:54 PM resident had pain to the tailbone region
-6/11/23 at 9:08 PM tailbone region open with yellow green purulent (pus-indicative of infection) drainage, MD notified.
-6/13/23 Wound nurse indicated she was asked to see the resident. The ulcer, which spanned from the tailbone to the anus, was 7.5 cm long and was full of slough (non-viable tissue). The resident verbalized pain to the buttock region. The wound nurse applied a dressing, but the resident immediately removed it.
-6/14/23 the resident's physician assessed the resident and sent the resident to the hospital emergency department due to agitation and to rule out a stroke or sepsis from a wound infection. The resident returned with a diagnoses of wound infection.

Skin and Wound Evaluation Forms revealed the following:
-There was no form filled out when the resident was admitted on 6/9/23
-6/13/23 the ulcer was described as an unstageable pressure ulcer (unable to determine depth due to slough), the wound had 90% slough, signs of infection including increased drainage, redness and pain, moderate amount of purulent (pus) drainage. There was no length or width documented.
-No form documented for 6/20/23
-6/27/23 the ulcer was noted to be improved. The ulcer was 7.9 cm long, was 100% covered with slough, did not have signs of infection and the note indicated the resident frequently removed the dressings.

On 6/29/23 at 10:20 AM Staff 1 (LPN-Resident Care Manager) stated Resident 79 was admitted to the facility with a pressure ulcer to the tailbone region. Staff 1 stated staff were to assess all wounds, including pressure ulcers, and document in the clinical record on the skin assessment forms. Staff were to document treatment provided on the TAR. If a resident refused a treatment, staff were to attempt to provide the treatment on different shifts until the treatment was provided. Staff 1 also stated the pressure ulcers were to be monitored weekly. Staff 1 acknowledged the resident's pressure ulcer was not described in detail on the skin assessment sheet, treatments were not documented as provided for four days and skin assessments were not done on 6/20/23 when the wound nurse did not come into the facility. Staff 1 indicated the facility staff should have filled out the assessment if the wound nurse was not in the building.

, 2. Resident 16 was admitted to the facility in 2021 with diagnoses including multiple sclerosis (a disease of the central nervous system), pressure ulcer and on hospice.

A 12/15/22 Significant Change MDS indicated Resident 16 was on hospice and at risk for pressure ulcers due to decreased mobility and urinary incontinence. Staff were to provide skin treatments as ordered and monitor for any changes in Resident 16's skin condition.

A 5/13/23 Wound Nursing Order indicated to cleanse Resident 16's genital area wound. Apply Iodosorb (iodine gel) to the wound bed and cover with an adhesive foam dressing. The dressing was to be changed as needed if soiled or loose.

A 6/12/23 Wound Nursing Order indicated to monitor a blanchable (skin that turns white when pressed) redness located at the the base of Resident 16's genital area and notify the provider of any worsening.

A 6/13/23 Progress Note at 6:59 AM revealed Resident 16 had a very loose bowel movement and Staff 13 (LPN) redressed her/his pressure ulcer with new dressing after Resident 16 was cleaned. No additional information about Resident 16's wounds were documented.

On 6/13/23 at approximately 1:15 PM a hospice encounter note indicated the original wound to Resident 16's genital area continued to improve and a new Stage 1 pressure ulcer (wound which remained red when touched) was at the base of Resident 16's genital area according to a facility nurse since Resident 16 declined a wound assessment during the visit.

A 6/14/23 at 1:04 PM Skin and Wound Evaluation revealed Resident 16's wound located at the the base of her/his genital area was a Stage 3 (full-thickness skin loss) pressure ulcer and measured 4.3 cm long and 1.7 cm wide. Evidence of infection included increased drainage, redness and warmth and the wound was bleeding and had a scab. The evaluation also revealed the loss of skin was due to urine or friction. A note revealed it was the first time a nurse assessed the pressure ulcer wound and nursing used the 5/16/23 order to treat the wound.

On 6/29/23 at 5:06 PM Staff 13 stated on 6/13/23 at 6:59 AM she observed Resident 16 already had a scab on another pressure ulcer.

On 6/28/23 at 10:12 AM Staff 2 (DNS) stated the facility neglected to complete a wound assessment for Resident 16's second pressure ulcer and no investigation related to the wound was started.

Based on interview and record review it was determined the facility failed to ensure a resident's fall was investigated for 1 of 4 sampled residents (#76) reviewed for accidents. This placed residents at risk for unassessed risk factors. Findings include:

Resident 76 was admitted to the facility in 2023 with diagnoses including traumatic brain injury.

Review of the resident's Progress Notes revealed on 6/10/23 the resident fell two times. One time the resident fell from her/his recliner and another time the resident fell while she/he attempted to put her/his socks on.

A review of 6/10/23 fall investigations revealed there was no investigation for the resident's fall from the recliner.

On 6/28/23 at 10:10 AM Staff 2 (DNS) stated each fall was to be investigated to ensure risk factors were taken into account. Staff 2 acknowledged only one investigation was completed for the two falls which occurred on 6/10/23.

Based on interview and record review it was determined the facility failed to obtain specialized physician appointments for 1 of 1 sampled resident (#76) reviewed for bowel and bladder. This placed residents at risk for lack of specialized care. Findings include:

Resident 76 was admitted to the facility 6/1/23 with diagnoses including brain injury and urine retention.

6/1/23 hospital admission orders included the resident was to have urology and neurology follow-up appointments.

On 6/28/23 at 10:23 AM Staff 1 (LPN-Resident Care Manager) stated when a resident admitted from the hospital the nursing staff forwarded referrals for specialists to the social service department. Staff 1 indicated she was not aware of any appointments for Resident 76.

On 6/28/23 at 11:40 AM Staff 21 (Social Services) stated if a resident came directly from a hospital the nursing staff were to fax the specialist the referral form for an appointment. Staff 21 stated she was not notified the resident needed referrals to the urologist or neurologist but stated it was listed on the admission paperwork.

Based on interview and record review it was determined the facility failed to reorder pain medications in a timely manner for 1 of 3 sampled residents (#49) reviewed for pain. This placed residents at risk for unrelieved pain. Findings include:

Resident 49 was admitted to the facility 5/23/23 with diagnoses including cervical (neck) fractures.

5/23/23 hospital admission orders included orders for oxycodone (narcotic pain medication). The prescription did not have any refills and the pharmacy was to only dispense ten tablets.

Resident 49's 5/2023 MAR revealed the resident took one oxycodone on 5/23/23, three tablets on 5/24/23 and 5/25/23 and two tablets on 5/26/23. The last tablet was administered at approximately 11:00 AM. Only one dose on 5/25/23 at 8:41 PM was documented as ineffective. The following two doses on 5/26/23 were documented as effective.

Progress Notes from 5/24/23 through 5/27/23 revealed the resident was alert, oriented, pleasant and reported neck pain. The notes did not indicate the resident had unresolved pain.

A 5/29/23 Admission MDS and CAAs indicated Resident 49 was cognitively intact, had pain related to her/his neck injury and chronic knee pain. The resident's pain was almost constant.

On 6/26/23 at 12:18 PM Resident 49 stated on one weekend the facility ran out of her/his pain medication and she/he had to go to the hospital to get pain medication.

On 6/29/23 at 1:29 PM Witness 1 (Pharmacy Technician) stated the facility requested to pull one oxycodone from the emergency kit on the day the resident admitted to the facility. The pharmacy did not receive any additional refill requests unil the new order came in on 5/26/27 and 30 tablets were sent to the facility on 5/27/23.

On 6/29/23 at 1:51 PM Staff 4 (LPN) stated if a resident was running low on a narcotic they could ask the resident's provider to send in a new prescription to the pharmacy. The NP was in the facility multiple times a week so they could ask her in person or the staff could call the medical office. The medical providers were available seven days a week. Staff 4 stated the nursing staff should request medication refills before they ran out.

On 6/29/23 at 12:20 PM Staff 1 (LPN-Resident Care Manager) acknowledged the last pill was administered to the resident on 5/26/23 at approximately 10:00 AM. Staff 1 acknowledged the resident only had a prescription for ten pills, used up to three pills a day and staff did not call for a new prescription until the day the medication ran out. Staff 1 indicated the resident was transported to the hospital and was restarted on her/his pain medication the next day.

Based on interview and record review it was determined the facility failed to monitor a resident for psychotropic medication side effects for 2 of 5 sampled residents (#s 52 and 76) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include:

1. Resident 76 was admitted to the facility in 2023 with diagnoses including brain injury.

Admission orders dated 6/1/23 revealed the resident was to receive trazodone (antidepressant) PRN for inability to sleep and fluoxetine (antidepressant) every day.

A Pharmacist Communication form dated 6/1/23 indicated the resident was administered fluoxetine daily and trazodone. The combined use of the medications placed the resident at risk for serotonin syndrome (can cause symptoms ranging from tremors to death). The form directed staff to keep the Pharmacist Communication form in the MAR while the resident took both medications and to monitor the resident for symptoms including tremor, fast heart rate, low grade fever, confusion, muscle spasm and impaired mobility. Staff were to monitor for high fever, muscle activity, low or high blood pressures, seizures and lung injuries. If symptoms occurred the physician was to be notified and the medication was to be discontinued.

A Care Plan initiated 6/2/23 indicated the resident was on antidepressants and staff were to monitor for side effects including drowsiness, mood change, rigid muscles muscle cramps and vomiting. The care plan did not indicate the resident was at increased risk for serotonin syndrome.

A 6/2023 MAR revealed the resident was administered trazodone on eight occasions and fluoxetine daily. The MAR did not direct staff to monitor the resident for serotonin syndrome.

On 6/28/23 at 12:24 PM Staff 2 (DNS) stated the pharmacy review indicated the resident was at increased risk for serotonin syndrome and staff should monitor the resident. The resident's physician reviewed the recommendations and agreed. Staff 2 indicated if nursing staff saw the symptoms they would notify the physician and the medication would be discontinued.

On 6/28/23 at 12:38 PM Staff 4 (LPN) stated she was familiar with Resident 76 and administered the resident her/his medications. Staff 4 stated if the resident was to be monitored for serotonin syndrome it would be on the MAR and they would document each shift they monitored the resident for symptoms. If staff observed symptoms it would be documented in the progress notes and the physician would be notified. Staff 4 reviewed Resident 76's MAR and stated they were not currently monitoring the resident for serotonin syndrome.

, 2. Resident 52 was readmitted to the facility in 4/2022 with diagnoses including recurrent major depressive disorder and generalized anxiety disorder.

Records indicated on 6/1/23 Resident 52 started Hydroxyzine (antianxiety medication) for generalized anxiety disorder and on 6/2/23 started Abilify (antipsychotic medication) for recurrent major depressive disorder.

On 6/3/23 Resident 52 completed a PASRR (Pre-Admission Screening and Resident Review) Level II Evaluation (in depth evaluation to determine needs, settings, and services for residents with serious mental illness or intellectual disability). Suggested recommendations included increase of Abilify from 2mg daily to 5mg daily: monitor for potential side effects of nausea, vomiting, headache, tremor, insomnia, increase appetite and weight gain.

Both medications, Hydroxyzine and Abilify were not incorporated into Resident 52's 6/6/23 comprehensive care plan that reflected person-centered medication related goals and parameters for monitoring the resident's condition, including the likely adverse consequences.

On 6/29/23 at 4:45 PM Staff 17 (CNA) stated she was unaware Resident 52 received the antipsychotic and antianxiety medications. Staff 17 stated she would monitor the resident for adverse side effects through the resident's vital signs and by her knowledge of the resident.

On 6/30/23 at 9:32 AM Staff 10 (CNA) stated she was unaware what medications Resident 52 was receiving. When asked how she monitored the resident for any adverse side effects from her/his medications, she stated she watched the resident's mood and looked at the bottom of the kardex (abbreviated care plan), which showed what to monitor the resident for.

On 6/30/23 at 10:10 AM Staff 19 (Agency LPN-Charge Nurse) stated she was unaware of Resident 52's medications. She stated she monitored residents through their vital signs, how alert/oriented the residents were and any changes in their mentation.

On 6/30/23 at 11:37 AM Staff 16 (LPN-Resident Care Manager) stated a resident was placed on alert charting for at least three days for any new psychotropic medication. Residents were followed at all psychotropic meetings that occur monthly. Nurses and CNA staff were made aware of resident's new medications through their care plan or kardex. Staff 16 acknowledged Resident 52's care plan did not include the antipsychotic and antianxiety medications the resident was receiving, including the adverse side effects staff were to monitor.

Based on interview and record review it was determined the facility failed to ensure resident records were complete for 1 of 3 sampled residents (#49) reviewed for pain. This placed residents at risk for lack of pertinent medical assessment documentation in the clinical record. Findings include:

Resident 49 was admitted to the facility in 2023 with diagnoses including cervical (neck) fractures.

5/23/23 hospital admission orders included orders for oxycodone (narcotic pain medication). The prescription did not have any refills and the pharmacy was to only dispense ten tablets.

Progress Notes from 5/24/23 through 5/27/23 revealed the resident was alert, oriented pleasant and reported neck pain. The notes did not indicate the resident had unresolved pain and did not indicate the resident had to be transported to the hospital to obtain pain medication.

A 5/30/23 MDS indicated Resident 49 was cognitively intact.

On 6/26/23 12:18 PM Resident 49 stated on one weekend the facility ran out of her/his pain medication and she/he had to go to the hospital to get pain medication.

On 6/29/23 12:20 PM Staff 1 (LPN-Resident Care Manager) acknowledged the resident was transported to the hospital on 5/26/23 when her/his pain medication ran out and the staff did not document the resident's condition prior to discharge or condition upon return to the facility.

Refer to F755

Based on observation, interview and record review it was determined the facility failed to ensure the care plan was followed regarding infection control precautions for 1 of 3 sampled residents (#79) reviewed for pressure ulcers. This placed residents at risk for infections. Findings include:

Resident 79 was admitted to the facility in 2023 with diagnoses including a pressure ulcer.

A care plan dated 6/13/23 revealed the resident had a history of multi-drug resistant organisms in the lungs and was on enhanced barrier precautions. Staff were to wear a gown and gloves during care including when staff assisted the resident with showers.

On 6/29/23 at 9:18 AM a sign was observed by the entrance of Resident 79's room. The sign indicated the resident was on enhanced barrier precautions. The instructions indicated staff must wear mask, gown and gloves when providing high contact care. Staff 23 (CNA) was observed to exit Resident 79's room with a mask on. Staff 23 escorted Resident 79 to another room and shut the door.

On 6/29/23 at 9:36 AM Staff 23 stated she did not often work with Resident 79 and just finished assisting the resident with a shower. Staff 23 stated she did not wear a gown while providing care and acknowledged the sign on the resident's door entrance directed staff to wear a mask, gloves and gown while providing care.

On 6/29/23 at 9:40 AM Staff 22 (LPN-IP) stated Resident 79's care plan included enhanced barrier precautions and staff should follow the directions listed on the sign by the resident's door.

Based on interview and record review it was determined the facility failed to provide risk and benefits for the flu vaccine and/or provide vaccines for 4 of 5 sampled residents (#s 7, 13, 22 and 55) reviewed for immunizations. This placed residents at risk for illness and lack of informed consent. Findings include:

1. Resident 7 was admitted to the facility in 2020 with diagnoses including a stroke.

Review of the resident's clinical record revealed the resident received PCV13 (pneumonia vaccine) in 2019. No documentation was found to indicate additional pneumonia vaccines were offered or provided as required.

On 6/30/23 at 9:15 AM Staff 22 (LPN-IP) verified the resident was not offered additional pneumonia vaccines.

2. Resident 13 was admitted to the facility in 2020 with diagnoses including heart disease.

Review of the resident's record revealed there was no documentation the flu vaccine was offered for the 2022/2023 flu season.

On 6/30/23 at 9:15 AM Staff 22 (LPN-IP) stated she was not able to find any documentation related the resident's 2022/2023 flu vaccine.

3. Resident 22 was admitted to the facility in 2021 with diagnoses including heart disease.

Review of resident 22's record revealed she/he signed a consent for the influenza vaccine on 5/5/22, but there was no documentation to indicate the resident received the vaccine from 10/2022 through 3/2023. The record also indicated the resident received the last pneumonia vaccine 8/2018 and was eligible for another pneumonia vaccine. The record did not have documentation to indicate the facility offered or administered additional pneumonia vaccines as required.

On 6/30/23 at 9:15 AM Staff 22 (LPN-IP) verified the resident did not receive the flu vaccine and was not offered additional pneumonia vaccines.

4. Resident 55 was admitted to the facility in 2021 with diagnoses including kidney disease.

The resident's record revealed Resident 55 signed a consent to receive the PPSV23 pneumonia vaccine but there was no documentation to indicate the resident received the vaccine.

On 6/30/23 at 9:15 AM Staff 22 (LPN-IP) stated she was not able to find documentation to indicate the resident received the pneumonia vaccine after she/he signed the consent.

Based on interview and record review it was determined the facility failed to ensure a RN was available for at least eight consecutive hours per day between day and evening shifts for 3 of 26 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include:

Review of the Direct Care Staff Daily Reports from 6/1/23 through 6/27/23 revealed on 6/19, 6/20 and 6/21 the facility failed to have a RN scheduled on day or evening shifts.

On 6/30/23 at 9:05 AM Staff 2 (DNS) and Staff 3 (Administrator) acknowledged the facility lacked RN coverage on the identified days.

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OAR 411-085-0310 Residents' Rights: Generally

Refer to F550, F552, F553
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OAR 411-086-0260 Pharmaceutical Services

Refer to F554, F755
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OAR 411-086-0300 Clinical Records

Refer to F641, F842
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OAR 411-086-0060 Comprehensive Assessment and Care Plan

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

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

Refer to F686, F689, F758, F883
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OAR 411-086-0240 Social Services

Refer to F745
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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880
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