Avamere Riverpark of Eugene

1. Resident 98 was admitted to the facility in 12/2025 with diagnoses including ParkinsonGÇÖs disease (progressive nerve disorder resulting in uncontrolled muscle tremors), anxiety, and panic disorder.-á The facilityGÇÖs undated Admission Packet indicated GÇ£before any service animal may be denied access to the facility or allowed to remain with their Patient/handler, a detailed written assessment of the reasons for the denial must be completed including all reasons why the service animal may not remain.GÇ¥ The 12/9/25 Medication Profile by hospice revealed no documentation Resident 98 had a service animal. The 12/15/25 Admission MDS revealed Resident 98 had a BIMS score of 15 (cognitively intact).-á A 12/18/25 Hospice Note revealed Resident 98 requested medications every two hours to address the residentGÇÖs anxiety because she/he was anxious without her/his dog.-á A revised 12/19/25 care plan indicated animals were very important to have around for Resident 98 and interventions for the residentGÇÖs negative behaviors and trauma included speaking to her/him about her/his dog. -á An undated Request to have Service Animal at Facility document identified Resident 98GÇÖs care plan and abilities were reviewed, and it was determined the resident was not safe to care for her/his service animal in the facility. An attendant was required to meet the needs of her/his service animal during visits.-á On 2/24/26 at 11:15 AM, Witness 1 (Complainant) stated Resident 98 received no written notification why her/his service animal was not allowed to remain in the facility.-á On 2/26/26 at 9:40 AM, Staff 15 (LPN) stated Resident 98GÇÖs service animal visited weekly, the service animal was for the residentGÇÖs emotional support, and the resident was unsteady and a fall risk. -á -á On 2/27/26 at 9:27 AM, Staff 14 (Admissions Coordinator) stated she had a conversation with hospice prior to Resident 98GÇÖs admission and verbally explained the residentGÇÖs service animal could not remain in the facility. Staff 14 stated she was unsure if the verbal denial for the service animal was communicated to Resident 98 and indicated the resident had different expectations about her/his service animal once she/he arrived. Staff 14 acknowledged no written information about the denial for Resident 98GÇÖs service animal was provided, and the facility was responsible to provide adequate communication to Resident 98. -á On 2/27/26 at 1:19 PM, Staff 1 (Administrator) confirmed communication to hospice or Resident 98 about the denial for the residentGÇÖs service animal was not in writing and she expected the facility to follow their own policy. 2. Resident 99 was admitted to the facility in 10/2025 with diagnoses including brain cancer and personality disorder.-á A 10/16/25 facility Elopement Risk Evaluation revealed Resident 99 was a moderate risk for elopement.-á -á The 10/22/25 Admission MDS revealed Resident 99 used a Wander Guard (electronic alarm system) daily and had a BIMS score of 6 (severely cognitively impaired).-á The 10/2025 TAR revealed Resident 99 had orders for a Wander Guard and to verify placement on the residentGÇÖs left ankle every shift.-á A review of Resident 99GÇÖs clinical record revealed no evaluation or consent for the residentGÇÖs Wander Guard. On 2/27/26 at 1:09 PM, Staff 2 (DNS) stated Resident 99GÇÖs Wander Guard was attached to the resident because she/he was at risk of exiting the building which was unsafe for the resident due to her/his cognition. Staff 2 confirmed Resident 99 was able to consent and was not evaluated or provided the option to consent to have a Wander Guard. -á On 3/2/26 at 9:11 AM, Staff 3 (Regional Director of Clinical) acknowledged the use of the Wander Guard for Resident 99 was a potential restraint and required an evaluation and consent for use.

F552 The facility was notified on 3/16/2026 of the following deficiency. The facility?failed to?ensure?a resident was informed in writing of the risks and benefits of a restraint and service dog denial for 2 of 9 sampled?residents (#s 98 & 99)?reviewed for accidents and choice. This placed residents at risk?for?not being informed.? Resident #98 and #99 are no longer residents within the facility; both discharged to the community as scheduled. House wide review of wander guard consents or resident requests were completed. Any issues reported during review were addressed at time of review. System Change: The DNS and designees completed education and training regarding need for consent prior to wander guard placement by either the resident or responsible party. Education was also provided to staff on service animal policy. Monitoring: DNS or assigned designee will audit up to 5 residents that had a wander guard initiated for proper consent and documentation as well as 5 residents who express desire to have service animal reside at facility. Audits will occur weekly x4 weeks, then monthly x4, and then as needed thereafter. Audits will be discussed at QAPI.

Resident 5 was admitted to the facility in 2023 with a diagnosis of chronic respiratory failure. A review of Resident 5's 12/2025 BIMS Assessment revealed she/he was cognitively intact.-á On 2/23/26 at 10:46 AM, Resident 5 stated she/he requested multiple times to be re-evaluated by the speech therapist because she/he was prescribed a minced and moist diet, which included many pureed foods. Resident 5 stated she/he refused to eat pureed foods and wanted a diet with no pureed foods. Resident 5 stated she/he had been waiting several months to be re-evaluated by the speech therapist.-á-á A review of the resident's clinical record revealed she/he requested her/his diet be re-evaluated at Care Conferences completed in 7/2025 and 1/2026. A Progress Note on 7/30/25 revealed Resident 5 reported she/he did not like his/her current diet.-á Resident 5's Annual MDS completed 10/2025 revealed Resident 5 had declined weight and mid-arm circumference checks and was at risk for weight loss, muscle loss, weakness and delayed wound healing.-á An 11/25/25 Progress Note revealed the resident reported poor appetite due to disliking her/his food. On 2/27/26 at 12:35 PM, Staff 32 (SLP) stated she had not re-evaluated Resident 5's swallowing. Staff 32 stated she had not completed a Risk/Benefit Assessment with the resident.-á On 2/27/26 at 1:40 PM, Staff 6 (Resident Care Manager/LPN) stated she had not completed a Risk/Benefit Assessment with Resident 15 related to her/his diet. She stated a Risk/Benefit Assessment should have been completed.-á On 2/27/26 at 1:59 PM, Staff 2 (DNS) stated when a resident wants something that is medically contraindicated staff should try and reach a mutually agreeable solution with the resident and a Risk/Benefit Assessment should be completed with the resident.-á

F561 The facility was notified on 3/16/2026 of the following deficiency. Facility?failed to?facilitate?the?resident’s?right to make choices about their diet for 1 of?4 (#5) residents reviewed for choices. This?puts?residents at risk?for?lack of self-determination.? A risk vs benefit conversation was held with resident #5 regarding SLP recommendations. Resident made informed decision to deviate from recommendations to her preference.  A house wide audit was conducted those with preferences outside of diet were addressed. System Change: The DNS and designees completed education on the importance of allowing residents to self determine their care to promote resident centered care plans. Monitoring: DNS or assigned designee will audit up to 5 residents on their satisfaction of diet texture and conduct any risk vs benefits conversations as necessary. Audits will occur weekly x4 weeks, then monthly x4, and then as needed thereafter. Audits will be discussed in QAPI.

Resident 47 was admitted to the facility in 7/2025 with diagnoses including Amyotrophic Lateral Sclerosis (ALS is a disease that destroys the connection between the brain and muscles). An 10/2025 Quarterly MDS indicated Resident 47 did not have swallowing issues and did not have significant weight loss. A 12/19/25 Progress Note indicated Resident 47 was not safe to swallow and recommendations were made for Resident 47 to be NPO (have nothing by mouth) and have a nasal gastric (NG) tube (a tube placed down the nose, to the stomach) placed for alternate means to obtain nutrition. A 1/12/26 Progress Note indicated Resident 47 was NPO since 12/19/25 which included food and medications, Resident 47 refused an NG tube, and Resident 47 lost 20 pounds since 10/2025. A review of Resident 47GÇÖs weight indicated she/he weighed 140.6 pounds on 10/7/25 and 121 pounds on 1/7/26. A 1/20/2026 Quarterly MDS indicated Resident 47 had issues with swallowing and significant weight loss. A 2/13/26 Progress Note indicated Resident 47 had an NG tube placed and tube feeding was started. A review of Resident 47GÇÖs medical record revealed no indication a Significant Change MDS was completed. On 2/26/26 at 12:49 PM, Staff 23 (RN MDS Coordinator) stated a Significant Change MDS is completed when a resident had a decline in two or more areas that did not resolve in two weeks. Staff 23 stated she was unsure if Resident 47 had a change in swallowing ability. On 2/26/26 at 1:24 PM Staff 24 (SLP) stated Resident 47 had a change in her/his ability to swallow safely in 12/2025. On 2/27/26 at 12:31 PM, Staff 2 (DNS) stated a Significant Change MDS was expected to be completed when a resident had a decline in two or more areas that do not resolve in two weeks. Staff 2 stated Resident 47 had a change in swallowing ability in 12/2025 and significant weight loss in 1/2026. Staff 2 acknowledged Resident 47 should have had a Significant Change MDS completed in 1/2026.

F637 The facility was notified on 3/16/2026 of the following deficiency. Facility?failed to?conduct a Significant Change MDS assessment for 1 of 4 sampled?residents (#47) reviewed for nutrition. This placed residents at risk for unassessed needs.?? A significant change MDS was completed for resident #47, along with other required evaluations and care plan updates.  A nutritional evaluation was completed on all residents. Any triggered resident was evaluated for the need of a significant change MDS. System Change: The DNS and designees completed staff education on the importance of identifying significant changes in residents and knowing what qualifies for a significant change. Monitoring: DNS or assigned designee will audit up to 5 residents who have had their diet texture downgraded to ensure a significant change MDS assessment was completed if indicated. Audits will be conducted weekly x4, then monthly x4, and then as needed thereafter. Audits will be discussed in QAPI.

Resident 3 was admitted to the facility in 11/2016 with diagnoses including epilepsy (seizure disorder). The 8/6/25 Care Plan for Resident 3 indicated a need for reminders and set up for oral care. A 2/11/26 quarterly MDS assessment revealed Resident 3 required setup or cleanup assistance for oral hygiene and had a BIMS score of 15, indicating she/he was cognitively intact. -á On 2/23/26 at 12:41 PM Resident 3 stated staff were directed to help her/him with brushing her/his teeth twice a day but did not. Resident 3 indicated she/he no longer requested oral hygiene assistance because she/he was told no by staff so frequently. On 2/24/26 at 10:35 AM Resident 3 estimated the last time she/he received help brushing her/his teeth was 1/2026. Resident 3 stated she/he had no idea where a toothbrush was since she/he had not used one recently. -á On 2/24/26 at 10:41 AM Resident 3GÇÖs overbed table, nightstand, restroom, and in-room sink were searched but no toothbrush was located. Atop the nightstand was an oral care basin containing toothpaste. On 2/25/26 at 10:31 AM Resident 3 reported GÇ£it didnGÇÖt happenGÇ¥ when asked if she/he got her/his teeth brushed in the evening of 2/24/26 or the morning of 2/25/26. -áResident 3 indicated she/he still did not have a toothbrush. -áThe oral care basin was again observed on top of Resident 3GÇÖs nightstand and contained toothpaste but no toothbrush. On 2/25/26 at 12:47 PM Staff 27 (CNA) reported he had not yet assisted Resident 3 with oral hygiene that day. Staff 27 was unable to locate a toothbrush in Resident 3GÇÖs room or bathroom. Staff 27 indicated oral hygiene supplies were usually kept in or on the nightstand.-á On 3/2/26 at 11:22 AM, Staff 2 (DNS) stated the expectation was for staff to offer oral hygiene opportunities at least twice a day to residents. Staff 2 confirmed Resident 3 was not provided oral hygiene as expected.

F676 The facility was notified on 3/16/2026 of the following deficiency. Facility?failed to?provide care and services to?maintain?oral hygiene for 1 of 5 sampled?residents (#3) reviewed?for ADLs. This placed residents at risk for reduced oral health.?? Resident #3 still resides within facility. Nursing met with resident to ensure ADL needs have been met. Care plans and ADLs reviewed and updated per resident’s needs and preferences. A house wide audit was conducted on all independent residents to ensure that their care needs (oral hygiene) is being met. System Change: DNS and designees completed staff education on standards of care with oral hygiene practices with independent residents. Monitoring: DNS or assigned designees will audit up to 5 independent residents to ensure that their oral hygiene needs are being met. Audits will occur weekly x4, then monthly x4, and then as needed thereafter. Results will be discussed in QAPI.

2. Resident 57 admitted to the facility in 6/2025 with diagnoses including type two diabetes mellitus with diabetic neuropathy. -á The 7/3/25 Care Plan indicated Resident 57 required reminders and setup assistance with oral care. A 12/22/25 quarterly MDS revealed Resident 57 required setup or cleanup assistance for oral hygiene and had a BIMS score of 15 indicating intact cognition. On 2/23/26 at 2:50 PM Resident 57 stated staff did not assist her/him with oral hygiene despite requests. -á On 2/24/26 at 11:34 AM, Resident 57 stated she/he required total assistance from staff with tooth brushing. When asked where the oral hygiene supplies were located, the resident indicated she/he did not know and had never seen a toothbrush in her/his room. On 2/24/26 at 11:41 AM and 2/25/26 at 10:59 AM no toothbrush or toothpaste were located on Resident 57GÇÖs overbed table, in the nightstand, or at a sink in residentGÇÖs room or restroom. A dry toothbrush and facility issued toothpaste were located at the bottom of a large plastic bin on the top shelf of the closet across the room. The oral hygiene items were not visible as the bin was filled with large personal care items including body wash, deodorant, and an unopened box of toothpaste brought by the residentGÇÖs family for her/his use. -á On 2/25/26 at 12:48 PM Staff 27 (CNA) stated so far in the shift (6:00 AM to 2:00 PM) he had not assisted Resident 57 with brushing her/his teeth. Staff 27 was not able to locate oral hygiene items in Resident 57GÇÖs room. -áStaff 27 acknowledged brushing teeth is an expected part of daily care for residents.-á On 3/2/26 at 11:22 AM, Staff 2 (DNS) stated the expectation was for staff to offer oral hygiene opportunities at least twice a day to residents. -áStaff 2 confirmed Resident 57GÇÖs experience did not meet this expectation. , Resident 5 was admitted to the facility in 2023 with a diagnosis of chronic respiratory failure. Resident 5's 10/2025 Annual MDS indicated she/he was cognitively intact.-á A review of Resident 5's Care Plan completed 1/2026 indicated she/he required the assistance of staff for personal hygiene.-á On 2/23/26 Resident 5 was observed with unbrushed, matted hair. On 2/23/26 at 10:48 AM, Resident 5 stated staff do not brush her/his hair daily. Resident 5 stated she/he wanted the knots brushed out of the hair on the back of her/his head and she/he could not do it.-á On 2/27/26 at 9:28 AM, Staff 23 (CNA) stated he cared for Resident 5 that morning and the previous day and did not brush Resident 5's hair.-á On 2/27/26 10:46 AM, Staff 33 (CNA) stated she never brushed Resident 5's hair when providing care for her/him. On 2/27/26 at 11:01 AM, Staff 34 (CNA) stated she never brushed Resident 5's hair when providing care for her/him. On 2/27/2026 at 1:59 PM, Staff 2 (DNS) stated her expectation was for staff to offer to brush residents' hair daily.-á

F677 The facility was notified on 3/16/2026 of the following deficiency. Facility?failed to?provide care and services to?maintain?grooming and oral hygiene for 2 of 5 sampled?residents (#s 5 and 57) reviewed for ADLs. This placed residents at risk for unmet ADL needs.? Resident #5 was seen by the inhouse hairdresser and received a cut and style per preference.  Nursing met with resident #57 and #5 to ensure ADL needs have been met. Care plan for ADLs reviewed and updated per resident’s needs and preferences. A house wide audit on all dependent residents was completed to ensure their care needs (oral hygiene and grooming) were being met. System Change: DNS and designees completed staff education on standards of care with oral hygiene and grooming practices for dependent residents. Monitoring: DNS or assigned designees will audit up to 5 dependent residents to ensure that their oral hygiene needs are being met. Audits will occur weekly x4, then monthly x4, and then as needed thereafter. Results will be discussed in QAPI.

2. Resident 10 was admitted to the facility in 10/2025 with diagnoses including heart failure and a stroke. A 1/8/26 Physician Order revealed orders for daily weights and to call the provider if Resident 10 gained two to three pounds over a two-day period or five pounds in one week. A review of Resident 10GÇÖs weights revealed the following: -2/7/26 weight was 176.6 pounds -2/9/26 weight was 180.2 pounds -2/13/26 weight was 181.4 pounds -2/14/26 weight was 186 pounds A review of Resident 10GÇÖs medical record revealed no evidence the provider was notified of Resident 10GÇÖs weight gain. On 2/25/26 at 12:23 PM, Staff 9 (LPN) stated from 2/7/26 through 2/9/26 Resident 10 gained 3.6 pounds and from 2/13/26 through 2/14/26 Resident 10 gained 4.6 pounds. Staff 9 stated Resident 10GÇÖs provider was not notified of the weight gains. On 3/2/26 at 12:07 PM, Staff 2 (DNS) stated staff were expected to notify the provider of weight gain per the orders. 3. Resident 11 was admitted to the facility on 1/26/26 with diagnoses including a stroke and alcoholic cirrhosis (liver disease). A review of admission orders revealed a 1/26/26 order for weekly basic metabolic panel labs (a blood test that measures eight different substances in your blood). A review of Resident 11GÇÖs 2/2026 MAR revealed the weekly basic metabolic panel labs were charted as not being completed on 2/2/25, 2/9/26, and 2/16/26 by Staff 31 (LPN). On 2/25/26 at 1:43 PM Staff 22 (LPN Resident Care Manager) acknowledged Resident 11 was admitted with orders for a weekly basic metabolic panel lab and stated the labs were not completed as ordered. On 2/25/26 at 1:50 PM, Staff 31 stated Resident 11 did not have the weekly basic metabolic panel lab completed on 2/2/26, 2/9/26, or 2/16/26 because he had not been trained on obtaining blood samples for labs. On 3/2/26 at 11:55 AM, Staff 2 (DNS) stated labs are expected to be completed as ordered. , Resident 57 was admitted to the facility in 6/2025 with a diagnosis of type 2 diabetes mellitus. A review of Resident 57s clinical record revealed an order for hydrocodone-acetaminophen, a pain reliever, to be administered up to twice daily as needed for pain. The resident's MAR for 2/20/26 revealed two doses of hydrocodone-acetaminophen were recorded on 2/20/26.-á A review of the facility's narcotic administration log revealed Resident 57 received 3 administrations of hydrocodone-acetaminophen on 2/20/26.-á Resident 57 was not available for an interview. On 3/2/26 at 7:49 AM, Staff 39 (LPN) stated she administered a dose of hydrocodone-acetaminophen to Resident 57 at 10:49 PM on 2/20/26. Staff 39 stated she was able to enter the administration in the resident's MAR, so she was not aware two doses of the medication had already been administered to Resident 57 for the day.-á On 3/2/26 at 8:55 AM, Staff 38 (CMA) stated he administered hydrocodone-acetaminophen to Resident 57 at 2:49 PM and just before Resident 57 went to bed at approximately 8:30 PM. Staff 38 stated he neglected to enter his second administration of hydrocodone-acetaminophen to Resident 57 in the MAR.-á On 3/2/26 at 12:40 PM, Staff 2 (DNS) stated her expectation was staff would immediately enter all medications into the MAR when they were administered.-á

F684 The facility was notified on 3/16/2026 of the following deficiency. Facility?failed to?follow physician orders for 3 of 8 sampled residents (#’s 10, 11, & 57) reviewed for edema, care planning, and unnecessary medications. This placed residents at risk for unidentified conditions.?? Resident #10 discharged to community as planned; provider was notified of weight gains and no adverse effects occurred due to delayed provider notification. Resident #11 still residents in facility; provider was notified of missed labs and no adverse effects from missed meds or delayed provider notification. Resident #57 still residents in facility and provider notified of extra dose of pain medication; no adverse effects noted. House wide audit of resident’s weight to ensure provider notification on weight gain. House wide audit of ordered laboratory tests was completed to ensure all labs are drawn and reported to provider timely.  A third house wide audit was completed on all residents with non-time specific PRN narcotics was done to ensure proper administration.  Following house wide audits any areas out of compliance were addressed. System Change: DNS and designees completed nursing education on facility weight protocol and appropriate provider notifications. Education on lab orders with emphasis on timely collection and result notifications to provider. Education done on notifying provider if unsuccessful with drawing bloodwork in house. Education was also provided on following provider orders verifying that the resident has not exceeded the daily limits. Monitoring: DNS or assigned designee will audit 5 resident for proper provider notification of weight gains and delayed lab results and non-times specific PRN medications administered correctly. Audits will be conducted weekly x4, then monthly x4, and then as needed thereafter. Results will be discussed at QAPI.

2. Resident 99 was admitted to the facility in 10/2025 with diagnoses including brain cancer and personality disorder. A 10/16/25 facility Elopement Risk Evaluation revealed Resident 99 was a moderate risk for elopement with no history of wandering or elopement. The instructions for the evaluation indicated it was to be completed with any significant change or as needed. A 10/20/25 revised care plan indicated Resident 99 was an elopement risk, staff were to provide frequent checks for the resident, she/he used a wheelchair for mobility, the resident was encouraged to attend activities to provide a distraction, and to evaluate her/his needs if the resident appeared to seek the exit.-á The 10/22/25 Admission MDS revealed Resident 99 used a Wander Guard (electronic alarm system) daily and had a BIMS score of 6 (severely cognitively impaired). A 10/25/25 Elopement investigation revealed Staff 12 (CNA) went on break at 2:20 PM, returned at 2:50 PM, and was informed Resident 99 was taken to activities by Staff 13 (CNA). Staff 12 found the resident in the parking lot, and it was determined the resident entered the door security code to exit the building.-á On 2/26/26 at 9:19 AM, Staff 9 (RN) stated after she completed the initial elopement assessment for Resident 99, Staff 9 indicated she noticed increased agitation by the resident who wanted to smoke more often. Staff 9 stated she wrote nursing notes and acknowledged a revised elopement risk evaluation was warranted and was not completed.-á On 2/26/26 at 10:20 AM, Staff 12 stated Resident 99 required close supervision prior to her/his elopement. Staff 12 revealed the resident attempted to get out the door ""a lot"" but never exited without someone who was available to take the resident for a walk. Staff 14 stated there were ""multiple"" times she saw Resident 99 use the security code to get outside.-á On 2/26/26 at 12:40 PM and 2:50 PM, Staff 6 (Resident Care Manager-LPN) stated staff were required to have Resident 99 within their ""line of sight.""-á Staff 6 stated additional interventions were implemented to address Resident 99's increased agitation and exit seeking behaviors and confirmed a new elopement assessment was not completed, needed supervision did not occur when staff went on break at the time of the resident's elopement, and Staff 6 did not verify the thoroughness of the investigation. On 2/26/26 at 1:08 PM, Staff 13 (CNA) stated Resident 99 became aggressive while Staff 14 was on break, so he traded the task to supervise the resident to another staff. On 2/26/26 at 3:09 PM, Staff 7 (activity assistant) stated Resident 99 often came and left from activities, and he was not informed Resident 99 was an elopement risk which required additional care for the resident. On 2/26/26 at 3:45 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged a thorough investigation was expected to understand who last saw the resident and what occurred prior to the elopement. On 3/2/26 at 9:11 AM, Staff 3 (Regional Director of Clinical) expected staff to follow Resident 99's plan of care.-á , 1. Resident 102 admitted to the facility on 12/22/25 with diagnoses including non-displaced type II dens fracture (stable fracture of the second cervical vertebra requiring neck immobilization), metabolic encephalopathy (brain dysfunction due to systemic metabolic disturbance), and delirium due to medical condition (acute, fluctuating confusion caused by illness).-á A 1/17/26 Elopement investigation revealed Staff 17 (CNA) was notified by a pedestrian that an elder person with a wheelchair was outside in the street crying and needed help. Staff 17 located Resident 102 standing behind her/his wheelchair holding onto it saying she/he was freezing and wanted to go home. Resident 102 was in the road about 20 feet from a busy intersection. Resident 102 was confused, resisted help but eventually sat in her/his wheelchair and allowed staff to bring her/him back to the facility. Staff 17 stated she was unsure how long Resident 102 was outside, but she/he was freezing cold and was not wearing a coat. On 2/25/26 at 6:24 PM, Staff 21 (LPN) reported she reviewed Resident 102's medical record prior to completing the Admission Elopement Risk Evaluation. Staff 21 stated she was aware the resident had severe cognitive impairment, with fluctuating cognition, and the resident was not consistently aware of her/his surroundings.-á On 2/26/26 at 9:26 AM, Staff 18 (CNA) stated Resident 102 was frequently confused and agitated during her shifts and made multiple attempts to exit the facility. Staff 18 stated she reported Resident 102's behaviors to a nurse. Staff 18 further stated the resident's exit-seeking behavior was ""hard not to notice."" Staff 18 reported on 1/17/26 at approximately 8:00 PM, she became aware Resident 102 was outside the facility unsupervised and assisted other staff to bring the resident back inside. Staff 18 estimated the resident had been outside for approximately 20 minutes before staff located her/him. Staff 18 further stated when Resident 102 was found, the resident was not wearing a jacket or shoes and appeared cold, wet, and confused. On 2/26/26 at 9:50 AM, Staff 15 (LPN) stated Resident 102 exhibited significant confusion and agitation. Staff 15 stated Resident 102 wandered throughout the facility in her/his wheelchair and attempted to exit through the front door on at least one occasion.-á On 2/26/26 at 2:54 PM, Staff 17 (CNA) stated Resident 102 exhibited exit-seeking behaviors shortly after admission and attempted to exit the facility multiple times. Staff 17 stated management was aware of the behavior. Staff 17 stated on 1/17/26, while on break, a pedestrian informed her that a resident was outside GÇ£hysterical and cold.GÇ¥ Staff 17 located Resident 102 near a busy intersection. Staff 17 stated the resident was cold, shaking, and was not wearing a jacket or shoes.-á On 2/26/26 at 4:26 PM, Staff 19 (RN) confirmed Resident 102GÇÖs cognition fluctuated and stated the resident attempted to exit the facility on 1/17/26 earlier in the day. Staff 19 stated she did not believe the resident required a wander guard prior to the elopement.-á On 3/2/26 at 10:26 AM, Staff 2 (DNS) and Staff 3 (Regional Director of Clinical) acknowledged the facility did not reassess Resident 102's elopement risk after staff became aware of exit-seeking behaviors.-á

F689 The facility was notified of the following deficiency on 3/16/2026. Facility?failed to?accurately assess a resident, thoroughly?investigate?and follow care plan interventions for elopement for 2 of 3 sampled residents (#99 & 102) reviewed for accidents. This placed residents at risk for elopement.??All current residents were re-evaluated for elopement risk and care plans updated accordingly. System Change: The DNS and designees completed facility education on elopement/elopement risks (including wandering) managing behaviors and interventions. Facility education was also completed on the Elopement and Code Pink policies. Monitoring: The DNS or assigned designees will review 5 residents following admission or change in behavior to ensure elopement status and care plan is appropriate. Audits will occur weekly x4, then monthly x4, and then as needed thereafter. Results will be discussed in QAPI.

Resident 8 admitted to the facility in 11/2025 with diagnoses including urinary retention (a condition related to the inability to completely empty the bladder when voiding). -á On 2/23/26 at 10:48 AM, Witness 2 (family member) indicated Resident 8 had four or more UTIs in the past year. A progress note dated 11/20/25 indicated Resident 8 required an appointment with a urologist specializing the treatment of urinary retention. -áStaff 16 (Social Services Director) scheduled Resident 8 for a urologist appointment on 12/2/25 and arranged transportation. -á Resident 8GÇÖs clinical record contained no documented evidence she/he was seen by the urologist as planned on 12/2/25.-á Resident 8 was diagnosed with UTIs on 12/26/25, 2/17/26, and 2/24/26. On 3/2/26 at 11:15 AM, Staff 2 (DNS) stated Resident 8 was referred to the urologist to help manage her/his recurring UTIs. -áStaff 2 confirmed Resident 8 missed the 12/2/25 appointment and the facility did not reschedule the missed appointment.-á

F690 The facility was notified of the following deficiency on 3/16/2026. Facility?failed to?provide care and services to prevent a UTI for 1 of 1 sampled?resident (#8) reviewed for urinary tract infections. This placed?resident?at risk for recurrent UTIs.?House wide audit was completed on all residents who are at risk for recurrent UTIs; care plans updated accordingly. System Change: The DNS or designee completed education to nursing staff on non-pharmacological interventions for UTI prevention and the importance of coordinating urology services as needed. Monitoring: New admits will be reviewed upon admission for histories of recurrent UTIs. If a resident is identified as high risk, their care plan will be updated and urology referral discussed with provider. Audits will occur weekly x4, then monthly x4, then as needed thereafter. Results will be discussed in QAPI.

-á 2. Resident 22 was admitted to the facility in 5/2025 with diagnoses including traumatic brain injury and chronic pain. -á The 2/10/26 Quarterly MDS indicated Resident 22 had a BIMS score of 15 (cognitively intact) and the residentGÇÖs pain occasionally interfered with her/his daily activities. -á A 2/10/26 revised Care Plan indicated Resident 22 required one staff to assist her/him with all transfers. If staff were uncomfortable with transfers or the resident was unsafe, two staff were permitted to transfer the resident. Resident 22 was occasionally incontinent of bowel and bladder. -á A 2/13/26 Summary Call Data by Room/Bed report revealed, at 3:55 PM, Resident 22GÇÖs call light was answered after 30 minutes. -á A 2/14/26 Grievance Communication Form revealed Resident 22 indicated her/his call light was not answered timely on 2/13/26 after the resident soaked her/his bed with water and required assistance. -á A 2/18/26 Grievance Communication Form revealed Resident 22 voiced concerns during a care conference of long call lights during resident smoke breaks. -á A 2/23/26 Summary Call Data by Room/Bed report revealed, at 6:33 PM, Resident 22GÇÖs call light was answered after 25 minutes. -á On 2/23/26 at 1:41 PM, Resident 22 stated there were issues with long call lights when residents had smoke breaks. Resident 22 stated she/he often required toilet assistance when assistance was requested. -á A 2/24/26 Grievance Communication Form revealed Staff 4 (CNA) informed Resident 22 she was going on a break and told another CNA to address the residentGÇÖs call light. -á On 2/24/26 at 2:36 PM, Staff 5 (CNA) stated a few weeks earlier Staff 28 (CNA) did not want to answer Resident 22GÇÖs call light while Staff 5 took residents to smoke around 4:00 PM. Staff 5 stated Resident 22 and Staff 28 had a disagreement the previous day. Staff 5 confirmed Resident 22 waited 30 minutes for care which was provided when Staff 5 returned. -á -áOn 2/27/26 at 1:35 PM, Staff 2 (DNS) stated Staff 28 removed himself from Resident 22GÇÖs care without communicating to the charge nurse. Staff 2 expected staff to address call lights timely through improved communication. -á -á On 3/2/26 at 11:50 AM, Resident 22 stated Staff 4 went on break and left her/his call light on to alert another CNA that she/he required assistance. Resident 22 stated she/he was in pain by the time assistance was provided. -á On 3/2/26 at 11:57 AM, Staff 4 confirmed the CNA who did not answer Resident 22GÇÖs call light timely on 2/23/26 was previously GÇ£firedGÇ¥ by Resident 22 from her/his care. Staff 4 stated communication between staff did not occur to answer Resident 22GÇÖs call light timely. -á On 3/2/26 at 12:29 PM, Staff 2 stated she compared the multiple grievances filed for Resident 22 and acknowledged the root cause of long call lights for the resident was not addressed. , 1. Resident 47 was admitted to the facility in 7/2025 with diagnoses including Amyotrophic Lateral Sclerosis (ALS is a disease that destroys the connection between the brain and muscles). -á A review of call light audits for Resident 47 revealed the following call lights on greater than 30 minutes: -11/2/2025 one hour and five minutes -11/7/2025 35 minutes -11/13/25 33 minutes -11/14/25 41 minutes -11/21/25 one hour and 12 minutes -á An 11/21/25 complaint alleged staff were ignoring Resident 47GÇÖs call light. -á A 1/4/26 revised care plan indicated Resident 47 was to have GÇ£cares in pairs."" -á A 1/26/26 Grievance Communication Form indicated on 1/25/26 Resident 47 requested to use the restroom at 9:36 PM and did not receive assistance until 10:15 PM. The conclusion indicated Resident 47 did have a longer wait time because when she/he requested assistance staff were not available due to, GÇ£a bunch of call lights in overtime twoGÇ¥ so Resident 47 waited in the front lobby and staff were not aware of her/his location. -á On 2/24/26 at 6:42 AM, Resident 47GÇÖs call light was observed on. -á On 2/24/26 at 7:15 AM, Staff 10 (CNA) was observed to answer Resident 47GÇÖs call light. Staff 10 acknowledged Resident 47GÇÖs call light was on for more than 30 minutes and stated there were no staffing issues this shift but Resident 47 needed two staff members to provide assistance and everyone was busy. -á On 3/2/26 at 9:21 AM Staff 35 (CNA) stated the facility was continuously short CNA staff which makes the shift, GÇ£hectic."" -á On 3/2/26 at 9:33 AM Staff 36 (LPN) stated the facility was short CNA staff, GÇ£quite a few nights."" Staff 36 stated she assisted the CNAs with answering call lights, but it got busy and residents got frustrated. -á On 3/2/26 at 9:37 AM Staff 37 (CNA) stated the facility has been short CNA staff. Staff 37 stated when they were short CNAs, it would get busy, the nurses would try to help answer call lights, but they also had a job to complete. Staff 37 stated when they were short CNAs rounds took longer than two hours to complete. -á On 2/26/26 at 9:32 AM, Staff 2 (DNS) stated the call lights would go into overtime after being on for seven and a half minutes and would go into overtime two after being on for 15 minutes.

F725 On 3/16/2026 the facility was notified of the following deficiency. Facility?failed to?address call lights?in a timely manner?for 2 of 6 sampled residents (#22 & 47) reviewed for staffing. This placed?resident?at risk for delayed care.?Residents #22 and 47 still resides in facility; no ASEs noted from long call light wait times.   House wide audit was conducted to see if any other residents have been affected, follow up completed as needed. System Change: The DNS and designees completed education to the nursing staff regarding call light response time expectations. Monitoring: The DNS or assigned designees will audit 5 random resident’s call light response times weekly x4, then monthly x4, and then as needed thereafter. Results will be discussed in QAPI.

The 1/2023 Ordering and Receiving Controlled Medications policy indicated, ""The pharmacy or nursing care center prepares an individual resident-controlled substance log for each controlled substance medication prescribed for a resident. This log is placed in the Narcotic book to be counted after every shift."" On 1/31/26, the North Hall narcotic book revealed 17 times out of 186 counting opportunities facility staff did not verify the narcotic count was correct. On 2/24/26, the North Hall narcotic book revealed 29 times out of 150 counting opportunities facility staff did not verify the narcotic count was correct. On 1/31/26, the South Hall narcotic logbook revealed 17 times out of 186 counting opportunities facility staff did not verify the narcotic count was correct. On 2/24/26, the South Hall narcotic logbook revealed 57 times out of 150 counting opportunities facility staff did not verify the narcotic count was correct. On 1/31/26, the Central Hall narcotic logbook revealed 17 times out of 186 counting opportunities facility staff did not verify the narcotic count was correct. On 2/24/26, the Central Hall narcotic logbook revealed 29 times out of 150 counting opportunities facility staff did not verify the narcotic count was correct. On 2/25/26 at 1:10 PM, Staff 2 (DNS) acknowledged two staff members were to count the narcotics after every shift and sign the narcotic logbook together verifying the narcotic count was correct.

F755 On 3/16/2026 the facility was notified of the following deficiency. Facility?failed to?ensure narcotic drug records were in order and a count of all controlled drugs was?maintained?for 6 of 6 medication carts reviewed for medication administration. This places residents at risk?for?drug diversion.?House wide audit completed; no narcotic discrepancies noted. System Change: The DNS and designees completed education on the importance of ensuring proper process of narcotic book counts and signatures. Monitoring: The DNS or assigned designee will audit all the narcotic book signatures to ensure compliance will be completed.  Audits will occur weekly x4, then monthly x4, and then as needed thereafter. Results will be discussed in QAPI.

Resident 4 was admitted to the facility in 12/2022 with diagnoses including heart failure and arterial fibrillation (an irregular heartbeat). -á A review of orders revealed a 6/11/24 order for metoprolol succinate (a medication used to treat high blood pressure), hold for a heart rate less than 60 beats per minute. -á A review of Resident 4GÇÖs 1/2026 MAR revealed Resident 4 was administered metoprolol succinate with a heart rate less than 60 beats per minute on: -1/10/26 heart rate was 59 per minute -1/22/26 heart rate was 59 per minute -1/24/26 heart rate was 52 per minute -1/29/26 heart rate was 52 per minute -á A review of Resident 4GÇÖs 2/2026 MAR revealed Resident 4 was administered metoprolol succinate with a heart rate less than 60 beats per minute on: -2/10/26 heart rate was 56 per minute -2/12/26 heart rate was 58 per minute -á On 2/25/26 at 10:03 AM, Staff 32 (LPN) stated she administered Resident 4 the metoprolol succinate on 1/10/26,1/24/26, 1/29/26, 2/10/26 and 2/12/26 and acknowledged Resident 4GÇÖs heart rate was less than 60 beats per minute on those dates, and the metoprolol succinate should have been held per orders. On 2/25/26 at 11:51 AM, Staff 9 (RN) stated on 1/22/26 Resident 4GÇÖs HR was 59 and she administered the metoprolol succinate. On 2/27/26 at 11:38 AM, Staff 7 (LPN Resident Care Manager) stated staff were expected to hold the metoprolol succinate if Resident 4GÇÖs heart rate was less than 60 beats per minute per orders. -á

F757 The facility was notified of the following deficiency on 3/16/2026. Facility?failed to?ensure residents did not receive any unnecessary medications for 1 of?5 (#4) sampled residents.?Resident #4 still resides at facility; no ADEs noted from this practice deficit. House wide audit of residents with medications with parameters has been completed to identify any other affected residents, i nvestigations completed of any discrepancies found. System Change: The DNS and designees completed education with nursing staff on administering medications with hold parameters. Monitoring: The DNS or assigned designees will audit 5 residents to ensure that medication parameters are being followed. Audits will occur weekly x4, then monthly x4, and then as needed thereafter. Results will be discussed in QAPI.

On 2/25/26-áSouth Hall medication cart observations revealed Resident 15's insulin had been removed from the refrigerator and was not dated. Staff to 22 (LPN) confirmed the insulin should've been dated after staff removed the insulin from the refrigerator.-á Resident 6's insulin dated 2/18/26 was observed unopened on the medication cart. Staff 22 confirmed the insulin should've been kept refrigerated until used. On 2/25/26 at 4:01 PM, Staff 3 (Regional Director of Clinical) stated all nursing staff are expected to follow proper medication storage requirements, including refrigeration and dating of insulin.-á -á-á

F761 On 3/16/2026 the facility was notified of the following deficiency. Facility?failed to?ensure?medications,?were stored properly for 1 of 3 medication carts reviewed. This placed?residents at risk for reduced medication effectiveness.??Pharmacy conducted a house wide audit to ensure proper medication storage. System Change: The DNS and designees completed education to nursing staff on proper medication storage with emphasis on labeling medications with an open/expiration date per facility protocol. Monitoring: The DNS and assigned designees will cart all medication/treatment carts for appropriate medication labeling. Audits will be conducted weekly x4, then monthly x4, and then as needed thereafter. Results will be discussed in QAPI

1. Resident 57 admitted to the facility in 6/2025 with diagnoses including type two diabetes mellitus with diabetic neuropathy. -á On 2/23/26 at 2:50 PM Resident 57 stated staff did not assist her/him with oral hygiene despite resident requests. -á On 2/24/26 at 11:34 AM, Resident 57 stated she/he required total assistance from staff to brush her/his teeth. When asked where the oral hygiene supplies were located, this resident indicated she/he did not know and had never seen a toothbrush in her/his room. On 2/27/26 at 9:11 AM Resident 57 reported she/he received assistance with brushing her/his teeth once that week on day shift on 2/25/26. Resident 57 stated she/he was not offered additional opportunities for oral hygiene. Resident 57GÇÖs 2/24/26 Task: GG-Oral Hygiene report indicated oral hygiene was completed by Staff 25 (CNA) during the day shift (6:00 AM to 2:00 PM). On 2/25/26 at 4:17 PM Staff 25 stated she did not complete oral hygiene with Resident 57 on 2/24/26. Resident 57GÇÖs 2/26/26 Task: GG-Oral Hygiene report indicated Staff 26 (CNA) assisted with oral hygiene during the evening shift (2:00 PM to 10:00 PM). On 2/27/26 at 10:13 AM Staff 26 stated he did not assist Resident 57 with brushing her/his teeth that week. -á On 3/2/26 at 11:22 AM Staff 2 (DNS) confirmed it was not acceptable for staff to document completion of care if it was not done.

F842 The facility was notified of the following deficiency on 3/16/2026. Facility?failed to?ensure resident records were?complete and?accurate?for 1 of 5 sampled residents (#57) reviewed for ADLs. This placed?resident?at risk for inaccurate medical records. Resident #57 still residents in facility; no ASEs noted from inaccurate documentation.? House wide audit was conducted to ensure that POC documentation accurately reflects resident’s assistance level. System Change: The DNS and designees completed education to nursing staff regarding appropriate documentation for services rendered. Monitoring: The DNS 5 residents will be audited to ensure accurate POC documentation. Audits will occur weekly x4, then monthly x4, and then as needed thereafter. Results will be discussed in QAPI.

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.

On 7/9/2025 the facility was notified of the following deficiency.  The facility failed to provide adequate incontinence and catheter care for two of the three sampled residents (14 and 16) reviewed for catheter care. This placed residents at risk for unmet care needs, skin breakdown, and loss of dignity.  Skin checks were completed for residents 14 and 16 and no skin impairments related to incontinence care.  Residents 14 and 16 report no ongoing concerns regarding incontinence or catheter care. System Change: Other residents have the potential to be affected; this placed all incontinent residents and those with catheters at risk.  Incontinent residents (bowel and bladder) were interviewed, and care plans have been updated based on resident feedback on care.  Education for staff has been completed to ensure proper incontinence and catheter care is being performed and based on resident preferences.  Shift huddles will occur to reinforce education; this will continue until substantial compliance is achieved. Monitoring: Direct observation audits will be conducted and competency validation on weekly, monthly and then needed thereafter. Results will be discussed in QAPI, including reviewing the plan of correction and revising as indicated.

******************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689 and F690 ********************************

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.

The facility was notified on 10/24/2024 of the following deficiency. The facility failed to ensure that a resident was treated with dignity for 1 of 1 sampled resident (#39) reviewed for medication administration. This placed residents at risk for lack of respectful encounters. Resident #39 was interviewed for concerns and does not recall the incident and does not show any signs or symptoms of distress related to the incident. Other residents have the potential to be affected. No other resident was identified to be affected during review of competency System Change: The DNS and designees completed education and training regarding protecting resident rights and specifically towards blood glucose monitoring and insulin administration in public areas. This education includes the rights of residents to determine where treatments take place. Monitoring: DNS or assigned designee will audit up to 5 nurses with blood glucose checks and insulin administration weekly to ensure that resident rights are honored. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Resident rights and dignity will be reviewed and discussed in QAPI.

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.

The facility was notified on 10/24/2024 of the following deficiency. The facility failed to ensure a resident's representative was included in the care planning process for 1 of 2 sampled residents (#74) reviewed for communication. This placed residents at risk for lack of input in the care planning process. SS have reached out resident #74's family and was able to gather alternative contact information for other family members interested in attending. Other residents have the potential to be affected. A house wide audit was completed, and calls were placed to resident's representatives who did not have an address on file. This information was updated in the residents EHR. System Change: Admin has developed and implemented education and training with the Social Services and the Business Office Manager regarding resident right to have family representatives participate in care planning process. Monitoring: Admin or assigned designee will audit to ensure resident families are invited to care conferences. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Resident rights to ensure a representative is included in the care planning process will be reviewed and discussed in QAPI.

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. , 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.

The facility was notified of the following deficiencies on 10/24/2024. The facility failed to notify the physician regarding refusals and changes in condition for 3 of 9 residents (#'s 26, 42, and 442) reviewed for medications and change of condition. This placed residents at risk for lack of physician involvement. The physician for resident #26 was notified of her weight and blood glucose checks refusals and both orders were discontinued. Provider for #42 has been notified of her hospitalizations related to her worsening BLE wounds and uncontrolled pain she was experiencing. Resident #442 is no longer in the facility. Other residents have the potential to be affected. An audit was completed for residents in the last 7 days to check for notification to the provider regarding CBG refusals, weight refusal, Change of condition. System Change: The DNS and designees completed education for nurses regarding the need to notify providers of treatment refusals and changes in conditions. Monitoring: DNS or assigned designee will audit up to 5 residents for provider notification of treatment refusals and change in conditions. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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.

The facility was notified on 10/24/2024 of the following deficiencies. 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. All three residents (#'s 42, 44 and 89) are back within the facility and Ombudsman notified. Other residents have the potential to be affected. Residents out of the facility during the review period were audited for completion of transfer form. No concerns identified. System Change: The DNS and designees completed education to nurses regarding the need to review the Acute Care Transfer form with the resident prior to hospitalizations. The IDT will review resident transfers and discharges at the stand up and stand down meeting to ensure residents or responsible party received the appropriate information and Transfer form. Monitoring: DNS or designee will audit up to 5 residents who are transferred or discharged to ensure the resident has received appropriate information and Transfer form. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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. , 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.

On 10/24/2024 the facility of notified of the following deficiencies. 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. Residents (#'s 42, 44 and 89) have returned back to their original rooms following their hospitalizations. Rooms had been held for residents with no bed hold fee. Other residents have the potential to be affected. Residents out of the facility during the review period were audited for completion of bed hold form. No concerns identified System Change: The Admin and designees completed Education to nurses regarding the need to review the Acute Care Transfer form with the resident prior to hospitalizations. The IDT will review resident transfers to the hospital at the stand up and stand down meeting to ensure residents or responsible party received information on bed hold policy and Bed Hold form was completed. Monitoring: DNS or designee will audit up to 5 residents who are transferred to hospital to ensure the resident has received information on the bed hold policy and Bed Hold form was completed. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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. , 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.

On 10/24/2024 the facility was notified of the following deficiency. The facility failed to complete comprehensive care plans within the required timelines and revised care plan interventions for 2 of 7 sampled residents (#'s 38 and 42) reviewed for change of condition, ADL care and edema. This placed the residents at risk for unmet needs. Resident #38's care plan has been revised to include updated interventions for UTI prevention. Resident #42's care plan has been revised to include offering peri-care and assistance to elevate legs when in bed. Other residents have the potential to be affected. A house wide audit of resident care plans to ensure they are updated and accurate has been completed. System Change: The DNS and designees completed education to nursing staff, social services, activities and dietary has been completed on the importance of personalizing care plans and updating as soon as changes to resident preferences or needs are found. A care plan review audit tool has been developed for RCMs to use when creating and updating resident care plans. Monitoring: DNS or designee will audit care plan revisions for up to 5 residents weekly for four weeks, monthly for three months and as needed thereafter. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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.

The facility was notified of the following deficiency on 10/24/2024. The facility failed to ensure professional standards were followed for 2 of 6 sampled residents (#'s 39 and 442) for medication administration. Resident #442's medications were inappropriately administered resulting in a change of condition which required hospitalization. Resident #442 is no longer in the facility. Resident #39 was assessed, and no adverse effects were observed. Others have the potential to be affected. A house wide audit was completed of all residents who require crushed medications with a medication review. System Change: The DNS and designees completed education and training to nursing staff regarding crushing medications as well as proper techniques to disinfect blood glucose monitors. Monitoring: DNS or designee will audit up to 5 nurses weekly on blood glucose monitor cleaning and perform a knowledge test on medication administration with focus on crushing medications. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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.

The facility was notified of the following deficiency on 10/24/2024. 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 diminished quality of life. Residents #'s 21 and 37 care plans have been updated to include preferences on types of activities enjoyed. Care plans were linked to the Kardex to make sure staff was aware of preferences in activities. Others have the potential to be affected. A house wide audit was completed on residents to ensure care plans accurately reflect resident's preferences and were linked to the Kardex. A new system was developed to notify staff of the current days activities and who may be interested in participating. System Change: The DNS and designees completed education to staff was completed on the importance of resident participation in activities, especially for those who are dependent for cares. Information was also provided to staff on how/where to find this information. Monitoring: DNS or designee will audit up to 5 residents activities care plans for activity preference and linking to the Kardex. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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. , 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.

The facility was made aware of the following deficiency on 10/24/2024. 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. Resident #13's skin assessment has been updated to accurately reflect the location of the pressure ulcers. Resident #62's skin assessment has been updated to reflect the type of wound (abrasion to pressure ulcer). Others have the potential to be affected. A house wide audit was completed on all current wounds for correct identification of wounds. Concerns identified were updated. System Change: The DNS and designees will completed weekly wound meetings which will be held with nurse managers to review wounds and ensure accurate identification of wounds. Education was developed and implemented house wide on importance of accurate wound assessments. Monitoring: DNS or designee will audit up to 5 residents for accuracy of wound assessments. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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.

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. , 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.

The facility was notified of the following deficiency on 10/24/2024. 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. Resident #42 had a second set of CPAP supplies ordered/received so that CPAP equipment can be cleaned while resident can still utilize CPAP during the day. Resident #17 had follow-up chest xray and was reassessed in person by the provider; no further orders were received. Others have the potentail to be affected. Residents with current CPAP and O2 were audited and concerns identified were updated. Resident dashboard was reviewed for indication of ongoing respiratory issues, no concerns identified. System Change: The DNS or designees completed educated on the importance of cleaning respiratory equipment. Staff were educated on completing assessments related to respiratory concerns Monitoring: DNS or designee will audit up to 5 residents with CPAPs for appropriate cleaning. DNS or designee will audit the dashboard up to 5 residents for accurate assessments of respiratory concerns. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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.

The facility was notified on 10/24/2024 of the following deficiency. The facility failed to provide sufficient staffing for 2 of 8 sampled residents (#'s 42 and 76) reviewed for staffing. This placed the residents at risk for unmet needs. Adjustments were made to CNA assignments and resident placement to balance acuity. Other have the potential to be affected. Adjustments were made to CNA assignments and resident placement to balance acuity. System Change: The Admin or designees completed training on acuity-based staffing. IDT will continue to review the acuity of admitting residents to determine the best placement options. IDT will also continue to review acuity on the ICF units as resident conditions change and/or level of assistance required increases. Monitoring: DNS or designee will audit resident acuity on up to 5 residents (looking at 2 person assists, paraplegic and quadriplegic residents, residents who are incontinent, etc.). Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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

The facility was notified of the following deficiency on 10/24/2024. The facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#442) reviewed for change of condition. Resident 442's medications were inappropriately administered resulting in a change of condition which required hospitalization. Resident #442 is no longer within facility. Other residents have the potential to be affected. A house wide audit was completed of all residents who require crushed medications with a medication review. System Change: The DNS and designees completed education and training to nursing staff regarding crushing medications that should not be crushed. Monitoring: DNS or designee will audit up to 5 residents who receive crushed medication for proper administration of medication. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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.

The facility was notified of the following deficiency on 10/24/2024. 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 the residents at risk of being uninformed of their legal rights. Residents #13 and #76 had a new review of the arbitration agreement and the resident charts were updated with their preference. Other residents have the potential to be affected. Residents currently in the facility in the arbitration agreement had a new review of the arbitration agreements and changes per resident preferences were updated. System Change: Admin completed education with Social and Guest Services related to the importance of ensuring resident understands arbitration terms. Monitoring: Admin or designee will be auditing up to 5 residents to validate the understanding of the arbitration agreement. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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.

The facility was notified of the following deficiency on 10/24/2024. The facility failed to ensure the community use glucometer was properly sanitized between resident use for 1 of 1 sampled resident (#39) reviewed during CBG checks. Resident #39 had no negative outcomes related to deficiency. Competencies for LN on shift were completed to ensure proper sanitization was occurring. Other residents have the potential to be affected. This placed all residents who required CBG checks at risk for bloodborne illness. Competencies for LN on shift were completed to ensure proper sanitization was occurring. System Change: The DNS and designees completed competencies for LN on shift were completed to ensure proper sanitization was occurring. Education was given to LNs on the proper cleaning of a glucose monitor. Monitoring: DNS or designee will audit up to 5 nurses weekly on blood glucose monitor cleaning. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

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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. , 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.

The facility was notified on 12/10/2024 of the following deficiency. The facility failed to follow infection control standards for three of four sampled residents (#’s 21, 42, and 505) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Residents #’s 21, 42 and 505 had no negative outcomes related to the deficiency. Resident # 505’s wound is healing with no complications; no signs or symptoms of infection. Other residents have the potential to be affected. This placed all residents and those who require wound dressing changes at risk for exposure and contraction of infectious diseases. Education for staff has been completed to ensure proper infection control standards. System Change: The DNS and designees completed education with staff regarding EBP (enhanced barrier precautions) and to LNs (licensed nurses) on proper infection control measures regarding wound care. Monitoring: DNS or designee will audit up to 5 and their wound care practices. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. DNS or designee will audit up to 10 employees with infection control measures. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results of both audits will be reviewed and discussed in QAPI.

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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.

On 12/17/2024 the facility was notified of the following deficiency. The facility failed to follow infection control standards for two of four sampled residents (#’s 600 and 605) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Residents # 600 and 605 had no negative outcomes related to the deficiency. Resident # 605 was able to be taken off droplet precautions following antibiotic completion. System Change: Other residents have the potential to be affected. This placed all residents at risk. Education for staff has been completed to ensure proper infection control standards are being followed. Shift huddles are occurring daily to reinforce education; this will continue until substantial compliance is achieved. The Infection Preventionist or designee will complete infection control standards with new hires during their orientation period. Monitoring: 1:1 education was provided to staff observed not following infection control standards. Further education regarding precautions infection control standards and enhanced barrier precautions Audits will occur daily with direct observation and competency validation until substantial compliance is achieved. Results will be discussed in QAPI, including reviewing the plan of correction and revising as indicated.

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.

The facility was notified on 10/24/2024 of the following deficiency. 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. Others have the potential to be affected. Residents currently receiving antibiotics were reviewed for proper antibiotic use. No concerns identified System Change: The DNS or designee provided education regarding antibiotic stewardship for the nurses and infection preventionist. Monitoring: DNS or designer will audit up to 5 residents using antibiotics for appropriate use. Audits will occur weekly for four weeks, monthly for three months and as needed thereafter. Results will be reviewed and discussed in QAPI.

******************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F550 and F553 ******************************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 ******************************** OAR 411-088-0080 Notice Requirements Refer to F623 ******************************** OAR 411-088-0050 Right to Return from Hospital Refer to F625 ******************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ******************************** OAR 411-086-0230 Activity Services Refer to F679 ******************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686 and F689 ******************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658, F695 and F760 ******************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ******************************** OAR 411-086-0110 Administrator Refer to F847 ******************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 and F881 ********************************

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

*************************** 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.

F684  Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choices. Residents effected: Facility was notified of the following deficiency on 3/28/2024. 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 and harm. Finding include: (1) Resident #9 scheduled morphine was out of stock and dose missed on two different occasions (10/11/23 and 12/11/23), (2) Resident #3 resident was left alone in bathtub when care planned for 1 person assist for bathing on 2/2/24, and (3) Resident #5 resident did not receive colchicine from 1/7/24 through 1/18/24. These placed the residents at risk for increased pain and injury during bathing. For resident #9 we have collaborated with his provider, and they are now writing for larger quantities and pharmacy is now sending the full 60-day supply. Resident #3s bathing care plan was reviewed and appropriate for ADL needs and immediate staff in serving implemented. Resident #5 has been discharged from the facility. Identification of Others: This also puts other residents at risk for missed medications, increased pain, and injury during bathing. The facility has developed and implemented education and training regarding following residents care plans, education regarding the facility bathing protocol, process for missing medications and pharmacy notification. Education started immediately following each specific incident with hall huddles, all staff meetings, nurse meetings and CNA meetings. Facility wide medication cart audits completed to ensure all medication was properly ordered and received. Facility also conducted a bathing care plan audit to ensure all resident were on the appropriate level of care to ensure that other residents had not been affected. Systemic Changes: The facility has developed and implemented education and training regarding following residents care plans, as well as education regarding the facility bathing protocol, process for missing medications and pharmacy notification. The cause of deficiencies is related to lack of understanding and education regarding care plans, the process of reordering narcotics in a timely manner, and the process of missing medications. Ongoing education will be provided for new hires and annually during staff meetings. Monitoring: Audit of narcotics has been implemented twice weekly starting on 3/25/24. In process of twice weekly medication cart audits x4 weeks and then will move to monthly. Audit of staff knowledge and visual checks regarding bathing policy and care plan have been implemented on 2/5/24. Completed weekly audits x4 and have moved to monthly audits. Audit on all admissions to make sure all medications have been delivered by pharmacy in a timely manner has been implemented 2/12/24. Completed weekly audits x4 and have moved to monthly audits. DNS or assigned staff will continue with the audit processes. All findings will be reviewed in QAPI until significant compliance is met. Compliance date: Facility alleges compliance on 4/4/2024.

************************************ 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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. The RCM and Social Services updated the residents care plan with the resident to confirm that the residents # 34s wishes were respected related to allowing him to choose his care givers. The facility has personalized the residents care plan preferences and allow him to direct his own care as much as able and safe to do so safely. Also updated care plan to state; Assign consistent caregivers to build trust. Other potential residents effected: This placed residents at risk for lack of respectful encounters. The facility was notified of no additional deficiencies at this time related to lack of respectful encounters. Concerns regarding lack of respectful encounters are investigated. The facility has developed and implemented education and training regarding protecting resident rights, and the resident right to choose not to work with certain staff members. Education started immediately with hall huddles, all staff meetings, nurse meetings, and assigned online Relias education. The facility completed weekly interviews with residents, staff, and family members, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training regarding protecting resident rights, and the resident right to choose not to work with certain staff members. The facility conducted interviews with residents, and further concerns were investigated and addressed. Ongoing education will be provided regarding protecting resident rights for new hire, and annually. Staff interviews are to be conducted to ensure they understand resident rights. The cause of deficiencies is related to lack of understanding of resident rights and how to protect resident rights related to choosing not to work with certain staff members. Monitoring: DNS or assigned staff will complete 3 resident/resident family interviews weekly to ensure resident rights are honored. DNS or assigned staff will complete 3 staff interviews weekly to ensure resident rights are honored and staff understand resident rights and that resident can choose not to work with certain individuals. Assessments are done weekly for 4 weeks, and then monthly for 3 months. QAPI will review resident rights ongoing for 2023.

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. , 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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Confirmed 63 wishes for amitriptyline honored. Confirmed consents for # 76 resident BIMS score has improved, and resident can now give consent for his psychotropic medications. Audit done on residents with psychotropic medications to confirm that consents for psychotropic medications were completed, and that care plans reflected current psychotropic medications. Deficiencies found were corrected by getting consents signed and care plans updated. Audits started to confirm that consents are done on admission and with medication changes. Audits to confirm that if the resident cannot give a consent that education and consent is done with family. Audits started to confirm that care plans are completed for new psychotropic medications. Other potential residents effected: This placed residents at risk for lack of appropriate medical treatment decisions. Resident audits were done on 07/05/2023 to determine if there were other concerns related to consents for psychotropic medications, and care planning for psychotropic medications. Deficiencies were addressed so that residents have signed consents and updated care plans for psychotropic medications. The facility completed audits for residents, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training regarding psychotropic medications for nurses and IDT team members. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that new admissions and residents with new psychotropic medications have consents signed correctly and care plans updated. The cause of deficiencies is related to; lack of understanding of when to complete consents, who to do consent with, and when to start care plan for new psychotropic medication. Monitoring: Audits were done on residents with psychotropic medications to confirm that consents were signed, and care plans were updated. Audits will be done to confirm; consents are completed correctly on admission and with new orders for psychotropic medications, correct diagnosis is on the order, and high-risk medication education has been completed. These audits will be done weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by social services or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. LPN RCM gave the resident a copy of his care plan and reviewed his preferences for foley catheter care and foley catheter replacement. Resident # 34s care plan was updated to reflect the residents' wishes. Audits were done on residents to offer a copy of their care plan. Residents who wanted a copy of their care plans were given a copy of their care plans and progress notes added related to accepting or refusing copy of care plans. Residents who declined were informed that they could request a copy if they wanted a copy. Audits started to confirm that care plans are offered at care conferences and at 72-hour huddles following admission and as requested by residents. Other potential residents effected: This placed residents at risk for lack of inclusion in the care planning process. This deficiency has the potential to also affect new admissions and residents due for quarterly care conferences. Resident audits were done to determine if there were other concerns related to the right to participate in planning care, by being provided with a copy of their care plan. Deficiencies were addressed so that residents were offered a copy of their care plans. Residents will be offered copies of their care plans after admission and with quarterly care conference, and as requested by the resident. The facility completed audits for residents, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses and IDT team members regarding including residents in care planning by offering them a copy of their care plans. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that new admissions and residents with Quarterly care conferences are offered a care plan. The cause of these deficiencies is related to not offering care plans to residents after admission, at quarterly care conferences, or when requested. Monitoring: Audits were done on residents to determine who would like a copy of their care plan and who did not want a copy of their care plan. Audits will be done to confirm that copies of resident care plans are offered following admission, with quarterly care conferences, and when requested by residents. These audits will be done weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by social services or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Resident 34 is still using this medication and has had the self-administration audit completed. An audit was done to determine who has an order for medication at bedside. Residents asked on admission and with Quarterly care conferences if they want to self-administer medications. If a resident asks to be able to keep a medication at bedside for self-administration, then a self-administration assessment will be completed. Audits started to confirm that a resident who requests self-administer medications has been assessed to safely self-administer medications. Other potential residents effected: This placed residents at risk for adverse medication reactions. This deficiency has the potential to affect other residents who are asking to keep medications at bedside for self-administration. Resident audits were done to determine if there were other residents requesting to be able to self-administer medications. Deficiencies were addressed so that residents wanting to self-administer medications have been checked for safety to self-administer medications. The facility completed audits for residents, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses and IDT team members regarding assessing residents to be able to self-administer medications. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that new admissions and residents with Quarterly care conferences, and those requesting to self-administer a new medication are assessed for the ability to safely self-administer medications. The cause of these deficiencies is related to staff not knowing when to do self-administration assessments and not assessing the resident for the ability to safely self-administer medications. Monitoring: An audit was done on residents to determine who has an order to self-administer medications and who wants to self-administer medications. Audits will be done to confirm; that residents who want to self-administer medications are able to do so safely and follow the rules for self-administration of medications. These audits will be done weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by RCMs or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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. , 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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Confirmed that resident #14s MDS GDR was corrected. Confirmed that MDS for resident #76 had oral assessment was corrected. An audit was done for residents for oral assessments including resident #76, care plans updated related to dental needs, residents with dental pain have orders for treatment, and residents who are requesting dental services were referred to a dentist. Audits started to confirm that residents get an oral assessment on admission, and a second oral assessment within 7 days of admission and an oral assessment quarterly. Audits to confirm that care plans are updated, pain is managed, and dental referrals are getting done. Other potential residents effected: This placed residents at risk for unassessed needs. This deficiency has the potential to affect other residents who are due for a GDR and oral assessment. Resident audits were done on residents to determine if there were other residents with GDR and oral assessment needing to be done. Deficiencies were addressed so that residents who are due for a GDR were assessed for a gradual dose reduction as part of the psychotropic medication review process. Deficiencies were addressed so that residents needing updated dental care plans, orders, and treatments were identified. Residents requesting dental appointments had notifications sent to social services to assist with setting up dental appointments. The facility completed audits for residents, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses and IDT team members regarding doing dental assessments, and GDR reviews. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that new admissions and residents with Quarterly care conferences, and those requesting dental services get an oral assessment. Audits will be done to confirm that GDR reviews are done during the psychotropic medication review process. The cause of these deficiencies is related to not doing oral assessments quarterly and when requested by residents. Additional training and education needed for the team reviewing psychotropic medication review regarding the GDR process. Monitoring: An audit was done on residents to determine who has dental concerns. Audits will be done to confirm; that new residents get a 2nd oral assessment within 7 days, and that long term residents get an oral assessment quarterly and when needed for new dental concerns. These audits will be done weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by RCMs or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings. House wide audit was done for residents on psychotropic medications to review when they had GDR. Psychotropic medication review done on residents due for review. Audits will be done to confirm was a GDR indicated, was a GDR attempted, was a GDR completed, and was the process documented in the psychotropic review assessment. Audits will be done monthly along with psychotropic medication review for 4 months. Audits will be completed by RCMs, Social Services, or designee and turned into the DNS or Administrator monthly for 4 months. Audits results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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 unnecessary medications. Confirm care plan updated for resident # 49 related to edema. Resident #49 has discharged. Confirmed care plan updated for resident # 66. (Care plan updated resident is no longer on enhanced barrier precautions related to wound care. The resident's wound has healed and no longer requires EBP) Confirm care plan updated for resident # 69. (Care plan and Kardex updated to clarify the use of the bolster pillow.) Audits started to confirm that staff know where to find the Kardex binders, and electronic Kardex. Audits to confirm that staff know what changes have been made to the Kardex for their residents. Audits started to confirm that care plan binders are updated when changes are made to the Kardex. Audits to confirm that NMO, Risks investigations, Change of Conditions, and changes to infection control are updated timely in the care plan and added to the Kardex. Other potential residents effected: This placed residents at risk for lack of resident centered interventions. This deficiency has the potential to affect other residents who have new medications, risks with new interventions, change of conditions with new interventions, and new infection control interventions. Resident audits were done on residents to determine if there were other residents needing updated care plans related to infection control, risk investigations, new medications, and changes of conditions. Deficiencies were addressed so that residents needing updated care plans were identified. Residents needing updated care plans were reviewed and care plans updated. The facility completed audits for residents, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses and IDT team members regarding updating care plans and Kardex related to Infection control, risk management, new medications orders, and changes of condition. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that new medications, risk management, changes of condition and changes to infection control are added to the care plan timely and updated on the Kardex. The cause of these deficiencies is related to staff not checking updated Kardex at the start of their shift and IDT team not making changes to the care plan and Kardex timely. Monitoring: An audit was done on residents to determine who needed updated care plans and Kardex related to Infection control, risk management, new medications orders, and changes of condition. Audits will be done to confirm; that resident with changes to Infection control, risk management, new medications orders, and changes of condition get their care plans updated timely and that the Kardex is updated and printed so that staff can review daily at the start of their shift. These audits will be done weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by RCMs or a designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. Based on interview and record review it was determined the facility failed to 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. Confirmed pain medication was reordered for resident # 48. Confirmed resident # 76 fall investigation was done. Education provided to staff about doing quality neurological assessments following a fall. New admission medications are audited to confirm there are no conflicting orders from the written order and the hard script orders. Audits started to confirm that staff know that conflicting orders need to be clarified with the provider and documented in the progress notes. Audits started to get new pain medication orders if the admission order is for 5 days or less. Falls are assessed for timely investigation started, neuro assessments tarted if needed, and neuro assessments completed appropriately. Other potential residents effected: This placed residents at risk for increased pain and unidentified injuries. This deficiency has the potential to affect other residents who have conflicting orders or orders that need additional clarification with the provider. This deficiency has the potential to affect other residents who have had falls requiring neurological assessments. Resident audits were done on new admissions to confirm that orders needing clarification were clarified with the provider. Fall audits started for new falls to confirm risk started timely, neurological assessments done if needed. Deficiencies were addressed so that residents needing updated or clarified orders had a request sent for new orders. The facility completed audits for residents, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses and IDT team members regarding clarification of orders and documentation when an order is clarified with a provider and falls risks starting timely with neurological assessment if needed. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that new medications requiring clarification are sent to the provider for clarification and documentation is done in the progress notes. Audits will also be done to confirm that pain medications for 5 days or less are sent to the provider for a new prescription. Audits will be done to confirm that fall risks are started timely, interventions are put into place, and neurological assessments are started. The cause of these deficiencies is related to staff not documenting when they are seeking clarification on orders so that there is a clear trail of documentation for medication questions and clarification, and staff not knowing when to do a fall risk with neurological assessments. Monitoring: An audit was done on new residents to determine who needed orders clarified. Audits started for fall investigations to confirm investigation started timely and neuro assessments started if indicated. Audits will be done to confirm that order that needs clarification is clarified with the provider and clear documentation is put in the residents chart regarding the updated provider recommendations. Audit will also include sending a request for a new prescription for new pain medication order that is for 5 days or less. Audits will be done on fall investigations to confirm that risks are started timely, interventions are put in place, care plans are updated, neuro assessments are started, and residents are placed on alert for monitoring. These audits will be done weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by RCMs or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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 a Stage 3 pressure ulcer. Resident # 16 confirmed that a risk was done, new orders were received, and care plan and Kardex was updated. Resident 79 immediate wound measures completed, wound care orders were put into place, resident has discharged from the facility. New skin issues are reviewed in the 24-hour report to determine if a risk needs to be started, orders requested, and care plan updated. Audits started to identify new skin risks, or worsening wounds. Audits started to confirm that new skin risks or worsening wounds have new orders, and updated care plans and Kardex. Audit started to review daily wound pictures that are due are completed. Other potential residents effected: This placed residents at risk for infections. This deficiency has the potential to affect other residents with new skin issues or worsening skin issues. Resident audits were done on current wounds for wounds that were needing a new risk management. Weekly skin audits done for residents for new skin issues that need a new risk management. Deficiencies were addressed so that residents needing a risk for a new skin issue had a risk management started. The facility completed audits for residents, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses and IDT team members regarding starting a risk management investigation for new skin issues and worsening wounds. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that wound assessment pictures are completed weekly as required. Audits will also be done to confirm that new or worsening skin issues will have a risk management investigation started, physician notified, new orders put in place, resident placed on alert for monitoring, and Care Plan and Kardex updated. The cause of these deficiencies is related to staff not starting a risk management for new skin issues and taking pictures weekly as required. Monitoring: A skin audit was done on residents to determine if residents had new skin issues that needed risk management investigation. Audits will be done to confirm; that pictures and assessments are done weekly as required, and that new skin issues have a risk management investigation started, provider notified, new orders obtained, alert charting started, and care plans and Kardex updated. These audits will be done weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by RCMs or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Fall investigation started as soon as the state notified facility of the fall for resident # 76. Progress notes reviewed in the 24-hour report to determine if a risk needs to be started for new falls. Audits started to identify new falls by reviewing the 24-hour reports. Audits started to confirm that risks for new falls are started, the resident is placed on alert, and the care plan and Kardex are updated with new interventions. Other potential residents effected: This placed residents at risk for unassessed risk factors. This deficiency has the potential to affect other residents with falls. Resident audits were done on the 24-hour reports for falls that needed a new risk management. Deficiencies were addressed so that residents needing a risk for a new fall had a risk management started. The facility completed audits for residents, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses and IDT team members regarding starting a risk management investigation for falls. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that falls have risk management started, resident placed on alert, and care plans and Kardexs updated with new interventions. The cause of these deficiencies is related to staff not starting a risk management for falls or not understanding the definition of a fall in a skilled nursing facility. Monitoring: A chart audit was done on residents to determine if residents had new fall that needed a risk management investigation. Audits will be done to confirm; new falls have a risk management investigation started, alert charting started, and care plans and Kardex updated. These audits will be done weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by RCMs or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Hospital admission or readmission orders reviewed for other patients who have been admitted to Riverpark. Social Services have verified that physician visits have been arranged. Social Services or designee will audit hospital orders to ensure follow-up physician visits are scheduled promptly. Other potential residents effected: This placed residents at risk for lack of specialized care. This deficiency has the potential to affect residents who are new admission or had recent appointments with follow up appointments. Hospital admission or readmission orders reviewed for other patients who have been admitted to Riverpark. Social Services have verified that physician visits have been arranged. Deficiencies were addressed so that physician visits have been arranged. The facility completed audits physician visits and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for Social Services on admission process and importance of timely scheduling for physician visits following hospitalization. Education for nurses and IDT team members regarding physician appointments. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that physician visits are ordered that the physician visit was made, and that the steps to document the appointment were completed. The cause of these deficiencies is related to; Appointments not being passed on to social services timely. Monitoring: An audit was done to confirm Hospital admission or readmission orders reviewed for other patients who have been admitted to Riverpark. Social Services have verified that physician visits have been arranged. Audits will be done to confirm that physician visits are ordered that the physician visit was made, and that the steps to document the appointment were completed. Audits will be completed weekly for 4 weeks and then monthly for 3 months. The audits will be completed by social services or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Confirmed that medications are ordered and available for resident # 49. Resident has discharge. Pain medication reviewed on each unit to confirm that medication cards are available and pain medication is available to residents as ordered. The medication reordering process was updated to confirm medications are available on admission, for new orders, and for daily administration of medications. Audits started to get new pain medication orders if the admission order is for 5 days or less. Other potential residents effected: This placed residents at risk for unrelieved pain. This deficiency has the potential to affect other residents with pain medications. The Medication carts were audited for medications that needed to be reordered. Deficiencies that identified were ordered electronically and delivered prior to the weekend. The facility medication audits and concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses and CMAs on reordering medications. Education for nurses and IDT team members regarding reordering medications. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that medication in the blue is reordered electronically, the sticker is pulled, and if not reordered yet the medication is reordered electronically. The cause of these deficiencies is related to not reordering medications with a short supply from the hospital and staff who are passing medication not reordering medications when the card gets into the blue reorder range. Monitoring: An audit was done to confirm that medications are being reordered per policy. Audits will be done to confirm that medication in the blue is reordered electronically, the sticker is pulled, and if not reordered yet the medication is reordered electronically. Audits started to get new pain medication orders if the admission order is for 5 days or less. Audits will be completed twice weekly for 4 weeks and then monthly for 3 months. The audits will be completed by RCMS, CMAs or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Confirmed resident # 52 care plan, TAR updated to monitor psychotropic medication side effects. Confirmed resident # 76 care plan, TAR updated to monitor psychotropic medication side effects. Audit done on residents on psychotropic medications to confirm that care plans, Kardex, and TAR have instructions to monitor for psychotropic medication side effects. Audits to confirm that residents with psychotropic medications have instructions to monitor for side effects when new psychotropic medications are ordered. Other potential residents effected: This placed residents at risk for adverse medication reactions. This deficiency has the potential to affect resident care on psychotropic medications. Audit done for the residents on psychotropic medications to confirm that care plans, Kardexs and TAR have instructions for staff to monitor for psychotropic medication side effects. Deficiencies were addressed and residents who needed updated care plans, Kardexs and TAR were updated. The facility completed audits psychotropic medication monitoring and issues were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses, IDT team members, related to monitoring residents for psychotropic medication side effects. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that residents with psychotropic medications have instructions in the care plan, Kardex, and TAR to monitor for psychotropic medication side effects. The cause of these deficiencies is related to not updating care plans, Kardexs, and TAR timely when new psychotropic medications are ordered. Monitoring: An audit was done for residents with psychotropic medications to confirm that care plans, Kardexs, and TAR are updated related to psychotropic medication monitoring. Audits will be done to confirm that residents with psychotropic medications have instructions in the care plan, Kardex, and TAR to monitor for psychotropic medication side effects weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by RCMS or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Confirm that Resident # 49 has notes in the record related to emergency department visit, resident has discharged. Audit done to confirm that residents that go to the emergency department have notes related to going to the ED and returning from the ED. Audits to be done by the admission nurse to confirm that residents who go to the ED have a progress note related to going to the ED, returning from the ED, to confirm the resident was placed on alert for monitoring and an SBAR change of condition assessment was completed. Other potential residents effected: This placed residents at risk for lack of pertinent medical assessment documentation in the clinical record. This deficiency has the potential to affect residents who go out to the emergency department for treatment. Audit done to confirm that resident who had gone to the emergency department had documentation related to going to the ED, returning from the ED, and SBAR change of condition assessment completed. Deficiencies were addressed and residents who needed additional documentation were updated. The facility completed audits related to emergency department visits and issues were investigated and addressed. System Change: The facility has developed and implemented education and training for nurses, IDT team members, related to documentation for residents who have changes of condition requiring transfer to the emergency department. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits will be done to confirm that residents who go to the emergency department have a transfer out to emergency department note, and a transfer back from emergency department note. The cause of these deficiencies is related to staff failing to properly document emergency department transfers. Monitoring: An audit was done for residents who transferred to the emergency department to confirm that documentation was completed. Audits will be done to confirm that residents who go to the emergency department have a transfer out to emergency department note, and transfer back from emergency department note weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by the admission coordinator or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. The IP nurse updated the list of residents on isolation precautions including Enhanced Barrier Precautions. RCMs and IP nurse updated resident # 79s care plan to reflect current isolation instructions. Mandatory education was started for staff who go into resident rooms and need to know about Enhanced Barrier Precautions. Staff will receive additional education related to Enhanced Barrier Precautions, EBP door signs, and the policy related to enhanced barrier precautions. Staff completing this training will sign an affirmation that they know this information and will follow the current policy. Audits will be done by designated staff to watch staff do EBP and provide immediate coaching and education if there are concerns. DPOC, Directed Plan of Correction will be submitted with the survey documents. Other potential residents effected: This placed residents at risk for infections. The facility IP completed a review of residents on EBP and confirmed that care plans and door cards were in place for residents requiring EBP. Audits started by the leadership team to identify deficiencies and provide immediate coaching and correction. The facility has developed and implemented education and training regarding EBP using information from the CDC about EBP, review of the EBP door card, and EBP Avamere Policy. Education will be done by DNS, ADNS, or Infection control nurse. Staff will sign an attestation stating they have completed this training and will follow the EBP policy. Education started with hall huddles, all staff meetings, and nurse meetings. The facility has assigned leadership staff to do audits for each shift weekly to observe staff who are caring for residents on EBP to confirm that staff are correctly implementing EBP. Concerns identified will be corrected at the moment with written training. System Change: The facility has developed and implemented education and audits regarding Enhanced Barrier Precautions. The facility conducted audits of staff and deficiencies were corrected immediately in the moment. Ongoing education will be provided regarding Enhanced Barrier Precautions with audits on all shifts weekly. IDT leadership team calendar created to assign audits for each shift to do so many audits weekly. The cause of deficiencies is related to lack of understanding of when to use Enhanced barrier precautions. Monitoring: Administrator and DNS have created an Enhanced Barrier Precautions audit schedule. Designated staff will audit day shift, evening shift, and night shift weekly for 4 weeks. Designated staff will also audit weekend shifts weekly for 4 weeks. An intervention will take place if staff are not following EBP to prevent risk of infection to other residents. Assessments are done weekly for 4 weeks, and then monthly for 3 months. QAPI will review Enhanced Barrier precautions ongoing for 2023.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Confirmed that resident 7 was offered a pneumonia vaccine and education was provided regarding vaccines and the resident was able to accept or refuse vaccination due to medical contradictions or refusal. Confirmed that resident received a pneumonia vaccine. Confirmed that resident 13 was offered vaccines and was allowed to accept or refuse vaccines. Confirmed that resident 22 was offered vaccines and was allowed to accept or refuse vaccines. Confirmed that resident 55 was offered was offered vaccines and was allowed to accept or refuse vaccines. Audit done to confirm that residents who are due for influenza vaccines and pneumonia vaccines are educated on the vaccines benefits and potential side effects, residents are given the chance to accept or refuse vaccinations due to medical contradictions or refusals and documentation is recording regarding accepting or refusing vaccines, residents who accept vaccines are given vaccines as requested. Audits to be done by the infection control nurse to confirm that residents who are due for influenza vaccines and pneumonia vaccines are educated on the vaccines benefits and potential side effects, residents are given the chance to accept or refuse vaccinations due to medical contradictions or refusals and documentation is done regarding accepting or refusing vaccines, residents who accept vaccines are given vaccines as requested. While administer vaccines as they are available from the pharmacy. Other potential residents effected: This placed residents at risk for illness and lack of informed consent. This deficiency has the potential to affect resident who are due for vaccines. Audit done to confirm that residents who are due for influenza vaccines and pneumonia vaccines are educated on the vaccines benefits and potential side effects, residents are given the chance to accept or refuse vaccinations due to medical contradictions or refusals and documentation is recording regarding accepting or refusing vaccines, residents who accept vaccines are given vaccines as requested. Deficiencies were addressed and residents who needed additional vaccines were provided education and the chance to accept or refuse vaccines. The facility completed audits related to vaccines and those who accepted vaccines were given vaccines as pharmacy supplies have allowed. System Change: The facility has developed and implemented education and training for nurses, IDT team members, related to offering vaccines, documentation for acceptance and refusal, and documentation for administration of vaccines. Education started with hall huddles, IDT training, all staff meetings, and nurse meetings. Audits to be done by the infection control nurse to confirm that residents who are due for influenza vaccines and pneumonia vaccines are educated on the vaccines benefits and potential side effects, residents are given the chance to accept or refuse vaccinations due to medical contradictions or refusals and documentation is done regarding accepting or refusing vaccines, residents who accept vaccines are given vaccines as requested. The cause of these deficiencies is related to staff failing to properly document vaccine consents, refusals, and vaccine administration. Monitoring: Audit done to confirm that residents who are due for influenza vaccines and pneumonia vaccines are educated on the vaccines benefits and potential side effects, residents are given the chance to accept or refuse vaccinations due to medical contradictions or refusals and documentation is recording regarding accepting or refusing vaccines, residents who accept vaccines are given vaccines as requested. Audits to be done by the infection control nurse to confirm that residents who are due for influenza vaccines and pneumonia vaccines are educated on the vaccines benefits and potential side effects, residents are given the chance to accept or refuse vaccinations due to medical contradictions or refusals and documentation is done regarding accepting or refusing vaccines, residents who accept vaccines are given vaccines as requested weekly for 4 weeks, and then monthly for 3 months. The audits will be completed by the infection control nurse or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

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.

Residents Effected: The facility was notified of the following deficiencies on 06/30/2023. 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. Human Resources and Administer will continue to advertise RN openings and promote facility school reimbursement program for LPNs going to school to become RNs. The (facility) will continue to utilize agency RN staff when available to help meet the need of the facility and meet staffing requirements. RN staffing will be monitored by the Administrator, or designee. Other potential residents effected: This placed residents at risk for lack of timely RN assessments and care. This deficiency has the potential to affect resident care related to RN coverage and timely assessments and cares. Audit done on the current RN coverage for the facility. Deficiencies were addressed so that RN coverage needs are posted to staff and agency staff to prevent going without RN coverage. The facility completed audits for RN coverage, and further concerns were investigated and addressed. System Change: The facility has developed and implemented education and training for Licensed staff and staffing team on the importance of maintaining appropriate RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift and meet minimum RN coverage for one hour per resident per week. Audits will be done to confirm that RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift and meet minimum RN coverage for one hour per resident per week. The cause of these deficiencies is related to; difficulty in RN recruitment, as well as RN PTO, RN sick calls, and RN agency coverage that falls through due to last minute sick calls or agency changes. Monitoring: An audit was done to confirm RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift and meet minimum RN coverage for one hour per resident per week. Audits will be done to confirm; RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift and meet minimum RN coverage for one hour per resident per week. RN staffing will be monitored by the Administrator, or designee. The audits will be completed by staffing coordinator, administrator or designee and turned into the DNS or Administrator weekly for 4 weeks and then monthly for 3 months. Audit results will be reviewed at the quarterly QAPI meetings.

*************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F550, F552, F553 *************************** OAR 411-086-0260 Pharmaceutical Services Refer to F554, F755 *************************** OAR 411-086-0300 Clinical Records Refer to F641, F842 *************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 *************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686, F689, F758, F883 ************************** OAR 411-086-0240 Social Services Refer to F745 *************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ***************************

Based on interview and record review it was determined the facility failed to protect residents' rights to make health care decisions for 2 of 3 sampled residents (#s 306 and 310) reviewed for resident rights. This placed residents at risk for health care decisions in conflict with residents' wishes. Findings include: 1. Resident 306 was admitted to the facility in 2017 with diagnoses including heart failure and end stage kidney disease. Resident 306's care plan for 12/2022 indicated the resident self-directed her/his own care and was able to make her/his needs known. The resident was normally in the activity room or doing activities with the activity department if not in her/his room or out for an appointment. The resident enjoyed being out and about. On 3/20/23 at 2:34 PM Staff 5 (CNA) said she was told by Staff 6 to get vitals on Resident 306 but the resident did not want to leave the activities room and she relayed that information to Staff 6. Staff 6 got mad and stomped down to the activities room and removed the resident from the room. Staff 5 said she saw Staff 6 take Resident 306 to her/his room even though the resident did not want to leave and indicated Staff 3 (Activities Director) also saw the resident removed from the room. On 3/21/23 at 3:07 PM Staff 3 said Resident 306 was an avid activities person. The resident often stayed in the activities room all day and sometimes had meals there. On 12/7/22 Staff 6 came to the activities room and told the resident she/he had to go back to her/his room. The resident did not want to go. Staff 6 "aggressively" unlocked the resident's wheelchair and took the resident to her/his room. Staff 6 put the resident in bed and would not get the resident back up for the next activity which the resident wanted to attend. The resident was upset by being forced to leave the activities room. On 3/21/23 at 4:15 PM Resident 306 indicated she/he did not remember anything that happened in 12/2022. On 3/22/23 at 11:26 AM Staff 6 indicated she would never force a resident to leave the room. She did not remember it happening. Staff 6 said the resident appeared abnormally tired, woke the resident up and asked if she/he was okay. Staff 6 said she remembered Staff 3 was upset with her because the resident wanted to leave the activity. Staff 3 said the resident was just fine where she/he was but Staff 6 removed the resident anyway. On 3/23/23 at 3:30 PM Staff 1 (Administrator) and Staff 2 (DNS) had no additional information. No Incident Report or documentation was found related to this incident. 2. Resident 310 was admitted to the facility in 2020 with diagnoses including multiple sclerosis (disease of the brain and spinal cord) and paraplegia (paralysis of the legs and lower body). On 3/22/23 at 12:18 PM Staff 15 (CNA) said a lot of residents complained about Staff 6 (LPN). Resident 310 said she/he would not work with her anymore. The resident said she was pushy and would not let the residents decide anything for themselves. On 3/23/23 at 10:06 AM Staff 16 (CMA) said Resident 310 refused to take a laxative from Staff 6 but said she/he would take a suppository at bedtime instead. Staff 6 gave the laxative to the resident anyway. The resident was alert and oriented and was angry at what Staff 6 had done. On 3/23/23 at 10:23 AM Resident 310 stated she/he had a big problem with Staff 6. Staff 6 said she/he was on the bowel list and needed to take a laxative. The resident told Staff 6 she/he was fine, did not want to take the medication but would take a suppository at bedtime. Staff 6 gave the medication to her/him anyway. The resident was very upset and said she/he keeps an eye on her. On 3/22/23 at 10:21 AM Staff 14 (RCM/LPN) said she was aware of Resident 310 and the bowel care issue. The resident was on the bowel care list but she/he refused the PRN bowel medication. Staff 6 gave it to the resident anyway. The resident asked if Staff 6 gave it to him anyway and she said yes.

Residents Effected: The facility was notified of the following deficiencies on 03/23/2023; two residents (#s 306, 310) were identified as the facility failing to protect residents rights to make health care decisions. Risk management started as a significant concern for resident 306 as soon as the state identified the concern. Personalized care plan to reflect resident preferences for activities. No ongoing concerns, resident does not recall incident. Grievance was completed for resident 310. Personalized care plan to reflect the residents preference for when he gets bowel care treatments. Initially after the incident resident 310 preferred that staff 6 not provide care for resident 310. The concern was resolved and resident 310 began to allow staff 6 to provide care. No ongoing concerns. Other potential residents effected: This deficiency has the potential to affect other residents. Resident interviews were done on 03/23/2023 to determine if there were any other concerns related to infringement of resident rights. The facility has developed and implemented education and training regarding protecting resident rights. Education started immediately with hall huddles, all staff meetings, nurse meetings, and assigned online Relias education. Facility was notified of 2 deficiencies. The facility conducted interviews with residents, and any further concerns were investigated and addressed. System Change: The facility provided education to nursing staff related to protecting resident rights. The facility conducted interviews with residents, and any further concerns were investigated and addressed. Ongoing education will be provided regarding protecting resident rights for new hire, annually. Staff interviews are to be conducted to ensure they understand resident rights. The cause of deficiencies is related to; lack of understanding of resident rights and how to protect resident rights. Monitoring: DNS or assigned staff will complete 3 resident interviews weekly to ensure resident rights are honored. DNS or assigned staff will complete 3 staff interviews weekly to ensure resident rights are honored and staff understand resident rights. Assessments are done weekly for 4 weeks, and then monthly for 3 months. QAPI will review resident rights ongoing for 2023.

Based on interview and record review it was determined the facility failed to protect the residents' rights to be free from mental and verbal abuse by Staff 6 for 3 of 6 sampled residents (#s 305, 309 and 314) reviewed for abuse. This placed residents at risk for further abuse and negative psychosocial impact. Findings include: Resident 305 was admitted to the facility in 2020 with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness), major depression and epilepsy. Resident 305 was alert and oriented. A 12/2/22 BIMS Evaluation indicated the resident was cognitively intact. A 12/9/22 Psychotropic Medication Review indicated Resident 305's status in the past month included occasional refusals of care and medications. The resident had no behaviors in the past month. The 12/2022 TAR indicated the resident had occasional behaviors including: agitation, refusal of care, swearing and sadness. Interventions included leave the room and return later. A complaint intake dated 12/8/22 indicated Staff 5 (CNA) and Staff 7 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305 to take her/his medications. Staff 6 also turned on all the lights in the resident's room, even though it was careplanned not to turn the resident's lights on, because it triggered the resident and "set her/him off". Staff 7 attempted to stop Staff 6 from yelling at the resident and leave the room but Staff 6 would not so she left and requested assistance from the RCM/LPNs. The complaint indicated facility management was well aware of Staff 6's behaviors but had done nothing about it. On 3/21/23 at 10:30 AM Staff 7 (CNA) stated she heard an altercation with very loud voices in unpleasant tones. She went to Resident 305's room and saw all the lights were on which would upset the resident. Staff 6 was passing medications and wanted the lights on even though the resident was care planned to not have the lights on. To deescalate the situation Staff 7 suggested Staff 6 open the door and use the light from the hallway but she would not. The resident and Staff 6 were both yelling and screaming and would not listen so she went to get help. The resident wanted the overhead light off, and for Staff 6 to leave the room, but she would not do so. Staff 6 did nothing to deescalate the situation. Staff 7 said she felt Staff 6 deliberately antagonized residents and many of them did not care for her. Staff 7 said she knew some residents would refuse their medications so they would not have to interact with Staff 6. Staff 7 believed this was verbal abuse and no one at the facility ever interviewed her about this incident. In an additional interview on 3/31/23 Staff 7 indicated while she was in the resident's room, she saw no medication cup on the table and no medications on the bed. Staff 6 and the resident were yelling about the lights. She did not see the resident grab or attempt to grab Staff 6 but both of them were very "heated". On 3/21/23 at 2:34 PM Staff 5 (CNA) said she and Staff 7 ran over when she heard Staff 6 yelling at Resident 305 in the resident's room. Staff 5 said Staff 6 had a "bad attitude" with the residents and with other staff. Resident 305 was care planned not to have the lights on in the room because it gave her/him headaches and "triggered the resident" but the lights were all on. Staff 7 tried to get Staff 6 to stop and leave the room but Staff 6 would not. On 3/21/23 at 3:07 PM Staff 3 (Activities Director) said she spoke to Resident 305 after the incident with Staff 6. The resident requested Staff 6 not work with her/him anymore. The resident told Staff 3 the nurse turned on all the lights and loudly and rudely told her/him "take your meds". The resident told Staff 6 to leave but she would not go away. Resident 305 had migraines and depression and Staff 6 was very loud, demanding and too energetic. Turning on the lights could trigger her/his migraine headaches. Staff 3 stated she had recommended to Staff 6 to step outside if she was overwhelmed and not to take things out on the residents. Staff 3 said " she would never allow an employee to speak to residents the way Staff 6 does". It was just not acceptable. On 3/23/23 at 10:21 AM Staff 14 (RCM/LPN) indicated she was aware that Staff 6 had issues with Resident 305 on previous occasions. There were multiple times when Staff 6 had negative interactions with the resident and with other residents also. She reported her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but nothing was done. Staff 6 would raise her voice to the residents and throw temper tantrums. Staff 14 said she told Staff 6 not to argue with residents and she had given verbal corrections. Staff 6 was also belittling, demeaning and disrespectful to residents and other staff. The administration were aware of the issues and concerns related to Staff 6 but no corrective action was taken. On 3/23/23 at 11:26 AM Staff 6 (LPN) indicated she remembered the incident with Resident 305. She said she knocked on the door, slipped into the room, shut the door and ran into the resident's roommate. She turned the light on over the sink because she knew the resident did not like the other lights on and she respected resident preferences. She told the resident she needed the light on for her safety. She set the cup of medications on the table by the bed. The resident told her to turn the light off and she told her/him she could not because she might fall. Staff 6 further stated she told the resident if she/he took the meds she would leave the room. The resident grabbed the meds and told her to get out again. Staff 6 said per OSBN she could not leave narcotics in the room so she had to stay. Staff 6 said she picked up two pills off the bed because the resident dropped them, and told the resident again to take the pills and she would leave. Staff 6 said she was in a tough situation because the resident was calling her names and yelling at her but she just took a deep breath. The resident then put some pills in her/his mouth. A CNA told her to leave the room but she could not, which escalated the resident even more. She saw the resident throw her/his head back with meds. She then said she was leaving the room and hoped the resident had swallowed the meds. Since the resident was so agitated she did not check the effectiveness of the medications. Staff 6 said it was unusual for her to turn the lights on without telling the resident. On 3/23/23 at 4:10 PM Resident 305 indicated she/he remembered the incident with Staff 6. Staff 6 charged into the room and even ran into the resident's roommate which the resident said showed she was not being careful. She yelled at her/him, "take your pills". Resident 305 asked which medications they were because there was one the resident did not want to take, but she just said, "morning meds". The resident asked again because she/he wanted to know which medications she was giving her/him. Staff 6 got really mad and started flipping on all the lights and yelling at me. The resident told her to "get the hell out" but she would not leave. Staff 6 said she was looking for pills and she grabbed some stuff off the resident's tray and again told her/him to, "Take your pills!" Resident 305 said the look in her eyes was really horrible and she scared the hell out of her/him. The resident had never seen her like that before. They were both yelling because she/he was mad and scared and Staff 6 just would not listen. Resident 305 said they had a few "go rounds" before and she/he did not want her working with her/him anymore. The resident said Staff 6 knew her/his care plan said not to turn on the lights because they hurt my eyes but she did it anyway. On 3/20/23 at 4:11 PM Staff 1 (Administrator) and Staff 2 (DNS) indicated Staff 4 (RCM/LPN) would have the information about this incident. No documentation was provided to indicate an investigation had been done. On 3/21/23 at 9:45 AM Staff 4 (RCM/LPN) indicated Staff 6 was overwhelmed very easily. Regarding the incident with Resident 305, Staff 4 said she was not an actual witness to the incident but she thought Staff 6 and Resident 305 were arguing. The CNAs came to her and told her there was a problem. She told the Staff 2 (DNS) and Staff 1 (Administrator). She heard the resident was upset by the lights being turned on in her/his room. She was told the nurse was arguing with the resident not yelling at the resident. She was aware staff should not argue with residents. She said she spoke with Staff 6 and with Resident 305 but she did not have anything documented. She stated she did not complete an investigation and she should have. She did not interview or speak to the CNAs who were present during the incident or to other residents or staff. 2. Resident 314 was admitted to the facility in 2018 with diagnoses including neurocognitive disorder with Lewy bodies (progressive dementia that leads to a decline in thinking, reasoning and independent function). On 3/23/23 at 4:32 PM Resident 314 was interviewed related to any possible abuse she/he may have witnessed in the facility. Resident 314 stated, "One of the nurses here is very mean to me." The resident said she/he could picture the nurse but was having trouble remembering the nurse's name. Resident 314 said her/his roommate would remember the nurses name because her/his roommate had trouble with the nurse too. The resident went on to say when she would ask the nurse for something the nurse would be mean and bad tempered to her/him and say, "just do what I say". The resident stated it was like she/he did not have any choice and all the residents were "at her mercy". The resident said the nurse was very rude to her/him, she was not patient or nice and made her/him feel bad. Resident 314 was very upset and she had some memory issues but her/his story was consistent. The resident's roommate was alert and oriented and identified the nurse in question as Staff 6. On 3/22/23 at 11:26 AM Staff 6 indicated she was not aware of any other residents who had an issue with her besides Resident 305. On 3/22/23 at 12:01 PM Staff 14 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 314. Staff 6 would raise her voice to residents, throw temper tantrums and argue with residents. She had given verbal corrections to Staff 6. Resident 314 had verbalized complaints such as Staff 6 was belittling (made her/him feel stupid), was not patient with her/him and Staff 6 demanded the resident take her/his pills and she/he had no right to refuse. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken. On 3/23/23 at 3:45 PM Staff 1 (Administrator) and Staff 2 (DNS) provided no additional documentation related to this incident. 3. Resident 309 was admitted to the facility in 2018 with diagnoses including stroke with hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) and respiratory failure. On 3/23/23 at 10:45 AM Resident 309 was interviewed related to any possible abuse she/he may have witnessed in the facility. The resident indicated there was a problem with Staff 6. Resident 309 said Staff 6 would get angry with her/him because she/he tried to intervene when Staff 6 was being mean to her/his roommate. Resident 309 said her/his roommate had memory issues and Staff 6 was short tempered and rude to the roommate which upset her/him a lot. Then Staff 6 would withhold or delay Resident 309's pain medications when the resident asked for them and say, "you don't get them yet." She would hold them as long as possible to get back at me. Resident 309 went on to say Staff 6 was rough and very aggressive and would always slam her medication cart around. Staff 6 was very belligerent and rude to her/him, the roommate, other residents and staff. Staff 6 snapped at everyone. The resident also said there was a recent incident where Staff 6 had put a pill in her/his medication cup that was not hers/his. When she/he told her, Staff 6 grabbed the pill from the resident and said it wasn't her/his medication. It was as if Resident 309 gave herself/himself the wrong medication. Resident 309 also stated she did not like to come out of her/his room when Staff 6 worked because it was so unpleasant to be around her. On 3/22/23 at 11:26 AM Staff 6 indicated she was not aware of any other residents who had an issue with her besides Resident 305. On 3/22/23 at 12:01 PM Staff 14 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 309. Staff 6 would raise her voice to residents, throw temper tantrums and argue with residents. She had given verbal corrections to Staff 6. Staff 14 said she was aware that Resident 309 had also reported complaints about Staff 6. Social Services was aware of the resident's concerns and it was discussed at the resident's care conference. The resident stated she did not feel safe around Staff 6. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken. On 3/23/23 at 3:45 PM Staff 1 (Administrator) and Staff 2 (DNS) provided no additional documentation related to this incident.

Residents Effected: The facility was notified of the following deficiencies on 03/23/2023; three residents (#s 305, 309 and 314) were reviewed for abuse. Investigation started for resident 305 as soon as additional information was provided. Resident 305 care plan updated to include do not attempt to give medications or do treatments when resident 305 is upset or agitated. Leave the room and come back later. Resident 305 refuses to have staff 6 provide cares. Updated care plan to reflect verbal aggression received. He has no other ongoing concerns from this incident but doesnt want to work with staff 6. Staff 6 no longer works in this facility. Facility made aware of concern with resident 314 on 04/17/2023. Risk of significant concern started for resident 314 on 04/18/2023. Care plan updated to include verbal aggression received. Interviewed resident to assess ongoing concerns. Staff 6 no longer works in this facility. Facility made aware of concern with resident 309 on 04/17/2023. Risk of significant concern started for resident 309 on 04/18/2023. Care plan updated to include verbal aggression received. Interviewed resident to assess ongoing concerns. Staff 6 no longer works in this facility. Other potential residents effected: This deficiency has the potential to affect other residents. Resident interviews were done on 03/23/2023 to determine if there were any other concerns related abuse. The facility has developed and implemented education and training regarding preventing, reporting, and investigating abuse. Education started immediately with hall huddles, all staff meetings, nurse meetings, and assigned online Relias education. The facility conducted interviews with residents and staff. Any further concerns were investigated and addressed. System Change: The facility provided education to nursing staff related to recognition, reporting, and investigation abuse. The facility conducted interviews with residents, and any further concerns were investigated and addressed. Ongoing education will be provided regarding preventing abuse for new hires and annually. Staff interviews are to be conducted to ensure they understand abuse, how to report abuse, and their roles in investigation of abuse. The cause of these deficiencies is related to lack of understanding of abuse and abuse reporting. Monitoring: DNS or assigned staff will complete 3 resident interviews weekly to ensure resident rights are honored. DNS or assigned staff will complete 3 staff interviews weekly to ensure resident rights are honored and staff understand resident rights. Assessments are done weekly for 4 weeks, and then monthly for 3 months. QAPI will review resident rights ongoing for 2023.

Based on interview and record review it was determined the facility failed to report an allegation of abuse for 1 of 6 sampled residents (#305) reviewed for abuse. This placed the residents at risk for diminished psychosocial wellbeing and abuse. Findings include: Resident 305 was admitted to the facility in 2020 with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness), major depression and epilepsy. Resident 305 was alert and oriented. On 12/8/22 Staff 5 (CNA) and Staff 7 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305 to take her/his medications. Staff 6 also turned on all the lights in the resident's room, even though it was careplanned not to turn the resident's lights on, because it triggered the resident and "set her/him off". Staff 7 attempted to stop Staff 6 from yelling at the resident and to leave the resident's room but Staff 6 would not listen or assist to deescalate the situation so Staff 7 left to get help. The complaint intake also indicated facility management was aware of Staff 6's behavioral issues but no corrective action was taken. On 3/21/23 at 9:45 AM Staff 4 (RCM/LPN) said the CNAs came and told her there was a problem between Staff 6 and Resident 305. Staff 4 stated she told Staff 2 (DNS) and Staff 1 (Administrator). Staff 4 said she was told the nurse was arguing with the resident. Staff 6 was aware staff should not argue with residents. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegation. She stated she did not complete an investigation and she should have. She did not interview or speak to the CNAs who were present during the incident or to other residents or staff. Since she did not investigate the incident, which was later identified as abuse, it was not reported as required. No documentation was provided by the facility to show they investigated this incident.

Residents Effected: The facility was notified of the following deficiencies on 03/23/2023; one resident (#s 305) was identified for a failure to report abuse. Investigation started for resident 305 as soon as additional information was provided. Resident 305 care plan updated to include do not attempt to give medications or do treatments when resident 305 is upset or agitated. Leave the room and come back later. Resident 305 refuses to have staff 6 provide cares. Updated care plan to reflect verbal aggression received. He has no other ongoing concerns from this incident but doesnt want to work with staff 6. Staff 6 no longer works in this facility. Other potential residents effected: This deficiency has the potential to affect other residents. Audit done on grievances, care concerns, and risk management to review if anything that was reported to leadership should have been reported to the state. The facility has developed and implemented education and training regarding reporting abuse. Education started immediately with hall huddles, all staff meetings, nurse meetings, and assigned online Relias education. The facility conducted reviews of previous investigations, and any further concerns were investigated and addressed. System Change: The facility provided education to nursing staff related to recognition, reporting, and investigation abuse. The facility conducted interviews with residents, and staff related to reporting abuse. Any further concerns were investigated and addressed. Ongoing education will be provided regarding preventing abuse for new hires and annually. Staff interviews are to be conducted to ensure they understand abuse, how to report abuse, and their roles in investigation of abuse. The cause of these deficiencies is related to lack of understanding of abuse and abuse reporting. Monitoring: DNS or assigned staff will complete 3 resident interviews weekly to ensure resident rights are honored. DNS or assigned staff will complete 3 staff interviews weekly to ensure resident rights are honored and staff understand resident rights. Assessments are done weekly for 4 weeks, and then monthly for 3 months. QAPI will review resident rights ongoing for 2023.

Based on interview and record review it was determined the facility failed to thoroughly investigate and rule out potential abuse for 1 of 6 sampled residents (#305) reviewed for abuse. Without thorough investigations, the facility could not prevent or prohibit further abuse. This placed residents at risk for continued abuse. Findings include: On 12/8/22 Staff 5 (CNA) said she heard Staff 6 (LPN) yelling and screaming at Resident 305. Staff 5 stated she felt it was verbal abuse but no one interviewed her about it. On 12/8/22 Staff 7 (CNA) indicated she heard Staff 6 yelling at Resident 305. She tried to get Staff 6 to stop yelling and leave the room but Staff 6 would not. Staff 7 felt it was abuse but no one interviewed her about it. On 3/21/23 at 9:45 AM Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. She told Staff 1 (Administrator) and Staff 2 (DNS) about the incident. She said the nurse was arguing with the resident. She was aware staff should not argue with residents. No documentation was found or provided to indicate the incident was investigated. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. She stated she did not complete an investigation and she should have. She did not interview or speak to the CNAs who were present during the incident or to other residents or staff. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. No documentation of an investigation was provided by Staff 1 (Administrator) or Staff 2 (DNS) when requested.

Residents Effected: The facility was notified of the following deficiencies on 03/23/2023; one resident (#s 305) was identified for a failure to investigate abuse. Investigation started for resident 305 as soon as additional information was provided. Resident 305 care plan updated to include do not attempt to give medications or do treatments when resident 305 is upset or agitated. Leave the room and come back later. Resident 305 refuses to have staff 6 provide cares. Updated care plan to reflect verbal aggression received. He has no other ongoing concerns from this incident but doesnt want to work with staff 6. Staff 6 no longer works in this facility. Other potential residents effected: This deficiency has the potential to affect other residents. Audit done on grievances, care concerns, and risk management to review if anything that was reported to leadership should have been reported to the state. The facility has developed and implemented education and training regarding investigation abuse. Education started immediately with hall huddles, all staff meetings, nurse meetings, and assigned online Relias education. The facility conducted reviews, and any further concerns were investigated and addressed. System Change: The facility provided education to nursing staff related to recognition, reporting, and investigation abuse. The facility conducted interviews with residents, and any further concerns were investigated and addressed. Ongoing education will be provided regarding preventing abuse for new hires and annually. Staff interviews are to be conducted to ensure they understand abuse, how to report abuse, and their roles in investigation of abuse. The cause of these deficiencies is related to lack of understanding of abuse, abuse reporting, and abuse investigations. Monitoring: DNS or assigned staff will complete 3 resident interviews weekly to ensure resident rights are honored. DNS or assigned staff will complete 3 staff interviews weekly to ensure resident rights are honored and staff understand resident rights. Assessments are done weekly for 4 weeks, and then monthly for 3 months. QAPI will review resident rights ongoing for 2023.

Based on interview and record review it was determined the facility failed to ensure Staff 6 (LPN) adhered to professional standards of practice related to abuse and residents' changes in condition for 5 of 8 sampled residents (#s 305, 309, 312, 314 and 315) reviewed for abuse and change of condition. This failure resulted in Residents 305, 309 and 314 who experienced mental and verbal abuse and Residents 312 and 315 experienced a noted decline in condition without timely intervention prior to the residents' hospitalization. Findings include: OAR 8510450040 "Scope of Practice Standards for All Licensed Nurses" indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. OAR 8510450050 "Scope of Practice Standards for Licensed Practical Nurses" indicated the following: (2) Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation. Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care, and applying practical nursing knowledge drawn from the biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Licensed Practical Nurse shall: (a) Conduct and document initial and ongoing focused nursing assessments of the health status of clients by: (A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care. (D) Anticipating and recognizing changes or potential changes in client status; Identifying signs and symptoms of deviation from current health status; and (C) Selecting appropriate nursing interventions and strategies. OAR 8510450070 "Conduct Derogatory to the Standards of Nursing Defined" indicated the following: Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: (1) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. (2) Conduct related to other federal or state statute/rule violations: 1. a.) Resident 305 was admitted to the facility in 2020 with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness), major depression and epilepsy. Resident 305 was alert and oriented. A complaint intake dated 12/8/22 indicated Staff 5 (CNA) and Staff 7 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305 to take her/his medications. Staff 6 had also turned on all the lights in the resident's room, even though it was careplanned not to turn all the lights on, because it triggered the resident and "set her/him off". Staff 7 attempted to stop Staff 6 from yelling at the resident and to leave the room to deescalate the situation but Staff 6 would not cooperate so she left to get help. The complaint indicated facility management was aware of Staff 6's behaviors but no corrective action was taken. On 3/21/23 at 9:45 AM Staff 14 (RCM/LPN) acknowledged she had not identified the incident as possible mental and verbal abuse by Staff 6 and she failed to investigate the incident. Staff 14 did notify Staff 1 (Administrator) and Staff 2 (DNS) of the incident but they also failed to identify it as possible abuse. The incident was later determined to be mental and verbal abuse of Resident 305 by Staff 6. b.). Resident 309 was admitted to the facility in 2018 with diagnoses including stroke with hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) and respiratory failure. On 3/22/23 at 12:01 PM Staff 4 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 309. Staff 6 would raise her voice to residents, throw temper tantrums and argue with residents. She had given verbal corrections to Staff 6. Staff 4 said she was aware that Resident 309 had also reported complaints about Staff 6. Social Services was aware of the resident's concerns and it was discussed at the resident's care conference. The resident stated she did not feel safe around Staff 6. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken. The incident was later determined to be mental and verbal abuse of Resident 309 by Staff 6. c.) Resident 314 was admitted to the facility in 2018 with diagnoses including neurocognitive disorder with Lewy bodies (progressive dementia that leads to a decline in thinking, reasoning and independent function). On 3/22/23 at 12:01 PM Staff 14 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 314. Staff 6 would raise her voice to residents, throw temper tantrums and argue with residents. She had given verbal corrections to Staff 6. Resident 314 had verbalized complaints such as Staff 6 was belittling (made her/him feel stupid), not patient with her/him and Staff 6 demanded the resident take her/his pills and she/he had no right to refuse. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken. 2. a.) Resident 312 was admitted to the facility in 2022 with diagnoses including hemicraniectomy (surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure), HIV disease and viral Hepatitis C. On 3/22/23 at 12:18 PM Staff 15 (CNA) stated she had been working on Sunday 3/12/23. She was in the dining room and noticed that Resident 312 had fluid coming out of the back of her/his head, her/his hair was matted down with fluid and there was leaking onto the neck area. Due to the resident's background of brain surgery with a skull flap (allows access to the brain) she was very concerned. She asked the resident's CNA Staff 9 if the nurse Staff 6 (LPN) knew about the drainage. Staff 6 said she would contact the doctor but then did nothing about it. Staff 15 felt Staff 6 would not respond so went to Staff 18 (LPN). Staff 18 looked at the resident and said the resident should go out to the hospital. Staff 18 spoke to Staff 6 and expressed concerns about the resident's condition. Staff 6 said the resident was fine and she was not sending the resident to the hospital and just wiped off the fluid with gauze without using gloves (on a resident with a brain wound and infectious diseases). Staff 9 came by later and told her Staff 6 was squeezing the resident's head like a pimple and they both knew that was wrong. Staff 18 had talked to the DNS but nothing was done to correct the situation. The evening shift came on and finally sent the resident to the hospital. No documentation was found in the resident's medical record to indicate Staff 6 called or tried numerous times to contact the physician; no assessment of the resident was completed by Staff 6 related to the possible change of condition for Resident 312 and no interventions were noted. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a possible change of condition for Resident 312 or that Staff 2 (DNS) had done any follow up to ensure the resident received appropriate care. On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) stated the Central Hall charge nurse called her about Resident 312. Cognitively the resident was at baseline so she left it in the hands of the DNS. On Friday 3/10/23 the resident had complained about her/his head hurting. Staff 11 stated she expected the LPNs to know when they should send a resident to the hospital. They should do an assessment. She found no assessment for Resident 312. Staff 6 said she tried to reach the physician but there was no documentation to verify she had tried. Staff 11 thought Staff 6 had sent the resident out to the hospital but she did not. Staff 6 just put the note in the medical record for the evening shift nurse. Staff 6 should have been able to make the determination to send the resident out as needed without waiting for the physician to return a call. She knew it was a Sunday and reaching the physician would not be easy. There were also instructions to send the resident to the hospital if her/his condition worsened because the neurosurgeon was on call that weekend. b.) Resident 315 was admitted to the facility in 2018 with diagnoses including spastic cerebral palsy, persistent asthma and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). On 3/24/23 at 8:58 AM Staff 17 (CNA) said Staff 15 (CNA) and Staff 9 (CNA) reported concerns to her about the condition of a couple of residents that day (3/12/23) including Resident 315. They told her the resident was having difficulty breathing so Staff 6 told the CNA to give her/him a shower to help the breathing but the resident needed to go to a hospital not take a shower. The resident had trouble breathing since early morning and she/he could not eat. The resident's respirations were 135. They told Staff 6 this was not normal for the resident but she would not send the resident out. She did one breathing treatment which did not help. Nothing else was done by Staff 6. The resident was finally sent out by the evening shift nurse by Staff 13. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The resident received nebulizer treatment, IV steroids, oxygen and IV magnesium. The resident remained with increased difficulty breathing and audible rhonchi (secretions in the airway) and therefore the hospitalist was consulted for admission. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) indicated she expected LPNs to know when they should send someone out to the hospital and when to do an assessment. There was no assessment or documentation by Staff 6. Staff 11 said if Resident 315's breathing was as bad as staff indicated she/he should have been sent out to the hospital without waiting. Staff 11 understood Staff 6 did one nebulizer treatment for Resident 315 but it was not effective. Staff 11 also said Staff 6 directed the CNA to give the resident a shower to help his breathing. That was not an appropriate medical treatment for a resident in respiratory distress. See F600 and F684

Residents Effected: The facility was notified of the following deficiencies on 03/23/2023; five residents (#s 305, 309, 312, 314 and 315) were reviewed for abuse and change of condition. Investigation started for resident 305 as soon as additional information was provided. Resident 305 care plan updated to include do not attempt to give medications or do treatments when resident 305 is upset or agitated. Leave the room and come back later. Resident 305 refuses to have staff 6 provide cares. Updated care plan to reflect verbal aggression received. He has no other ongoing concerns from this incident but doesn't want to work with staff 6. Staff 6 no longer works in this facility. Facility made aware of concern with resident 314 on 04/17/2023. Risk of significant concern started for resident 314 on 04/18/2023. Care plan updated to include verbal aggression received. Interviewed resident to assess ongoing concerns. Staff 6 no longer works in this facility. Facility made aware of concern with resident 309 on 04/17/2023. Risk of significant concern started for resident 309 on 04/18/2023. Care plan updated to include verbal aggression received. Interviewed resident to assess ongoing concerns. Staff 6 no longer works in this facility. Investigation started for resident 312 related to significant concerns about hospitalization on 03/12/2023. Investigation found that using the Significant Change of Condition UDA would have captured the needed documentation, communication, assessments, and interventions, and this was completed at the the time of the incident and could have identified the concern if it was completed. Chart review done for resident 315 related to significant concerns about hospitalization on 03/12/2023. Investigation found that using the Significant Change of Condition UDA would have captured the needed documentation, communication, assessments, and interventions, and this was completed at the the time of the incident and could have identified the concern if it was completed. Other potential residents effected: This deficiency has the potential to affect other residents. Audit done on grievances, care concerns, and risk management to review if anything that was reported to leadership should have been reported to the state. The facility has developed and implemented education and training regarding investigation abuse. Education started immediately with hall huddles, all staff meetings, nurse meetings, and assigned online Relias education. The facility conducted reviews, and any further concerns were investigated and addressed. The deficiency with identifying changes in condition has the potential to affect other residents. The DNS completed an audit of Transfers out to the Hospital. Audit did confirm the need for additional training and direction related to using the SBAR change of condition UDA for acute and significant changes in condition and for transfers out to the hospital. System Change: The facility provided education to nursing staff related to recognition, reporting, and investigation abuse. The facility conducted interviews with residents, and any further concerns were investigated and addressed. Ongoing education will be provided regarding preventing abuse for new hires and annually. Staff interviews are to be conducted to ensure they understand abuse, how to report abuse, and their roles in investigation of abuse. The cause of these deficiencies is related to lack of understanding of abuse, abuse reporting, and abuse investigations. Education provided to nursing staff regarding how to use the SBAR change of condition UDA. When to use the SBAR change of condition form. Recognition of changes of condition requiring emergency treatments and responses. Discussion of emergent, urgent, and routine concerns and what to look for related to different conditions. Education provided to RCMs regarding checking for changes of conditions requiring the use of the SBAR change of condition UDA. Education with RCMs regarding using the Quality Improvement Tool for review of Acute Care Transfers. The cause of these deficiencies is related to lack of understanding of how to use the SBAR change of condition UDA. Monitoring: DNS or assigned staff will complete 3 resident interviews weekly to ensure residents are free from abuse. DNS or assigned staff will complete 3 staff interviews weekly to ensure residents are free from abuse and staff understand how to recognize, report, and investigate abuse. Assessments are done weekly for 4 weeks, and then monthly for 3 months. QAPI will review resident rights ongoing for 2023. DNS or assigned staff will review transfers out to the hospital and residents with changes of condition during standup to determine if the SBAR change of condition UDA was completed. Assessments weekly for 4 weeks, and then monthly for 3 months using the Quality Improvement Tool for review of Acute Care Transfers.

Based on interview and record review it was determined the facility failed to to identify, assess and select appropriate interventions for residents' change in condition for 2 of 2 sampled residents (#s 312 and 315) reviewed for a change of condition. This failure resulted in Resident 312 and Resident 315 experiencing a noted decline in condition without timely medical intervention prior to the residents' hospitalizations. Findings include: 1. Resident 312 was admitted to the facility in 2022 with diagnoses including hemicraniectomy (surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure), HIV disease and viral Hepatitis C. A hospital History & Physical dated 3/12/23-3/16/23 indicated the resident had a hemicraniectomy on 6/20/22. The resident underwent a cranioplasty (neurosurgical procedure designed to repair or reshape irregularities or imperfections in the skull) on 1/12/23 it was noted the right brain hemisphere had necrosis and turned into a soupy yellow substance. Later the brain "broth" grew staph epidermidis (gram-positive bacteria). The resident was sent to the Emergency Department for swelling and drainage from the recent head injury site and was admitted to the hospital's neurosurgical service. An operative Note indicated the resident underwent: 1. Incision, irrigation and sharp debridement of the right posterior cranial wound. 2. Removal of underlying hardware. A Neurosurgery Progress Note dated 3/14/23 indicated the resident's primary admitting diagnoses included cellulitis (skin infection) of the scalp. The skull flap was not removed. It did not look infected, but there was a need to keep pressure on the head to prevent the fluid from reaccumulating. A broad spectrum antibiotic was ordered and staples needed to be removed in 2-3 weeks. On 3/21/23 at 12:01 PM Resident 312 stated she/he did not remember much about the day she/he went to the hospital but staff told her/him they would send her/him when they were ready. The resident remembered her/his head not feeling right and she/he wanted to go to the hospital for a couple of days prior. On 3/22/23 at 12:18 PM Staff 15 (CNA) stated she had been working on Sunday 3/12/23. She was in the dining room and noticed Resident 312 had fluid coming out of the back of her/his head, her/his hair was matted down with fluid and there was leaking onto the neck area. Due to the resident's background of brain surgery with a skull flap she was very concerned. She asked Staff 9 (CNA) if Staff 6 (LPN) knew about the drainage. Staff 6 said she would contact the doctor but then did nothing about it. Staff 15 felt Staff 6 would not respond so went to Staff 18 (LPN). Staff 18 looked at the resident and said the resident should go out to the hospital. Staff 18 spoke to Staff 6 and expressed concerns about the resident's condition. Staff 6 said the resident was fine and she was not sending the resident to the hospital and just wiped off the fluid with gauze without using gloves (on a resident with an surgical brain wound and infectious disease). Staff 9 came by later and told her Staff 6 was squeezing the resident's head like a pimple and they both knew that was wrong. Staff 18 had talked to the DNS but nothing was done during the entire day shift. On 3/23/23 at 10:48 Staff 9 indicated she got the resident up that morning and into her/his chair. She noticed the leakage from the back of the resident's head. She went and told Staff 6 who looked and touched it (with her hands not gloved for a resident with an open brain wound and infectious disease) but did not do anything else about it. She was very concerned so she spoke to Staff 15 (CNA) and Staff 17 (CNA). Staff 15 went and told another nurse Staff 18 because they felt it was serious and Staff 6 was not responding. Later Staff 9 said she saw Staff 6 squeezing the area on the resident's head with her two thumbs like she was squeezing a pimple. Staff 18 was told again and Staff 9 asked if she should contact the DNS. Staff 18 contacted the DNS. Later that day Staff 9 reported to Staff 6 the wound was still swollen and draining and Staff 6 just told her to change the pillowcase. It felt that Staff 6 was not acting fast enough and the resident needed to go to the hospital. This went on for all of day shift. When the evening shift nurse came on duty, she sent the resident out within the hour. The resident never said no to going out to the hospital. On 3/23/23 at 3:30 PM Staff 2 (DNS) indicated the leaking had been identified by an RCM/LPN on 3/10/23 and an appointment had been made for Monday 3/13/23. He received a call from the day shift nurse indicating the wound was draining a lot and staff felt Staff 6 was not addressing the issue. He called Staff 6 who told him she was cleaning the drainage out of the resident's hair. Staff 6 said she called the physician's office and left a message and was waiting for a call back. Staff 6 told him she kept trying to get a hold of the physician. The resident was not sent out until the evening shift came on duty. Staff 2 did not indicate he had done anything else about the situation. No documentation was found in the resident's medical record to indicate Staff 6 called or tried numerous times to contact the physician; no assessment of the resident was completed by Staff 6 related to the possible change of condition for Resident 312 and no interventions were noted. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a possible change of condition for the resident. No documentation was found to indicate Staff 2 (DNS) had done anything else about the situation. On 3/23/23 at 3:00 PM Staff 18 (LPN) said a CNA came to her and said Staff 6 was not listening to her about a problem with Resident 312. The resident (who had recent brain surgery) had an area on the head that was swollen and draining a significant amount of a clear but lightly bloody fluid from the surgical site. Staff 18 went and spoke with Staff 6 who said she would take care of it. Staff 18 told Staff 6 if there was significant drainage, she should send the resident to the hospital. Staff 18 knew an RCM/LPN had noticed a little drainage the day before and they had called the neurosurgeon and set an emergency appointment for Monday but were told if the area got worse (swollen and drainage) the resident should go to the hospital because the neurosurgeon was on call at the hospital that weekend. Staff 6 said it was just an abscess and blew her off. Staff 18 stated another staff member, Staff 17 (CNA) came to her and said she saw Staff 6 trying to drain the wound herself. Staff 6 had her two thumbs and was pushing on the wound area like you would squeeze a pimple. Staff 18 indicated you should never do that for a brain surgery patient. The RCM/LPN was notified and then the DNS but nothing happened. The resident did not get sent to the hospital until the evening shift nurse came to work and she sent the resident out. Staff 6 should have assessed the resident but she did not. The resident was admitted to the hospital and had a surgical procedure and also had cellulitis (a skin infection) of the scalp. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. When she came in to work CNAs came up to her and told her there was a problem with Resident 312. The resident had fluid leaking from her/his surgical incision, the area was swollen and Staff 6 had been pressing on the area trying to drain it. They were all worried about the resident and felt Staff 6 was not addressing the issue. Staff 6 told her Resident 312 did not want to go to the hospital. Staff 13 went and saw the resident and thought she would have to convince the resident to go to the hospital but the resident told Staff 13 she/he had been asking to go to the hospital for three days so of course she/he would go. Then Staff 19 (CMA) told me Staff 6 kept telling her to give Resident 312 a pain pill, but you are not supposed to give pain medication if the resident may be going out to the hospital. Staff 6 first told Staff 13 to give the pain pill but Staff 13 would not because it should not be done under the circumstances and Staff 6 should know that was the case. Staff 13 said she had to assess the resident first. Staff 13 sent the resident out within the first hour she was on duty. Staff 6 put a note in the record which made it appear she had sent the resident out but she did not. Staff 13 indicated Staff 6 did not like to take recommendations from other staff and did not listen to them. Staff 13 was upset about the issue with Resident 312 because the resident wanted to go to the hospital. She tried to explain to Staff 6 as a nurse you should be able to assess a resident and determine that it would be more important to send the resident to the hospital if needed than to wait for a call back from a physician on a weekend. Staff 13 stated Staff 6 did not identify the change of condition, did not assess the resident and failed to intervene on the resident's behalf. On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) stated the Central Hall charge nurse had called her about Resident 312. Cognitively the resident was at baseline so she left it in the hands of the DNS. On Friday 3/10/23 the resident had complained about her/his head hurting. Staff 11 stated she expected the LPNs to know when they should send a resident to the hospital. They should do an assessment. She found no assessment for Resident 312. Staff 6 said she tried to reach the physician but there was no documentation to verify she had tried. Staff 11 thought Staff 6 had sent the resident out to the hospital but she did not, the evening shift nurse did. Staff 6 just put the note in the medical record. She should have been able to make the determination to send the resident out as needed without waiting for the physician to return a call. She knew it was a Sunday and reaching the physician would not be easy. 2. Resident 315 was admitted to the facility in 2018 with diagnoses including spastic cerebral palsy, persistent asthma and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). On 3/12/23 at 10:22 AM Staff 6 (LPN) wrote: Resident presented with complaints of cough and congestion and audible wheezing noted. Breathing treatment inhaler given with little relief. Resident had Duoneb (breathing treatment) prior to breakfast. The resident stated, "It helped a little". On 3/23/23 at 10:11 AM Staff 21(CNA) said Resident 315 was breathing wrong. The resident's vitals were off and the resident said she/he needed to go to the hospital. Staff 21 said she had just started her evening shift when she noticed the resident was not breathing right. A CNA on the front hall called her into the room and the resident said she/he could not breath well so Staff 21 ran and grabbed the nurse. Another staff told her the resident was in bed all day and that was not normal behavior for the resident. She was very concerned about the resident. She knew the resident well and he did not look or sound good. On 3/24/23 at 8:58 AM Staff 17 (CNA) indicated Staff 15 (CNA) and Staff 9 (CNA) reported concern to her about the condition of a couple of residents that day (3/12/22) including Resident 315. They told her the resident was having difficulty breathing and Staff 6 told the CNA to give the resident a shower to help the breathing but the resident needed to go to a hospital not take a shower. The resident had trouble breathing since early morning and she/he could not eat. The resident's respirations were 135. The CNAs stated they told Staff 6 but she did not send the resident out. She had done one breathing treatment earlier which did not help. Nothing else was done by Staff 6. The resident was finally sent out by the evening shift nurse Staff 13. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. When she came in to work CNAs came up to her and told her there was a problem with Resident 315. Multiple staff came to tell her to keep an eye on Resident 315 as the resident was not breathing well and did not look good. Within an hour she sent the resident out to the hospital. After shift change report she went in to see Resident 315. The resident's stats were down and she/he looked bad. The resident should have been sent out earlier. Staff 13 stated she had never sent two people out to the hospital in that short amount of time. The resident had a c-pap mask on and by the way she/he was breathing she could tell she/he must have had breathing issues for quite a while. Two CNAs changed the resident and said the resident could barely breathe. Staff 13 looked at the resident's history and the aides got her/ him ready. When she was on the phone with 911 for Resident 315 she requested Staff 6 to assist with the call to the hospital on the conditions of the resident during the day but Staff 6 would not do so. Staff 13 said Staff 6 should have sent both the residents out to the hospital but did not do so. No documentation was found to indicate Staff 6 had assessed Resident 315 or provided appropriate interventions for a resident with respiratory distress. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The resident received nebulizer treatment, IV steroids, oxygen and IV magnesium. The resident remained with increased difficulty breathing and audible rhonchi (secretions in breathing) and therefore the hospitalist was consulted for admission. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) indicated she expected the LPNs to know when they should send someone out to the hospital and when to do an assessment. There was no assessment or documentation by Staff 6. Staff 11 said if the resident's breathing was as bad as they said, she/he should have been sent out to the hospital without waiting. She understood Staff 6 did one nebulizer treatment for Resident 315 but it was not effective. Staff 11 also said for Staff 6 to direct the CNA to give the resident a shower to help his breathing was not an appropriate medical treatment for a resident in respiratory distress.

Residents Effected: The facility was notified of the following deficiencies on 03/23/2023; two residents (#s 312, and 314) were reviewed for failure to identify, assess, and select appropriate interventions for residents with a change in condition. Investigation started for resident 312 related to significant concerns about hospitalization on 03/12/2023. Investigation found that using the Significant Change of Condition UDA would have captured the needed documentation, communication, assessments, and interventions, and this was completed at the the time of the incident and could have identified the concern if it was completed. Chart review done for resident 315 related to significant concerns about hospitalization on 03/12/2023. Investigation found that using the Significant Change of Condition UDA would have captured the needed documentation, communication, assessments, and interventions, and this was completed at the the time of the incident and could have identified the concern if it was completed. Other potential residents effected: The deficiency with identifying changes in condition has the potential to affect other residents. The DNS completed an audit of Transfers out to the Hospital. Audit did confirm the need for additional training and direction related to using the SBAR change of condition UDA for acute and significant changes in condition and for transfers out to the hospital. System Change: The facility provided education to nursing staff regarding how to use the SBAR change of condition UDA. When to use the SBAR change of condition form. Recognition of changes of condition requiring emergency treatments and responses. Discussion of emergent, urgent, and routine concerns and what to look for related to different conditions. Education provided to RCMs regarding checking for changes of conditions requiring the use of the SBAR change of condition UDA. Education with RCMs regarding using the Quality Improvement Tool for review of Acute Care Transfers. The cause of these deficiencies is related to lack of understanding of how to use the SBAR change of condition UDA. Monitoring: DNS or assigned staff will review transfers out to the hospital and residents with changes of condition during standup to determine if the SBAR change of condition UDA was completed. Assessments weekly for 4 weeks, and then monthly for 3 months using the Quality Improvement Tool for review of Acute Care Transfers. QAPI will review resident rights ongoing for 2023.

Based on deficient practice in the areas of Freedom from Abuse, Neglect and Exploitation, Investigate/Prevent/Correct Alleged Violations and failure to adhere to Professional Standards of Practice of nursing to identify, assess and intervene for residents' Change of Condition it was determined the facility was not administered by the management team in an effective and efficient manner to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. As a result: Residents 305, 309 and 314 were mentally and verbally abused and Residents 312 and 315 experienced delays in treatment for significant changes of condition requiring hospitalization. Findings include: 1.The facility failed to ensure residents were free from mental and verbal abuse. a. On 12/8/22 Staff 5 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305 to take her/his medications. Staff 5 indicated facility management was aware of Staff 6's behaviors but had done nothing about it and Staff 6 continued to work with residents. On 12/8/22 Staff 7 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305. Staff 7 said she felt Staff 6 deliberately antagonized residents and many of them did not care for her. Staff 7 said she knew some residents would refuse their medications so they would not have to interact with Staff 6. Staff 7 said she believed this was verbal abuse but no one at the facility ever interviewed her about this incident and Staff 6 continued to work with residents. On 3/23/23 Staff 14 (RCM/LPN) indicated Staff 6 had negative interactions with Resident 305 and with other residents also. Staff 6 would raise her voice to the residents and throw temper tantrums. Staff 14 said she told Staff 6 not to argue with residents and she had given verbal corrections. Staff 6 was also belittling, demeaning and disrespectful to residents and other staff. She reported her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but nothing was done. On 3/20/23 Staff 1 (Administrator) and Staff 2 (DNS) indicated Staff 4 (RCM/LPN) would have the information about this incident. No documentation was provided to indicate an investigation had been done by Staff 1 or Staff 2. On 3/21/23 Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. She told Staff 1 (Administrator) and Staff 2 (DNS) about the incident. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. She stated she did not complete an investigation and she should have. She did not interview or speak to the CNAs who were present during the incident or to other residents or staff. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. b. On 3/23/23 Resident 314 stated one of the nurses was very mean to her. The resident said the nurse was very rude to her/him, she was not patient or nice and made her/him feel bad. The resident's roommate was alert and oriented and identified the nurse in question as Staff 6. On 3/22/23 Staff 14 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 314. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but no corrective action was taken. On 3/23/23 Staff 1 (Administrator) and Staff 2 (DNS) provided no additional documentation related to this incident. c. On 3/23/23 Resident 309 indicated there was a problem with Staff 6. Staff 6 was very belligerent and rude to her/him, her/his roommate, other residents and staff. Staff 6 snapped at everyone. Resident 309 also stated she did not like to come out of her/his room when Staff 6 worked because it was so unpleasant to be around her. On 3/22/23 Staff 14 (RCM/LPN) indicated she was aware Resident 309 had reported complaints about Staff 6. The resident stated she did not feel safe around Staff 6. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken and Staff 6 continued to work with residents. On 3/23/23 at 3:45 PM Staff 1 (Administrator) and Staff 2 (DNS) provided no additional documentation related to this incident. Refer to F 600 2. The facility failed to ensure staff to resident incidents were investigated to rule out abuse. a. On 12/8/22 Staff 5 (CNA) said she heard Staff 6 (LPN) yelling and screaming at Resident 305. Staff 5 stated she felt it was verbal abuse but no one interviewed her about it and Staff 6 continued to work with residents. On 12/8/22 Staff 7 (CNA) indicated she heard Staff 6 yelling at Resident 305. She tried to get Staff 6 to stop yelling and leave the room but Staff 6 would not. Staff 7 felt it was abuse but no one interviewed her about it. On 3/21/23 at 9:45 AM Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. No documentation of an investigation was provided by Staff 1 (Administrator) or Staff 2 (DNS) when requested. Refer to F 610 3. The facility failed to ensure residents were comprehensively evaluated and received timely treatment for serious changes of conditions which resulted in hospital admissions. a. Resident 312 was admitted to the facility in 2022 with diagnoses including hemicraniectomy (surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure), HIV disease and viral Hepatitis C. On 3/22/23 Staff 15 (CNA) stated she went to Staff 6 about Resident 312 having swelling and fluid draining from the site where she had brain surgery. Due to the resident's background of brain surgery with a skull flap (allows access to the brain) she was very concerned. Staff 6 said she would contact the doctor but did not and did nothing else about the CNAs concerns. Staff 15 then notified another nurse Staff 18 (LPN) who recommended Staff 6 send the resident out to the hospital. Staff 6 did not. Staff 18 spoke to the DNS and he called Staff 6 but nothing was done to correct the situation and no additional interventions were attempted. On 3/23/23 at 10:48 Staff 9 (TITLE) indicated noticed swelling and leakage from the back of Resident 312's head. She told Staff 6 who looked and touched it (with her hands not gloved for a resident with an open brain wound and infectious disease) but did not do anything else about it. Staff 9 also said she saw Staff 6 squeezing the area on the resident's head with her two thumbs like she was squeezing a pimple. Later Staff 9 reported to Staff 6 the resident's head was still swollen and draining and Staff 6 told her to change the pillowcase. Staff 9 felt that Staff 6 was not acting fast enough and the resident needed to go to the hospital On 3/23/23 at 3:30 PM Staff 2 (DNS) indicated the leaking had been identified by an RCM/LPN on 3/10/23 and an appointment had been made for Monday 3/13/23. He received a call from the day shift nurse indicating the wound was draining a lot and staff felt Staff 6 was not addressing the issue. He called Staff 6 who told him she was cleaning the drainage out of the resident's hair. Staff 6 said she called the physician's office and left a message and was waiting for a call back. She did not send the resident to the hospital although numerous staff had indicated she should. Staff 2 did not indicate he had done anything else about the situation. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. She was the nurse who send finally sent Resident 312 to the hospital. Staff 6 did not identify the resident's change of condition, did not assess the resident and failed to intervene on the resident's behalf. No documentation was found in the resident's medical record to indicate Staff 6 called or tried numerous times to contact the physician; no assessment of the resident was completed by Staff 6 related to the serious change of condition for Resident 312 and no interventions were noted. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a possible change of condition for the resident. No documentation was found to indicate Staff 2 (DNS) had done anything about the situation or provide any intervention for the resident. b. Resident 315 was admitted to the facility in 2018 with diagnoses including spastic cerebral palsy, persistent asthma and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). On 3/24/23 at 8:58 AM Staff 17 (CNA) indicated Staff 15 (CNA) and Staff 9 (CNA) reported concerns to her about the condition of Resident 315. They told her the resident was having difficulty breathing and Staff 6 told the CNA to give the resident a shower to help the breathing. They felt the resident needed to go to a hospital not take a shower. The resident had trouble breathing since early morning and could not eat. The resident's respirations were 135. The CNAs stated they told Staff 6 but she would not send the resident to the hospital. Staff 6 did one breathing treatment earlier which did not help. Nothing else was done by Staff 6. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. When she came in to work multiple CNAs came to her and told her there was a problem with Resident 315. Resident 315 was not breathing well and did not look good. Staff 13 went in to see the resident. The resident's stats were down and she/he looked bad. The resident had a c-pap mask on and by the way she/he was breathing she could tell she/he must have had breathing issues for quite a while. She assessed the resident, checked the resident's history and sent him out with an hour of starting her shift. When she was on the phone with 911 for Resident 315, she requested Staff 6 assist with the call to the hospital on the conditions of the resident during the day but Staff 6 would not do so. Staff 13 said Staff 6 should have sent the resident out to the hospital in the morning when his breathing issues had worsened, but she did not. This was the second resident Staff 6 had failed to send out to the hospital that day. No documentation was found to indicate Staff 6 had assessed Resident 315 or provided appropriate interventions for a resident with respiratory distress. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The resident received nebulizer treatment, IV steroids, oxygen and IV magnesium. The resident remained with increased difficulty breathing and audible rhonchi (secretions in breathing) and therefore the hospitalist was consulted for admission. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). Refer to F600, F610, F658 and F684 4. The facility failed to ensure Professional Standards of Practice were adhered to related to Abuse and Changes of Condition. a.) On 3/21/23 at 9:45 AM Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. The incident was later determined to be mental and verbal abuse of Resident 305 by Staff 6. On 3/21/23 no documentation of an investigation was provided by Staff 1 (Administrator) or Staff 2 (DNS) when requested. b.) On 3/22/23 at 12:01 PM Staff 4 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 309 and she was aware that Resident 309 had also reported complaints about Staff 6. The resident stated she did not feel safe around Staff 6. Staff 14 took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken and Staff 6 continued to work with residents. The incident was later determined to be mental and verbal abuse of Resident 309 by Staff 6. No documentation was found or provided related to Resident 309's reported complaints about Staff 6. c.) On 3/22/23 at 12:01 PM Staff 14 (RCM/LPN) indicated Staff 6 had multiple negative interactions with residents including Resident 314 who complained Staff 6 was mean to her/him. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken and Staff 6 continued to work with residents. The incident was later determined to be mental and verbal abuse of Resident 314 by Staff 6. No documentation was found or provided related to Resident 314's reported complaints about Staff 6. d.) On 3/22/23 Staff 15 (CNA) stated she went to Staff 6 about Resident 312 having swelling and fluid draining from the site where she had brain surgery. Due to the resident's background of brain surgery with a skull flap (allows access to the brain) she was very concerned. Staff 6 said she would contact the doctor but did not and did nothing else about it. Staff 15 then notified another nurse Staff 18 (LPN) who recommended Staff 6 send the resident out to the hospital. Staff 6 did not. Staff 18 spoke to the DNS and he called Staff 6 but nothing was done to correct the situation. On 3/27/23 Staff 11 (RCM/LPN) stated she expected LPNs to know when they should send a resident to the hospital. They should do an assessment. She found no assessment for Resident 312. Staff 6 said she tried to reach the physician but there was no documentation to verify she had tried. Staff 6 failed to make the determination to send the resident out as needed. Staff 6 knew it was a Sunday and reaching the physician would not be easy. There were also instructions to send the resident to the hospital if her/his condition worsened because the neurosurgeon was on call that weekend. Staff 6 failed to identify, assess or intervene for the resident with a change of condition that required hospitalization. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a serious change of condition for Resident 312 or that Staff 2 (DNS) had done any follow up to ensure the resident received appropriate care. e.) On 3/24/23 Staff 17 (CNA) indicated Staff 15 (CNA) and Staff 9 (CNA) reported concerns to her about the condition of Resident 315. The resident had trouble breathing since early morning and she/he could not eat. The resident's respirations were 135. Staff 17 said they told Staff 6 this was not normal for the resident but she would not send the resident out. She did one breathing treatment for the resident which did not help. Nothing else was done by Staff 6. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). On 3/27/23 Staff 11 (RCM/LPN) indicated she expected LPNs to know when they should send someone out to the hospital and when to do an assessment. There was no assessment or documentation by Staff 6. Staff 11 said if Resident 315's breathing was as bad as staff indicated he should have been sent out to the hospital without waiting. She understood Staff 6 did one nebulizer treatment for Resident 315 but it was not effective. Staff 11 also said Staff 6 had directed a CNA to give the resident a shower to help her/his breathing. That was not an appropriate medical treatment for a resident in respiratory distress. Refer to F600 and F658

Residents Effected: The facility was notified of the following deficiencies on 03/23/2023; Residents 305, 309 and 314 were mentally and verbally abused and Residents 312 and 315 experienced delays in treatment for significant changes of condition requiring hospitalization. Investigation started for resident 305 as soon as additional information was provided. Resident 305 care plan updated to include do not attempt to give medications or do treatments when resident 305 is upset or agitated. Leave the room and come back later. Resident 305 refuses to have staff 6 provide cares. Updated care plan to reflect verbal aggression received. He has no other ongoing concerns from this incident but doesn't want to work with staff 6. Staff 6 no longer works in this facility. Facility made aware of concern with resident 314 on 04/17/2023. Risk of significant concern started for resident 314 on 04/18/2023. Care plan updated to include verbal aggression received. Interviewed resident to assess ongoing concerns. Staff 6 no longer works in this facility. Facility made aware of concern with resident 309 on 04/17/2023. Risk of significant concern started for resident 309 on 04/18/2023. Care plan updated to include verbal aggression received. Interviewed resident to assess ongoing concerns. Staff 6 no longer works in this facility. Investigation started for resident 312 related to significant concerns about hospitalization on 03/12/2023. Investigation found that using the Significant Change of Condition UDA would have captured the needed documentation, communication, assessments, and interventions, and this was completed at the the time of the incident and could have identified the concern if it was completed. After hospitalization the resident returned to the facility and returned to baseline. Chart review done for resident 315 related to significant concerns about hospitalization on 03/12/2023. Investigation found that using the Significant Change of Condition UDA would have captured the needed documentation, communication, assessments, and interventions, and this was completed at the the time of the incident and could have identified the concern if it was completed. After hospitalization the resident returned to the facility and returned to baseline. Other potential residents effected: This deficiency has the potential to affect other residents. Resident interviews were done on 03/23/2023 to determine if there were any other concerns related abuse. The facility has developed and implemented education and training regarding recognizing, reporting, and investigation abuse. Education started immediately with hall huddles, all staff meetings, nurse meetings, and assigned online Relias education. The facility conducted interviews with residents and staff. Any further concerns were investigated and addressed. The deficiency with identifying changes in condition has the potential to affect other residents. The DNS completed an audit of Transfers out to the Hospital. Audit did confirm the need for additional training and direction related to using the SBAR change of condition UDA for acute and significant changes in condition and for transfers out to the hospital. System Change: The facility provided education to nursing staff related to recognition, reporting, and investigation abuse. The facility conducted interviews with residents and staff. Any further concerns were investigated and addressed. Ongoing education will be provided regarding preventing abuse for new hires and annually. Staff interviews are to be conducted to ensure they understand abuse, how to report abuse, and their roles in investigation of abuse. The cause of these deficiencies is related to lack of understanding of abuse and abuse reporting. The facility provided education to nursing staff regarding how to use the SBAR change of condition UDA. When to use the SBAR change of condition form. Recognition of changes of condition requiring emergency treatments and responses. Discussion of emergent, urgent, and routine concerns and what to look for related to different conditions. Education provided to RCMs regarding checking for changes of conditions requiring the use of the SBAR change of condition UDA. Education with RCMs regarding using the Quality Improvement Tool for review of Acute Care Transfers. The cause of these deficiencies is related to lack of understanding of how to use the SBAR change of condition UDA. Monitoring: DNS or assigned staff will complete 3 resident interviews weekly to ensure there are no concerns for abuse. DNS or assigned staff will complete 3 staff interviews weekly to ensure there are no concerns for abuse. Assessments are done weekly for 4 weeks, and then monthly for 3 months. QAPI will review allegations of abuse ongoing for 2023. DNS or assigned staff will review transfers out to the hospital and residents with changes of condition during standup to determine if the SBAR change of condition UDA was completed. Assessments weekly for 4 weeks, and then monthly for 3 months using the Quality Improvement Tool for review of Acute Care Transfers. QAPI will review resident rights ongoing for 2023.

*************************** OAR 411-085-0310 Resident Rights Refer to F550 *************************** OAR 411-085-0360 Freedom from Abuse, Neglect, and Exploitation Refer to F600, F609, F610 *************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658 *************************** OAR 411-086-0110 Quality of Care Refer to F684 *************************** OAR 411-086-0010 Administration Refer to F835 ****************************

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#4) reviewed for abuse. This placed residents at risk for negative psychosocial outcomes. Findings include: Resident 4 admitted to the facility in 5/2020 with diagnoses including paraplegia (paralysis of the lower body) and anxiety. Resident 2 admitted to the facility in 9/2020 with diagnoses including bipolar personality disorder (a mental disorder characterized by unstable moods and behaviors). Resident 2's Progress Notes indicated she/he was involved in an incident on 2/6/22 where she/he was found yelling at another resident while holding a bathroom scale and threatening to throw it at the other resident. A review of Resident 2's Care Plan in effect as of 3/26/22 did not indicate any history of resident to resident altercations nor interventions to prevent future altercations. A Progress Note dated 3/26/22 revealed Resident 2 threatened Resident 4 with a pair of scissors. According to the note this was "an ongoing behavior for this resident". The Incident Report initiated on 3/26/22 indicated Resident 4 attempted to propel her/his wheelchair around Resident 2 in the hallway when Resident 2 pulled out a pair of scissors with the sharp tips pointed outward towards Resident 4 while calling her/him names and urging Resident 4 to fight. The Incident Report revealed during an interview with Resident 4 on 3/30/22 the resident reported she/he initially felt shaken up by the incident and felt better after time outside away from Resident 2. On 8/9/22 at 3:00 PM Staff 16 (LPN) reported the resident wouldn't come out of her/his room that evening without being escorted by staff and wanted her/his room door open which was not usual. Staff 16 said Resident 4 confided the incident was one of the few times she/he was actually afraid. A review of Resident 4's Progress Notes revealed no documentation to indicate the facility followed up with the resident or monitored her/him to determine psychosocial outcome from the incident. On 8/11/22 at 10:03 PM Staff 2 (DNS) reported the altercation between Resident 2 and Resident 4 was verbal with threats of violence. He stated Social Services should have followed up with Resident 4 a few times after the incident to ensure she/he felt safe.

Resident 2 is no longer in the facility. Resident 4 remains emotionally stable with no long-term psychological harm. Care plan updated for resident 4 to reflect a history of receiving a resident verbal altercation. DNS will identify those residents who have been affected or could potentially be affected by a resident-to-resident altercation. Update care plans to protect other residents from residents who have initiated resident-to-resident altercations. Update care plans of residents who were on the receiving end of a resident-to-resident altercation to monitor and assess for any ongoing triggers. Facility will do an audit of all current residents involved in a resident-to-resident altercation. Audit care plans of those involved in a resident-to-resident altercation to confirm the required care plans are in place. DNS will provide education provided to IDT and nursing staff regarding updates to care plans when there are resident-to-resident altercations. Education provided to social services, resident care managers, and charge nurses regarding placing residents on alert when there is a resident-to-resident altercation. IDT will review all new resident-to-resident altercations daily and then daily for 4 weeks. Medical records or designated auditor will follow up to ensure that steps have been completed, care plans updated, and proper documentation completed. Audits will be reviewed at at QAPI for 2022.

Based on interview and record review it was determined the facility failed to timely administer PRN pain medications for 1 of 3 sampled residents (#5) reviewed for pain medications. This placed residents at risk for increased pain. Findings include: Resident 5 admitted to the facility in 2021 with diagnoses including quadriplegia (paralysis of all four limbs). The residents 6/21/22 Quarterly Assessment indicated the she/he experienced constant pain rated 8 out of 10. A review of Physician's Orders dated 6/7/22 indicated Resident 5 had the following ordered for her/his pain management: *Scheduled Oxycodone (a medication used for pain) 10 mg tid at 6:00 AM, 12:00 PM and 9:00 PM. *Oxycodone 10 mg every four hours PRN *Scheduled and PRN Oxycodone must be given two hours apart from each other. On 5/27/22 a public complaint revealed the following: *On 6/17/22 Witness 3 (Complainant) observed Resident 5 inform staff she/he was in pain and requested pain medication at approximately 3:00 PM and she/he did not receive the medication until approximately 45 minutes later. *On 6/24/22 Witness 3 again observed Resident 5 request pain medication at approximately 3:05 PM. Witness 3 reported a CNA informed the resident at some point after the CMA was on lunch break and would return shortly. Witness 3 stated when they left the resident at 4:00 PM, she/he still did not receive the requested pain medication. A review of the facility's Controlled Substance Log Book revealed Resident 5's Oxycodone was signed out for administration as follows: *On 6/17/22 at 3:48 PM Staff 29 (CMA) administered Oxycodone, over 45 minutes after the pain medication was requested. *On 6/24/22 at 4:18 PM Staff 29 administered Oxycodone, over an hour after the pain medication was requested. On 8/8/22 at 2:36 PM Staff 29 stated she could not recall long medication waits for Resident 5. In an interview on 8/10/22 3:30 PM Resident 5 stated she/he waited up to two hours at times for her/his pain medication. On 8/11/22 at 11:46 AM Staff 2 (DNS) reported he expected staff to administer prn pain medications within ten minutes. He stated staff should count out the medication cart and hand off the keys to ensure residents receive their medications timely. Staff 2 stated residents should not have to wait for staff to return from lunch breaks.

Resident 5 is currently staying in the facility. She has multiple prn and scheduled pain medications ordered. Times adjusted for scheduled medications and prn pain medications so that pain medications do not fall at shift change. Care plan reviewed and pain management plan updated. IDT team will interview residents with pain medications to assess who is affected by this delay in receiving prn pain medications if they are getting their prn pain medications timely. DNS and/or designee will provide education to nursing staff regarding prn pain medication wait times, and what is a reasonable wait time for PRN medication. Education provided to nursing staff regarding their role in pain management as it relates to CNAs, CMAs, and Nurses. Education provided to nursing staff regarding having someone available on the unit to give PRN pain medications. Administrator, DNS, and/or designee will do weekly audits to determine if residents are receiving PRN pain medications timely. months. Audit prn medication wait times weekly for 4 weeks and then monthly for 2 months. Audits will be reviewed at QAPI for the rest of 2022.

OAR 411-085-0360 Abuse

Refer to F600 ********************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F697 *******************

Based on interview and record review it was determined the facility failed to assist residents to formulate an advanced directive and periodically review the resident's wishes regarding cardiopulmonary resuscitation (CPR) for 3 of 5 sampled residents (#s 46, 70 and 88) reviewed for advanced directives. This placed residents at risk for healthcare decisions to conflict with resident wishes. Findings include: 1. Resident 46 was admitted to the facility in 3/2022 with a diagnosis including fracture of right lower leg. A 3/10/22 hospital History and Physical revealed Resident 46 was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) for code status. No advanced directives were identified on Resident 46's face sheet. No POLST (Physician's Orders for Life Sustaining Treatment), was found in Resident 46's clinical records. No documentation was found to indicate Resident 46's medical choices were discussed with her/him or with a representative. On 5/6/22 at 10:30 AM and 10:38 Staff 5 (RCM/LPN) stated she would check the file to see if there was an Advance Directive for Resident 46. Staff 5 confirmed Resident 46 did not have an Advance Directive in her/his clinical records. On 5/9/22 at 10:26 AM Staff 35 (Social Services), Staff 36 (Social Services) and Staff 38 (Social Services) stated the process for the Advance Directive was to ask the resident or representative during the admission process and move forward with the process if the resident or representative accept. Staff 35, Staff 36, and Staff 38 stated staff should follow up with the resident or representative if the resident wanted to complete an Advance Directive to ensure the Advance Directive was in the medical records. , 2. Resident 30 admitted to the facility in 7/2021 with diagnoses including dementia and depression. A revised care plan dated 10/26/21 revealed no Advance Directive was on file and Resident 70 expressed interest so a blank copy was provided to her/him. A 4/7/22 Significant Change MDS revealed Resident 70's BIMS was 7 indicating she/he was cognitively impaired. A interview was attempted on 5/5/22 at 2:00 PM and on 5/6/22 at 11:18 AM and Resident 70 would not respond to any questions. No Advance Directive was found in the clinical records no documentation was found regarding Resident 70's medical choices were discussed with her/him or with a representative. On 5/9/22 at 10:26 AM Staff 35 (Social Services), Staff 36 (Social Services) and Staff 38 (Social Services) stated the process for the Advance Directive was to ask the resident or representative during the admission process/care conference and move forward with the process if the resident or representative wanted to complete the Advance Directive. Staff 35, Staff 36 and Staff 38 stated they should follow up with the resident or representative to ensure it was completed so the Advance Directive could be placed in medical records. Staff acknowledged no follow up was completed with Resident 70. 3. Resident 88 admitted to the facility in 1/2021 with diagnoses including COPD (chronic obstructive pulmonary disease) and depression. A revised care plan dated 10/26/21 revealed no Advance Directive was on file and Resident 88 expressed interest so a blank copy was provided to her/him. A 1/19/22 Care Conference revealed Resident 88 was working on her/his Advance Directive. A 4/22/22 Admission MDS revealed Resident 88's BIMS was 15 indicating she/he was cognitively intact. On 5/4/22 at 12:19 PM Resident 88 stated she completed an Advance Directive and her/his daughter had a copy but could not recall if the facility had one on file or not. No Advance Directive was found in the clinical records for Resident 88. On 5/9/22 at 10:26 AM Staff 35 (Social Services), Staff 36 (Social Services) and Staff 38 (Social Services) stated the process for the Advance Directive was to ask the resident or representative during the admission process/care conference and move forward with the process if the resident or representative wanted to complete the Advance Directive. Staff 35, Staff 36 and Staff 38 stated they should follow up with the resident or representative to ensure it was completed so the Advance Directive could be placed in medical records. Staff acknowledged no follow up was completed with Resident 88.

•Social Services will follow up with resident 46, 70 and 88 to assist in retrieving or filling out an Advance Directive. •An audit of resident charts will be conducted to ensure that current residents have been asked about Advance Directives and a copy obtained if available. All charts have been reviewed to ensure that code status is in place •Education provided to social service team, resident care managers, and charge nurses about the important of code status wishes, and advance directives. Advance Directives will be discussed at initial care conference. CPR wishes will be discussed quarterly and on admission. •Every admission and re-admission will be audited each week for the next 4 weeks and then monthly, by the Social Service Director or Designee to ensure that residents were asked about Advance Directives. The results of this audit and any concerns will be brought to QAPI.

Based on observation, interview and record review it was determined the facility failed to implement a care plan for 1 of 1 sampled resident (#76) reviewed for respiratory services. This placed residents at increased risk for unmet respiratory needs. Findings include: Resident 76 was admitted to the facility in 4/2022 with a diagnosis including COPD (Chronic obstructive pulmonary disease). A 4/7/22 Admission Nursing Database revealed Resident 76 had difficulty breathing, was on oxygen at two liters per minute through nasal cannula (a device used to deliver supplemental oxygen). A 4/11/22 Admission MDS revealed Resident 76 was administered oxygen. A review of Resident 76's care plan revealed no documentation of her/his respiratory status, goals or interventions. On 5/2/22 at 8:38 AM, 5/4/22 at 9:20 AM and 5/4/22 at 11:45 AM Resident 76 was observed with a nasal cannula in place receiving oxygen from an oxygen concentrator (a medical device that provides oxygen). On 5/5/22 at 12:53 PM Staff 5 (RCM/LPN) confirmed Resident 76's care plan did not include her/his respiratory status, goals or interventions and stated her/his respiratory information should be included on the care plan.

•Resident number 76 has discharged from the facility. •All residents using oxygen have been audited to ensure that a respiratory care plan is in place. •Education provided to resident care managers and charge nurses about the importance of care planning for oxygen usage. •Audits done for 4 weeks and then monthly to ensure that a respiratory care plan is in place for all new admissions who are using oxygen. The results of this audit and any concerns will be brought to QAPI.

Based on interview and record review the facility failed to follow physician orders for 2 of 4 sampled residents (#s 37 and 80) reviewed for pressure ulcers. This placed residents at risks for unmet needs. Findings include: 1. Resident 37 was admitted to the facility in 12/2020 with diagnoses including diabetes and stroke. A 4/25/22 BIMS evaluation revealed Resident 37's BIMS was 15 indicating she/he was cognitively intact. A physician recapitulation order dated 4/21/22 directed staff to administer 125 units of Humulin (short acting insulin), Pen-Injector subcutaneously one time daily in the evening. Staff were to notify the provider if Resident 37's CBG (capillary blood glucose) was less than 70 or greater than 300. A review of the 4/2022 Diabetic Administration record and nursing notes revealed the following: -4/2/22 Resident 37's CBG was 61 and a number "five" indicated to hold and refer to nurses, notes. -The 4/2/22 EMAR order note indicated Resident 61 was responsive and wanted orange juice. No documentation was found if the physician was notified of the low blood sugar or if her/his blood sugar was rechecked. -4/3/22 Resident 37's CBG was 89 and a number "five" indicated to hold and refer to nurses' notes. -The 4/3/22 EMAR order note indicated Resident 37's insulin was out of stock. "Held anyway due to low CBG. The pharmacy states will send in tonight's run." No documentation was found to indicate if the physician was notified of her/his insulin being out of stock, if insulin was delivered from the pharmacy or if Resident 37 received her/his insulin later that shift. On 5/5/22 at 3:25 PM and 5/6/22 at 12:54 PM Staff 26 (RCM/LPN) stated staff was expected to follow physician orders and staff should have called the physician on 4/2/22 regarding the low blood sugar and Resident 37's blood sugar should have been administered on 4/3/22. On 5/9/22 at 11:25 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 39 (Regional Nurse Consultant) were present for an interview. Staff 1 and Staff 2 stated staff were expected to follow physician orders and recheck Resident 37's blood sugars on 4/2/22 as necessary to ensure the low blood sugar was trending upward. Staff 2 indicated the physician should have been notified regarding Resident 37's insulin being out of stock on 4/3/22 and inquired how to proceed if they received the insulin from the pharmacy during the shift. , 2. Resident 80 was admitted to the facility in 2021 with diagnoses including right leg amputation, left toe amputation and pressure ulcer. The 5/8/21 physician order indicated Resident 80 was non-weight bearing on the left foot, placed in a pressure relief boot and prevent pressure against the left heel wound. Multiple observations from 5/2/22 through 5/6/22 on day and evening shifts revealed Resident 80 did not have a pressure relief boot on her/his left foot. On 5/4/22 at 2:45 PM Resident 80 stated staff did not place her/his pressure relief boot on while she/he was in bed or in her/his wheelchair for months. A review of Resident 80's clinical record from 4/1/22 through 5/6/22 did not reveal Resident 80's pressure relief boots were placed on her/him while in bed or in her/his wheelchair. On 5/6/22 at 11:47 AM Staff 16 (RCM/LPN) acknowledged there was no documentation to reveal Resident 80's pressure relief boots were placed on her/him from 4/1/22 though 5/6/22.

•Provider aware of resident 37s blood sugar trends no changes to current orders. •All diabetic patients have been audited to ensure that hypo / hyperglycemia protocols are in place. •Education will be provider to clinical staff on signs and symptoms of hypoglycemia and Diabetic Management. •Audit weekly for 4 weeks and monthly on all hypo or hyperglycemic residents have documentation that reflects protocols for Diabetic Management. The results of this audit and any concerns will be brought to QAPI.

Based on observation, interview and record review the facility failed to assess, monitor and follow physician orders that were consistent with professional standards of practice for 1 of 4 sampled residents (# 37) reviewed for pressure ulcers. Resident 37 had a worsening wound. Findings include: Resident 37 was admitted to the facility in 8/2020 with diagnoses including diabetes and stroke. A revised care plan dated 10/25/21 indicated Resident 37 had an ADL self-care performance deficit and limited mobility related to stroke, morbid obesity and depression. Resident 37 required two-person assistance with bed mobility and repositioning. Resident 37 was at risk for impaired skin integrity and staff were to consult the wound nurse as appropriate. Resident 37 was readmitted on 4/25/22 with diagnoses of MRSA (methicillin resistant staphylococcus). A 4/25/22 Admission Nursing Database revealed Resident 37's BIMS was 15 indicating she/he was cognitively intact. Resident 37 had a right heal blister. The length was 2.0 cm by a width of 1.5 cm. The blister was intact with brown edges. A physician order dated 4/25/22 directed staff to protect the blister by covering with Meplilex (a border dressing), and change the dressing every three days on Mondays and Thursdays. Staff were directed to keep the heel offloaded from the bed surface at all times and were to use a green offloading boot or pillow. -There was no clinical documented evidence of weekly wound assessments for Resident 37's and the care plan was did not direct staff to offload her/his right heel. On 5/2/22 at 10:20 AM and 5/5/22 at 11:06 AM Resident 37 stated she had a wound on her/his right heel and was not sure how she/he acquired it. Resident 37 stated she/he was to have a heel protector on her/his right foot when in bed but it was was not always done. Resident 37 stated she/he only had her/his right heel bandage changed one time that she/he could recall. Random observations on 5/4/22 from 12:43 PM through 3:00 PM revealed Resident 37 was in bed and her/his right foot was resting on the mattress without a boot protector or pillow underneath the right foot. On 5/5/22 at 11:14 AM Resident 37 was in bed with her/his right foot uncovered, her/his right foot was rolled outward as she/he tried to lift her/his foot, her/his heel stuck to the sheet. Resident 37's right heel was not bandaged the wound was nickel size, red in the center and white around the outside edges of the wound. On 5/5/22 at 3:11 PM Staff 26 (RCM/LPN) entered the room and acknowledged Resident 37's right heel was not offloaded. Staff 26 described the wound and indicated a circle at the base of her/his right heel, the wound was reddish/purple and the outer portion was white, not hot or warm, no drainage to the wound and Resident 37 indicated the wound was not painful. On 5/5/22 interviews were completed with Staff 27 (CNA) at 12:30 PM, Staff 32 (CNA) at 2:39 PM and Staff 31 (CNA) at 2:56 PM. All stated Resident 37 was dependent for bed mobility and repositioning in bed. Staff stated they were not aware of and wounds on Resident 37 except for her/his incision site from a previous fall. On 5/5/22 at 3:25 PM Staff 26 (RCM/LPN) acknowledged Resident 37's wound was not monitored appropriately. The right heel wound did not have a dressing on it, was not offloaded while the resident was in and Resident 37 was not placed on weekly wound rounds. A Skin and wound Evaluation on 5/6/22 revealed Resident 37 had a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) and was present upon admission. The wound area measured 2.1 cm squared by 1.7 cm in length by 1.8 cm in width. On 5/9/22 at 11:25 Staff 1 (Administrator) and Staff 2 (DNS) expected staff to complete thorough skin audits upon admission or re-admission, ensure weekly skin and wound rounds were initiated and completed, the care plan to be reflective of Resident 37's skin integrity and staff to follow the care plan.

•Resident 37 has wound orders, care plan, Kardex in place. Followed on weekly wound rounds with united wound healing. •Current residents with pressure ulcers have been audited to ensure that they are being followed on weekly wound rounds and skin impairment is care planned appropriately. •Education provided to clinical staff regarding working as a team to identify new pressure ulcers and the importance of notifying the RCM to start following the resident on weekly wound rounds and to implement prevention and treatment strategies. •Skin checks to be done on admission, re-admission and with a second check by an RN within the first week. •Medical records will ensure that weekly skin checks are scheduled with 72 hours of admission. •Audits done weekly for 4 weeks, and monthly to ensure that the re-admission, admission, and the RN skin checks are being completed. The results of this audit and any concerns will be brought to QAPI.

Based on interview and record review the facility failed to ensure a resident was transferred safely for 1 of 2 sampled residents (#37) reviewed for accidents. Resident 37 sustained a fracture to her/his left femur. Findings include: Resident 37 was admitted to the facility in 8/2020 with diagnoses including diabetes and stroke. A revised care plan dated 10/25/21 indicated Resident 37 had an ADL self-care performance deficit and limited mobility related to stroke, morbid obesity and depression. Resident 37 required two-person assistance with bed mobility, repositioning and required a mechanical lift for transfers. A Fall Incident Report dated 3/27/22 revealed the following: -Resident 37 was being transferred from her/his bed to her/his wheelchair by Staff 28 (CNA) and Staff 29 (CNA) and the mechanical lift tipped over during the transfer. -Staff 28 indicated while transferring Resident 37, the mechanical lift legs were partially open to allow her/his wheelchair to fit as close to her/him as possible and Resident 37 was sideways in the mechanical lift directly above her/his wheelchair which was also sideways. When Staff 28 and Staff 29 pulled up the straps on the back of the mechanical lift to get her/him positioned correctly the entire mechanical lift tipped over sideways. -Staff 29 indicated while transferring Resident 37 she/he was hooked up to the mechanical lift and the mechanical lift legs were partially opened to get her/him as close to her/his wheelchair as possible. Resident 37 was sideways directly above the wheelchair when Staff 28 and Staff 29 pulled her/him back her/his weight shifted towards the bathroom and the mechanical lift just fell on top of her/him towards the bathroom and Staff 29 tried to push the mechanical lift out of the way but could not catch the lift in time. -The mechanical lift legs were not in a locked position and were not fully open when the mechanical lift tipped over onto Resident 37. The mechanical lift was rated for Resident 37's weight. -Resident 37 was on the floor and her/his head was against the bathroom door and the mechanical lift was pressed on top of her/him. -Staff 17 (LPN) assessed Resident 37 for injuries once the mechanical lift was removed off her/him. Resident 37 was yelling and screaming throughout the assessment and her/his pain level was 10 out 10. Resident 37 bumped her/his head during the fall, complained of pain to her/his left knee and left hip and her/his right great toenail was partially off and bleeding. -Resident 37 was sent to the hospital which revealed she/he had fractured her/his left leg. A 5/1/22 Plan of Correction revealed the following: -A facility incident report was completed regarding the 3/27/22 incident which revealed Resident 37 was being transferred from her/his bed to her/his wheelchair by Staff 28 (CNA) and Staff 29 (CNA) and the mechanical lift tipped over during the transfer. The mechanical lift legs were not in a locked position and were not fully open when the mechanical lift tipped over onto Resident 37. The mechanical lift was rated for Resident 37's weight. Resident 37 fractured her/his leg due to the fall. -All staff were educated and completed competencies regarding safe transfers. -Continued education occurred at the all staff meetings, CNA meetings and the Hoyer lift manufacturer training video was viewed at the meetings. -The results of the weekly audits completed were brought to Quality Assurance and Performance Improvement and further audits would be completed as directed. On 5/2/22 at 10:27 AM Resident 37 stated she/he had fractured her/his left leg due to a transfer in the mechanical lift. Resident 37 stated two CNAs were transferring her/him from her/his bed to her/his wheelchair and the whole lift "tipped over" and she/he was still in the "sling" when she/he hit the floor. Resident 37 stated staff got her/him unattached from the sling and moved the mechanical lift off her/him and her/his entire left side was "very painful." Resident 37 stated she/he was sent to the hospital and x-rays confirmed she/he broke her/his left femur as a result from the mechanical lift fall. On 5/6/22 at 11:28 AM Staff 28 stated she assisted with the transfer on 3/27/22 for Resident 37. Staff 28 stated she was behind the mechanical lift and had the control in her hand. Staff 29 was the other CNA in the room and Staff 29 was repositioning Resident 37 while in the sling to get her/him in the wheelchair. When Staff 29 pulled on the sling, the mechanical lift fell over on top of Resident 37. Staff 28 stated she remembered the legs of the mechanical lift being partially opened and one of them she thought was in a "locked" position. Staff 28 stated Resident 37 was still attached in the sling when the mechanical lift fell on top of her/him. Staff 28 stated Resident 37 was "crying in pain and yelling her/his leg hurt" and she/he did not want to be on the floor. Staff 28 stated Staff 17 entered the room, assessed her/him and the mechanical lift was pulled off Resident 37. On 5/9/22 at 9:36 AM Staff 29 stated she assisted with the transfer on 3/27/22 for Resident 37. Staff 29 stated Resident 37 was in the mechanical lift moving her/him from the bed to the wheelchair when Staff 28 (her CNA partner) pulled Resident 37 towards her, the mechanical lift tipped over on the floor and was on top of Resident 37. Staff 29 did not recall if the mechanical lift legs were locked or open because it "happened so fast." Staff 29 stated Resident 37 had some blood to her/his toe and landed on her/his left side. On 5/9/22 at 10:01 AM Staff 17 stated she was in the building working at the nurses' station on 3/27/22 when she heard a "loud crash" and entered Resident 37's room, and found her/him on the floor with the mechanical lift on top of her/him. Staff 17 stated the mechanical lift legs were not fully opened and they were not in a locked position causing the mechanical lift to tip over. Staff 17 stated Resident 37 was "hysterical, talking fast and swearing." On 5/9/22 at 11:25 AM Staff 39 (Regional Nurse Consultant) stated he was in the building when Resident 37 had her/his fall on 3/27/22. Staff 39 stated he entered the room and Resident 37 was up against the bathroom door and complained of pain to her/his left side. Staff did move her/him away from the bathroom door and she/he was having "increased pain" to her/his left leg. Staff 39 stated Staff 28 and Staff 29 were doing a "side transfer" with Resident 37 and should not have attempted the transfer. Staff 39 further stated the mechanical legs were not fully open or in a locked position when attempting to place Resident 37 in her/his wheelchair.

Based on observations, interview and record review it was determined the facility failed to provide respiratory care and services in accordance with physician orders for 1 of 1 sampled resident (#76) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: Resident 76 was admitted to the facility in 4/2022 with a diagnosis including COPD (Chronic obstructive pulmonary disease). A review of hospital signed physician orders Summary of Care Document revealed no physician orders for oxygen administration. A 4/7/22 Admission Nursing Database revealed Resident 76 had difficulty breathing, was on oxygen at two liters per minute through nasal cannula (a device used to deliver supplemental oxygen). A 4/11/22 Admission MDS revealed Resident 76 was administered oxygen. A review of Resident 76's care plan revealed no documentation of her/his respiratory status, goals or interventions. A review of the 4/2022 MAR and TAR revealed no treatment was in place for Resident 76's oxygen administration. A "O2 [oxygen] Sats" [saturation] Summary Report from 4/7/22 through 5/5/22 at 1:09 AM revealed Resident 76's oxygen saturations were checked 85 times with 59 instances of her/his oxygen saturations being checked while she/he was administered oxygen via nasal cannula. No documentation was found in clinical records to indicate Resident 76 had physician orders for her/his specific respiratory care needs, for the cleaning of the oxygen filter or replacement of the tubing. On 5/2/22 at 8:38 AM, 5/4/22 at 9:20 AM and 5/4/22 at 11:45 AM Resident 76 was observed with a nasal cannula in place receiving oxygen from an oxygen concentrator (a medical device that provides oxygen). Resident 76's oxygen concentrator filter was observed with a layer of dust and no date was found on Resident 76's tubing to indicate when the tubing was last changed. On 5/5/22 at 12:53 PM Staff 5 (RCM/LPN) confirmed Resident 76 did not have specific physician orders for her/his respiratory needs in place.

•Resident 76 has discharged from the facility. •Residents currently using oxygen have been audited to confirm that they have active orders for oxygen use, and equipment cleaning and maintenance. •Education provided to clinic staff regarding oxygen treatment and management. •Audit 5 residents using oxygen weekly for 4 weeks, and monthly to confirm that oxygen orders and equipment management is in place. The results of this audit and any concerns will be brought to QAPI.

Based on interview and record review it was determined the facility failed to ensure physcian orders were reviewed and signed by a physician for 1 of 4 sampled residents (#15) reviewed for pressure ulcers. This placed residents at risk for unassessed medical needs and adverse side effects of medication. Findings Include: Resident 15 was admitted to the facility in 7/2021 with diagnoses including diabetes and a leg fracture. During a review of the resident's clinical record on 5/3/22 no physician signed orders were found. On 5/9/22 at 10:53 AM Staff 1 (Administrator) and Staff 2 (DNS) stated Resident 15's physician had not signed or dated the resident's orders since 10/2021.

•Resident 15 has been discharged from the facility. •Audits done to confirm that 100% of residents have been reviewed to confirm that MD order review dates are scheduled. •Education provided to medical records and RCMs to ensure that the order review date is set up. •Audit done by medical records weekly for 4 weeks and monthly to confirm that re-admission and admissions are set up for physician order reviews. The results of this audit and any concerns will be brought to QAPI.

Based on observation, interview and record review it was determined the facility failed to provide menus which were implemented and to honor resident food choices for 5 of 5 sampled residents (#s 3, 9, 21, 46, and 90) reviewed for dietary needs. This placed residents at risk for unmet food preferences. Findings include: 1. Resident 46 was admitted to the facility in 3/2022 with a diagnosis including fracture of right lower leg. A 3/21/22 Admission MDS revealed Resident 46's BIMS was 14 indicating she/he was cognitively intact. On 5/2/22 at 11:01 AM Resident 46 stated on 4/22/22 she/he obtained her/his breakfast and it had two strips of bacon with nothing else. Resident 46 stated she/he requested eggs, potatoes and toast with the breakfast and did not receive those breakfast items. Resident 46 stated not obtaining all the food requested happened frequently. On 5/4/22 at 12:58 PM a lunch test tray from the kitchen was evaluated. Documented on the menu was chicken, polenta and vegetables. The reviewed lunch tray did not include polenta. On 5/4/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed resident's food trays did not always have what was documented on the menus. 2. Resident 90 was admitted to the facility in 4/2022 with a diagnosis including surgical aftercare. A 4/19/22 Admission MDS revealed Resident 90's BIMS was 15 indicating she/he was cognitively intact. On 5/3/22 at 8:51 AM Resident 90 stated she/he wished the kitchen would read the menu for her/his breakfast she/he received mostly potatoes and no toast. Resident 90 stated half of the time she/he did not receive what she requested on the menu. On 5/4/22 at 12:58 PM a lunch test tray from the kitchen was completed documented on the menu was chicken, polenta and vegetables. The lunch tray did not include polenta as documented on the menu. On 5/4/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed resident's food trays did not always have what was documented on their menus. On 5/9/22 at 10:34 AM Staff 15 (Dietary Manager) stated he continued to have a problem with getting supplies from their supplier. , 3. Resident 3 admitted to the facility in 4/2016 with a diagnoses including cellulitis of the lower legs and lymphedema. A 4/28/22 Quarterly MDS revealed Resident 3's BIMS was 15 indicating she/he was cognitively intact. On 5/3/22 at 8:32 AM Resident 3 stated she/he completed her/his diet menu the day prior but she/he did not always get what she/he requested and it happened frequently. On 5/4/22 at 12:58 PM a lunch test tray from the kitchen was reviewed and on the menu was chicken, polenta and vegetables. The lunch tray did not include polenta which was listed on the menu. On 5/4/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed resident's food trays did not always have what was documented on the menus. 4. Resident 21 admitted to the facility in 10/2017 with diagnoses including diabetes, end stage renal disease and chronic heart failure. A 2/9/22 Quarterly MDS revealed Resident 21's BIMS was 15 indicating she/he was cognitively intact. On 5/2/22 at 11:57 AM Resident 21 stated she/he "never gets the correct food items." Resident 21 stated at times she/he completed her/his own dietary slip for meals or staff would assist but when her/his meals came they were not correct or she/he could not eat the items brought to her/him such as potatoes, salty items and milk. An observation on 5/4/22 at 12:14 PM revealed Resident 21 received her/his meal tray along with her/his dietary slip which indicated she/he requested chicken noodle soup for lunch but instead she/he received potato soup. On 5/4/22 at 12:35 PM Resident 21 stated they served her/him potato soup instead of chicken noodle soup and this "happens all the time." Resident 21 stated she/he talked to staff and dietary staff but continued to receive the wrong items. On 5/4/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed resident's food trays did not always have what was documented on the menus. On 5/5/22 at 2:22 PM Staff 33 (CNA) stated on 5/4/22 the kitchen brought Resident 21 potato soup when she requested chicken noodle soup. Staff 33 further stated this was an ongoing issue with the kitchen. , 5. Resident 9 was admitted to the facility in 2019 with diagnoses including kidney disease. The 4/28/22 Annual MDS indicated Resident 9's BIMS score was 15 which indicated she/he was cognitively intact. On 5/2/22 at 8:07 AM Resident 9 stated she/he did not receive the food she/he ordered. Resident 9 stated she/he did not know what some of the menu items were and had to research them before she/he ordered a meal. On 5/2/22 at 8:57 AM, an observation and interview revealed Resident 9 had a bowl of sausage and two english muffins. Resident 9 stated she/he also ordered eggs and cereal but did not receive those items. Resident 9 stated this occurred daily. On 5/4/22 at 12:58 PM a lunch test tray from the kitchen was reviewed documented on the menu was chicken, polenta and vegetables. On 5/4/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed resident's food trays did not always have what was documented on the menu.

•Resident 3, 9, 21, 46, and 90. Resident 46 and 90 have discharged. Resident 3, 9, and 21 notified of supply chain issues and plans to improve communication. •Facility will continue with the meal manager program to oversee dietary choices and quality. •Education provided to staff regarding assisting resident with food choices. Education provided to the kitchen regarding resident choice and food quality. •Facility will interview 5 residents weekly for 4 weeks, and monthly to confirm that resident choices are being honored. The results of this audit and any concerns will be brought to QAPI.

Based on observation, and interview it was determined the facility failed to ensure proper flavor, palatability and food temperatures were maintained for food trays served from 1 of 1 facility kitchens reviewed for food service. This placed residents at risk for food that was not palatable, or appetizing. Findings include: 1. On 5/2/22 at 11:01 AM Resident 46 stated the flavor of the food was "mediocre to bad" and the week of 4/22/22 through 4/30/22 the flavor was "disgusting". Resident 46 stated she ate yogurt and fruit for two meals because the food was not good and that was the alternative meal, she/he chose but it was not satisfying and did not fill her/him up. On 5/2/22 at 12:30 PM Resident 90 stated sometimes the food was bad and she/he ordered the alternative meal. Resident 90 pointed at her/his lunch and stated she/he was eating the alternative meal as the lunch was not good. On 5/4/22 at 12:58 PM a lunch test tray was delivered to the survey team from the kitchen which contained of the mixed grilled vegetables, and burnt over cooked chicken which was dry and tough. On 5/4/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they did not personally care for mixed vegetables so they could not provide a comment on the flavor. Both Staff 1 and Staff 2 confirmed the chicken was tough. , 2. On 5/2/22 at 11:57 AM Resident 21 stated she/he [never gets the correct food items and yesterday her/his dinner was cold and tasted bad.] Resident 21 stated this was an ongoing issue with the kitchen. On 5/4/22 at 12:58 PM a lunch test tray was delivered to the survey team from the kitchen with mixed grilled vegetables, some burnt and over cooked chicken which was dry and tough. On 5/4/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they did not personally care for mixed vegetables so could not provide a comment on the flavor. Both Staff 1 and Staff 2 confirmed the chicken was tough. 3. On 5/3/22 at 8:32 AM Resident 3 stated she received her/his breakfast and the cream of wheat was "very runny and not good." On 5/4/22 at 12:58 PM a lunch test tray was delivered to the survey team from the kitchen with mixed grilled vegetables, some burnt and over cooked chicken which was dry and tough. On 5/4/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they did not personally care for mixed vegetables so could not provide a comment on the flavor. Both Staff 1 and Staff 2 confirmed the chicken was tough. , 4. On 5/2/22 at 8:57 AM Resident 9 stated The food was cold, the facility did not have warming plates for everyone and the food was burnt. Resident 9 had her/his breakfast in her/his room which had a bowl of burnt sausage and two english muffins which were burnt and hard. Resident 9 stated a week ago she/he ordered a cheese steak sandwich as an alternative for lunch. When Resident 9's sandwich arrived there was still a plastic wrapper on the cheese. On 5/4/22 at 12:58 PM a lunch test tray was delivered to the survey team from the kitchen which contained mixed grilled vegetables and burnt overcooked chicken which was dry and tough. On 5/4/22 at 1:15 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they did not personally care for mixed vegetables so they could not provide a comment on the flavor. Both Staff 1 and Staff 2 confirmed the chicken was tough.

•Facility will continue with the meal manager program to oversee dietary choices and quality. •Education provided to staff regarding assisting resident with food choices. Education provided to the kitchen regarding resident choice and food quality. •Facility will interview 5 residents weekly for 4 weeks, and monthly to confirm that resident choices are being honored. The results of this audit and any concerns will be brought to QAPI.

OAR-411-086-0040: Admission of Residents Advance Dirctive

Refer to F578 ***** OAR-411-086-0060: Comprehensive Assessment and Care Plan Refer to F656 ***** OAR-411-086-0110: Nursing Services: Resicent Care Refer to F684 and F695 ***** OAR-411-086-0104: Nursing Srvices: Problem Resolution & Preventive Care Refer to F686 and F689 ***** OAR-411-086-0200: Physician Services Refer to F711 ***** OAR-411-086-0250: Dietary Services Refer to F803 and F804

Based on interview and record review it was determined the facility failed to provide care and services to maintain grooming and hygiene for 3 of 13 sampled residents (#s 1, 16, and 23) reviewed for ADLs and accidents. This placed residents at risk for poor hygiene. Findings include: 1. Resident 23 was admitted to the facility in 5/2021 with diagnoses including fracture of left hip. A 5/19/21 Care plan indicated Resident 23 had a self-care performance deficit related to limited mobility and weakness with interventions including one person assistance with bathing. A 5/2021 Documentation Survey Report revealed Resident 23 did not receive a shower from 5/26/21 through 5/31/21. A 5/21/21 Admission MDS indicated Resident 23 required physical help with one-person for bathing and it was very important to Resident 23 to choose between tub bath, bed bath, sponge bath or shower. A 6/2021 Documentation Survey Report revealed from 6/1/21 through 6/20/21 no documentation Resident 23 received any type of bathing. No Documentation was found in clinical records Resident 23 received a shower for 26 days from 5/26/21 through 6/20/21. On 1/14/22 Resident 23 stated she/he went approximately a month without a shower. On 1/14/22 at 10:12 AM Staff 7 (CNA) stated in 6/2021 there were a lot of changes in the building and the shower schedules were messed up and Resident 23 was not placed onto the shower schedule. On 1/19/22 at 10:23 AM Witness 8 (Former CNA) stated in 6/2021 residents were not getting showers because of short staffing. Witness 8 stated some staff would document a resident received a shower if they did not have enough time to complete a shower on a resident. Witness 8 stated the level of care of the residents was not what it should be, and staff did not put the effort in to assist in improving the lives of the residents. In an interview on 1/21/22 at 10:18 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would run a report and review Resident 23's showers for 6/2021. Staff 2 stated he knew how shower scheduling was supposed to work and the policy . , 2. Resident 1 admitted to the facility in 10/2018 with diagnoses of stroke and bipolar disorder. A 8/24/20 revised care plan indicated Resident 1 had a self-care performance deficit related to limited mobility and weakness with interventions including two-person assistance with bed baths. A 5/2020 Documentation Survey Report revealed Resident 1 had six opportunities to receive a bed bath and the following was documented: -5/1/20: (RR) resident refused and she/he was (RA) resident was not available. -5/8/20: (RR) resident refused and she/he was (RA) resident was not available. -5/19/20: (RR) resident refused and she/he was (RA) resident was not available. -5/26/20: (RR) resident refused and she/he was (RA) resident was not available. -5/29/20: (RR) resident refused and she/he was (RA) resident was not available. No documentation was found in clinical records indicating Resident 1 received a bed bath in 5/2020. On 1/18/22 at 3:13 PM Staff 44 (CNA) stated she did not recall showering Resident 1 but if a resident refused staff should re-approach the resident two or three times and then report to the charge nurse and they were to follow up with the resident. Staff 44 stated if a resident was not available, they should check in with the resident to reschedule the shower. Staff 44 stated shower sheets were also supposed to be completed but sometimes Staff 44 would forget to complete these on the residents' scheduled shower days. On 1/19/22 at 3:25 PM Staff 14 (CNA) stated he may have given Resident 1 a few showers or bed baths and stated if Resident 1 refused a shower or bed bath Staff 14 should re-approach Resident 1 a couple of times and then report the refusals to the nurse. Staff 14 stated if Resident 1 was not available he would report to the next shift or attempt to reschedule a shower or bed bath with Resident 1. Staff 14 stated if Resident 1 received a shower or not shower sheets were to be completed but at times Staff 14 would forget to complete the shower sheets. On 1/20/22 at 10:18 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 1 did not appear to have received a shower or bed bath in 5/2020. Staff 2 stated he would expect his RCMs to follow up on patterns of refusals or if residents were not receiving a shower. , 3. Resident 16 was admitted to the facility in 6/2021 with diagnoses including aftercare following joint replacement surgery. a. A 6/29/21 Care plan indicated Resident 16 required two staff members at all times for all cares and required one person to provide physical assistance with bathing. An undated Task Schedule revealed Resident 16 was to receive showers on Monday and Thursday. A 7/5/21 Shower Audit form revealed a bed bath was provided and an attempt to shower Resident 16 was to be made the following day. No Documentation was found in clinical records indicating Resident 16 received a shower for ten days from 6/28/21 through 7/8/21. On 1/12/22 at 9:57 AM Resident 16 stated she/he asked for a shower when she/he admitted from the hospital. On 1/12/22 at 3:02 PM Staff 41 (CNA) stated Resident 16 required two person for care and it was difficult at times to find a second person to assist. On 1/14/22 at 10:12 AM Staff 7 (CNA) stated in 6/2021 there were a lot of changes in the building and the shower schedules were messed up. On 1/14/22 at 10:01 AM Staff 34 (LPN-Resident Care Manager) stated there was more resident demand for care during certain times of the day and two person care increased staffing needs. Staff 34 acknowledged showers should have been given as scheduled. b. The 6/29/21 Admission Nursing Assessment revealed Resident 16 was continent of bladder and occasionally incontinent of bowel and used the toilet. On 6/30/21 Physical Therapy Treatment Encounter Notes revealed a 3:00 PM appointment with the patient was declined because Resident 16 was incontinent of urine and was not cleaned up. On 1/12/22 at 9:57 AM Resident 16 stated on 6/30/21 staff were called into the room to assist with her/his toileting, left the room and did not return and she/he urinated in the bed. On 1/12/22 at 2:29 PM Staff 42 (Therapist) confirmed on 6/30/21 around 3:00 PM Resident 16 was assisted out of a wet bed and performed a lower body wash as part of her/his occupational therapy. On 1/12/22 at 3:02 PM Staff 41 (CNA) stated Resident 16 required two person for care and it was difficult at times to find a second person to assist. On 1/14/22 at 10:01 AM Staff 34 (LPN-RCM) stated there was more resident demand for care during certain times of the day and two person care increased staffing needs. Staff 34 acknowledged Resident 16 should not have been left in a wet bed.

1) Resident/s, 1, 16 and 23 have discharged. 2) Resident/s shower days were reviewed with resident/s and charts updated to reflect preferences. Resident/s who need two persons have been identified, CP, Kardex updated. Reviewed two people assist and reassigned for equal distribution on days and evening, assuring staff available and meeting resident/s needs. 3) LN & CNAs educated on showers, refusals and following up. 4) Prior to admission, medical records assigns showers and at 72-hour huddle showers are reviewed for resident preference. Showers Audits will be done weekly by RCM’s and refusals and missed showers followed up on. 5) DNS or designee will audit 5 residents weekly to ensure showers are received as scheduled or documented on appropriately. Audits will continue weekly x4 weeks, then monthly for 3 months. Any issue will be reviewed in QAPI. 6) Administrator and DNS responsible for compliance.

Based on interview and record review it was determined the facility failed to assess wounds, provide care, follow physician orders and keep maggots out of wounds for 1 of 6 sampled residents (#22) reviewed for and non-pressure skin. This placed residents at risk for decline in wounds. Findings include: Resident 22 was admitted to the facility in 12/2020 with diagnoses including cancer to the left chest. A 12/11/20 Care plan indicated Resident 22 had skin impairment to the left chest because of a tumor with interventions including consult wound nurse as appropriate, evaluate skin, and skin care per facility guidelines. A 12/20/20 Admission MDS indicated Resident 22 had a BIMS of 11 indicating moderate impairment. A 6/2021 TAR instructed staff to cleanse Resident 22's wound to the left chest with wound cleanser, pat dry, sprinkle Flagyl (an antibiotic to treat infections) onto wound bed, cover with a dressing and secure with tape every day shift and PRN with a start date of 5/1/21. The TAR indicated the following: - 6/1/21 referred the reader to nurses' notes, -6/4/21 no documentation indicating treatment was administered. -6/7/21 refused -6/8/21 refused -6/14/21 refused -6/15/21 refused -6/16/21 refused -6/24/21 no documentation treatment was completed. -6/27/21 referred reader to nurses' notes. A 6/1/21 eMar Order Note indicated wound care was not completed to Resident 22's wound as there was only one nurse on the unit with no wound care nurse and the evening shift nurse would be notified. No documentation was found in clinical records indicating Resident 22 received wound care for her/his left chest tumor on 6/1/21. No documentation was found in clinical records indicating wound treatment was completed later on 6/4/21. A 6/7/21 eMar Order Note indicated Resident 22 refused wound care and stated, "let me sleep". No documentation was found in clinical records indicating wound treatment was attempted later 6/7/21. A 6/14/21 eMar Order Note indicated Resident 22 refused wound treatment stating it was completed earlier. No documentation was found in the TAR Resident 22 received wound treatment "earlier" on 6/14/21. A 6/15/21 eMar Order Note listed the Resident 22's wound treatment information, with no other documentation listed. No documentation was found in clinical records indicating Resident 22 received wound care for her/his left chest tumor on 6/24/21 and why wound treatment was not completed. A 6/27/21 Progress Note revealed while Staff 6 (LPN) was removing Resident 22's dressing to complete daily wound care, many maggots were found in the wound. Resident 22 was notified of the impairment and asked if it would be okay to still watch TV. A 6/27/21 Skin Impairment Investigation indicated while Staff 6 was removing Resident 22's dressing for daily wound care, many maggots were discovered in her/his lateral side of the wound. Investigatory notes revealed Staff 30 (RNCM) reported Resident 22 was unsure about flies or maggots in the wound. Hospice was notified and cleaned the wound and removed the maggots. The investigation indicated there were no flies in the building and Resident 22's care plan was reviewed and updated. A 6/27/21 eMar Order Note indicated the hospice nurse would complete Resident 22's wound care. On 1/14/22 at 9:34 AM Staff 4 (CNA) stated there were not always dates on Resident 22's left chest dressing when he provided cares to Resident 22. Staff 4 stated the tape around the wound was not secured and the nurses would make several attempts to secure the tape around the wound. Staff 4 stated there were flies in Resident 22's room in 6/2021. On 1/14/22 at 10:06 AM Staff 6 stated when he found the maggots in Resident 22's wound the dressing was intact, but it was impossible to completely seal the wound due to its' size and location. Staff 6 stated he at times, he found the date on Resident 22's wound dressing to be in his handwriting after he had been off for a couple of days so he knew the wound was not treated daily as physician ordered. Staff 6 stated there was a concern with flies in Resident 22's room and he requested to have maintenance fix the flaps in 6/2021 on the windows as some were missing. Also, carbon bags were added to Resident 22's room to assist with reduction of the flies. Resident 22 stated the odor of the wound was attracting the flies. A 1/14/22 email from Staff 30 (RNCM) to Staff 2 (DNS) indicated maggots were first noticed by the wound nurse and reported to hospice on 6/27/21. Hospice then removed the maggots from the wound but they came and went no more than five times total. On 1/18/22 at 8:32 AM Witness 12 (Former CNA) stated, while providing cares to Resident 22 from 1/2021 through approximately 6/2021, at times she would observe no dates or dates which were old on Resident 22's left chest wound dressing. Witness 12 stated she observed flies in Resident 22's room and heard about maggots in her/his wound two instances. Witness 12 stated another nurse came to her to request tweezers to get the maggots out of the wound. On 1/19/22 at 10:34 AM Staff 31 (CNA) stated in 6/2021 there were flies in the Resident 22's room and there were over 200 to 300 maggots in her/his wound which occurred on at least three instances. There were fly traps in Resident 22's room, but they did not get rid of the flies. Staff 31 stated when she cared for Resident 22, she did not observe a date on her/his wound dressing. On 1/20/22 Staff 24 (Maintenance Lead) stated no one ever reported a concern with flies in a resident's room in 6/2021. In an interview on 1/21/22 at 10:12 AM and 6:03 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they would never want a resident to get maggots in their wound. Staff 2 stated he hung up charcoal bags to assist with odor control in Resident 22's room and he did not observe any flies in her/his room. Staff 1 and Staff 2 stated hospice came to treat Resident 22's wound and the documents indicated she/he was refusing to have her/his dressing changed. The documents indicated the maggots only occurred once. Staff 2 verified the screen in Resident 22's room was replaced and no flies were present. Refer to F925

1) Resident 22 has discharged. 2) Reviewed other resident/s in similar situation validating wound care was done, Dr. orders followed, and assessments done in a timely manner. 3) Weekly wound meeting with IDT team continues. 4) DNS or designee will audit wounds for completion of wound care, assessments, and Dr. orders weekly x4 weeks and then monthly for 3 months. Issues will be brought to QAPI 5) Administrator and DNS responsible for compliance.

Based on observation, interview and record review it was determined the facility failed to ensure resident's respiratory equipment was maintained for 3 of 3 sampled residents (#s 2, 34 and 35) reviewed for respiratory care. This placed residents at risk for respiratory issues. Findings include: 1. A public complaint was received and indicated Resident 2's Continuous Positive Airway Pressure (CPAP) machine was not being cleaned. Resident 2 admitted to the facility in 9/2020 with diagnoses including sleep apnea (breathing interrupted during sleep). A 10/25/20 physician order instructed staff to have Resident 2 use a CPAP machine while sleeping, clean the machine in the morning, empty water reservoir and wash Resident 2's face mask. On 1/10/22 at 2:38 PM Resident 2 stated staff did not always clean her/his CPAP machine on a regular basis. On 1/10/22 at 2:52 PM the CPAP machine was observed with approximately a third cup of water in the approximately two cup reservoir. Resident 2's face mask was sitting on top of her/his nightstand next to the CPAP machine and the hose was draped over the towel dispenser and over her/his sink in Resident 2's room. On 1/13/22 at 3:48 PM Staff 46 (LPN) stated Resident 2's CPAP machine should be cleaned daily the water emptied out and the face mask washed and dried. She/he typically hangs the tubing over something. On 1/20/22 at 10:27 AM Staff 2 (DNS) stated he would expect his staff to ensure Resident 2's CPAP machine was being cleaned consistently per physician orders and once the CPAP was clean the parts needed to be placed on a clean surface. 2. Resident 34 was admitted to the facility in 2/2020 with diagnoses of sleep apnea (breathing interrupted during sleep). A 2/19/20 physician order instructed staff to have Resident 34 used the Continuous Positive Airway Pressure (CPAP) machine while sleeping, clean the machine in the morning, empty the water reservoir and wash Resident 34's face mask. On 1/11/22 at 9:30 AM Resident 34's CPAP machine was observed with dust particles covering the top of the machine, the tubing and face mask was still attached to the machine and there was approximately a third cup of water in the approximately two cup reservoir. On 1/11/22 at 9:33 AM Resident 34 stated she/he wore the CPAP at night and staff assisted putting it on her/him. Resident 34 stated she/he thought the CPAP was cleaned but was not sure. On 1/11/22 at 1:57 PM Staff 2 (DNS) entered the room and confirmed the CPAP machine had dust particles on it and had not been cleaned. Staff 2 stated he would expect his staff to follow physician orders regarding cleaning of Resident 34's CPAP machine. , 3.Resident 35 admitted to the facility in 12/2021 with diagnoses including obstructive sleep apnea (breathing interrupted during sleep) and diabetes. The 12/6/21 Nursing Admission Database revealed Resident 35 utilized a CPAP (continuous positive airway pressure) machine. The 12/6/21 signed physician orders revealed Resident 35's CPAP mask was to be washed every morning and the reservoir emptied daily. The Treatment Administration Record revealed from 12/6/21 through 1/9/22 Resident 35 refused the cleaning of her/his mask and care of the machine reservoir. The 12/7/21 care plan indicated Resident 35's physician was to be notified if the resident's behaviors interfered with her/his medical needs. No documentation was found in the clinical record that revealed Resident 35's physician was notified of her/his refusals to clean her/his CPAP machine or mask. On 1/11/22 at 10:44 AM Resident 35 stated she/he utilized the CPAP machine all day long and refused the cleaning of the CPAP machine. On 1/11/22 at 12:48 PM Staff 48 (LPN) stated no options were discussed with Resident 35 related to the cleaning of her/his CPAP machine. On 1/11/22 at 1:34 PM Staff 2 (DNS) stated Resident 35's CPAP mask should be washed daily, the CPAP machine cleaned once per week and the physician notified of the refusals.

1) Resident/s 2, 34, 35 orders, TARS and CPs checked and all reflect the cleaning of machine, empty water reservoir and wash the mask in the AM for CPAPs. Resident 35 has two masks and tubing R/T refusing to take CPAP off. 2) Verified CPs, TAR and orders for residents in similar situation reflect the appropriate cleaning of machine, mask, and reservoir. 3) LN will be in-serviced on the proper cleaning of CPAP machine, mask, and reservoir. Residents using CPAP machines will have TARS, orders, and CP checked on admission and quarterly with quarterly review. 4) DNS or designee will audit CPAPs for cleaning of machine, mask and reservoir. Audits will be done weekly x4 weeks than monthly for 3 months. Any issues will be brought to QAPI 5) Administrator and DNS responsible for compliance.

Based on observation, interview and record review it was determined the facility failed to ensure proper flavor, food textures and food temperatures were maintained for food trays served from 1 of 1 facility kitchens reviewed for food service. This placed residents at risk for food that was not palatable, safe or appetizing. Findings include: 1. On 10/14/20 a public complaint was received and indicated food served at the facility was cold. Resident Council Minutes revealed the following: -9/15/20 nine out of 16 residents indicated the food was too spicy. 12 out of 16 residents would like the Dietary Department to start the Food Committee meetings again. Questionnaires or surveys would be an acceptable substitute for the meeting. -10/14/20 10 out of 13 residents stated they had not received the Food Committee questionnaires per the residents request from the 9/2020 Resident Council meeting. -seven out of 13 residents stated that the food was too dry and difficult to chew and was an ongoing concern that had not been resolved. -12/30/20 seven out of 14 residents stated their meals were not appetizing; (hard to chew, too salty/spicy and or looked strange). -No additional information was provided as to how the facility addressed the dietary concerns. On 1/10/22 Resident 4 indicated she/he only ate two meals a day per her/his request but that at times the food was cold and some items were over cooked. On 1/12/22 at 12:45 PM a sample lunch tray was provided to survey staff and each meal was served on a plate. A regular diet and a pureed texture meal were included. All meals were tasted, and were barely warm but not hot and the food was bland. On 1/12/22 at 12:47 PM Staff 1 (Administrator) and Staff 2 (DNS) tried the lunch meals and stated the meals were warm but not hot and Staff 2 stated the food was bland and did not have any taste.

1) Meal manager program is in place. Will add to the process a test tray which will be tested for appropriate temperatures at the end of tray service and documented. Administrator will have a weekly test tray. Meal Manager participants will be in-serviced about new process and appropriate food temperatures. 2) Palettes for maintaining food temperatures were ordered and were on back order. DM now has confirmation that palettes ordered are on their way. Estimated date of delivery 1/24/22. 3) Resident/s with concerns about food being bland will be interviewed and offered other spices if available. This will also be covered in monthly resident food committee. 4) Administrator or designee will audit meal manager temp checks weekly to ensure appropriate temps are maintained. Audits will continue weekly x4 weeks, then monthly for 3 months. Issues will be brought to QAPI 5) Administrator is responsible for compliance.

Based on interview and record review it was determined residents did not receive a prescribed diet for 1 of 3 sampled residents (#5) reviewed for diet orders. This placed residents at risk for worsening health conditions. Findings include: Resident 5 was admitted to the facility in 2/2020 with diagnoses including esophageal obstruction. A 5/28/21 Admission MDS revealed Resident 5 had a BIMS score of 15 which indicated she/he was cognitively intact. A physician order dated 5/24/21 revealed Resident 5 was on a slick pureed diet texture and to ensure all pureed items were moist and slick. A 6/23/21 Investigation revealed the following: -Staff 39 (LPN) heard Staff 19 (Former CNA) ask Resident 5 if she/he was ok. Staff 39 and Staff 19 entered Resident 5's room because she/he was coughing and vomiting. Resident 5 had a napkin on her/his bed side table that contained small pieces of pecans on top of the napkin. Resident 5 was able to breathe and talk. -Staff 19 stated she walked into Resident 5's room because she heard her/him coughing and Staff 39 walked by as Staff 19 was checking on the resident. Staff 19 stated Resident 5 had pieces of pecans on a napkin and she/he was coughing and vomiting to try and clear her/his throat. -Resident 5 stated the ice cream she/he was eating had pecans in it and caused her/him to choke. Resident 5 tried to clear her/his throat but could feel a pecan was still stuck and she/he could not clear it from her/his throat. -Staff 9 (LPN) was informed Resident 5 had a pecan stuck in her/his throat and could not clear the pecan. Staff 9 entered the room and Resident 5 had attempted to drink some water but spit it back up and Staff 9 encouraged the resident to try and cough the pecan up but was unable to clear her/his throat. Resident 5 was able to talk, her/his breathing was slightly labored and her/his skin was pale in color. -Staff 35 (Director of Rehabilitation) stated she was alerted Resident 5 was given ice cream with nuts in it and was having difficulty clearing her/his throat and was asked to provide assistance until the paramedics arrived. Staff 35 stated she had treated Resident 5 for dysphagia and completed a diet texture assessment. Staff 35 entered the room, and the resident was not in distress and pointed to her/his suprasternal notch as the location of obstruction. The nurse practitioner was alerted and agreed Resident 5 would be sent out to the hospital to aide in the clearance of Resident 5's throat. -The resident was transported to the hospital because she/he was unable to clear her/his throat. -Staff 38 (Dietary Assistant Manager) stated a CNA alerted her that Resident 5 was given the wrong diet texture and was choking. Staff 38 informed the kitchen staff and staff needed to pay more attention to residents diets and textures. -Staff 40 (Dietary Aide) stated she should have kept a closer eye on diets and textures and failed to catch the pecan ice cream being placed on Resident 5's food tray because of her/him being on a pureed diet. -Staff 20 (Former Dietary Aide) stated he was in the kitchen and failed to give the right consistency to Resident 5 when plating her/his food and knew she/he was a pureed diet. Staff 20 stated he was in a hurry and grabbed the wrong ice cream that had nuts in it. -Resident 5 had no injuries from the event and was not in distress but the hospital did have to remove the pecan piece from her/his throat -Resident 5 returned from the hospital on 6/24/21 in stable condition after the removal of the impacted food. A 7/16/21 Plan of Correction revealed the following: -A facility incident report was completed regarding the 6/23/21 incident which revealed Resident 5 received the wrong therapeutic diet, she/he was served ice cream that had pecans in it and Resident 5 was unable to clear the pecans from her/his throat. Resident 5 was sent to the hospital for evaluation and removal of the pecan. Resident 5 returned to the facility on 6/24/21. -All residents that required specific diet textures/pureed were reviewed. Nurse management and Dietary Manager identified residents who were an aspiration risk and ensured they were receiving the appropriate diet and texture. -Dietary staff were educated on appropriate diet, texture and checking dietary slips while preparing meal trays to ensure all residents received the correct diet. -CNAs were educated on confirming the correct diet prior to delivery of the meal and CNAs were educated on following appropriate aspiration precautions for all residents. -Nursing staff was re-educated on aspiration precautions and ensuring staff were delivering appropriate diets to all residents. -To ensure ongoing compliance Staff 2 DNS or designee will complete audits in the kitchen to ensure the correct diet was being served and would complete audits to ensure CNAs were following appropriate guidelines for delivery of food trays. -The results of the weekly audits completed were brought to Quality Assurance and Performance Improvement and further audits would be completed as directed by the committee. An attempt was made to reach Staff 20 (Dietary Aide) on 1/12/22 but the phone number was no longer in service. On 1/12/22 at 9:51 AM Staff 38 (Dietary Assistant manager) stated she recalled the incident on 6/23/21 and a CNA informed her Resident 5 received ice cream with nuts in it, was choking, and Resident 5 was on a pureed diet. Staff 38 indicated the resident was an aspiration risk and was only supposed to receive pureed food items. Staff 38 stated they had a three-person process to ensure residents received the correct diet but on 6/23/21 the kitchen was busy and Staff 20 grabbed the wrong ice cream and failed to double check the ticket. On 1/12/22 at 10:00 AM Staff 37 (Dietary Aide) stated Resident 5 was on a pureed diet and Staff 20 was new to the kitchen and was the last person to check the diet card and he placed the pecan ice cream on Resident 5's lunch tray without checking the ticket. Staff 37 stated they were informed Resident 5 was sent out to the hospital because the pecans got stuck in her/his throat. On 1/12/22 at 10:10 AM Staff 23 (Dietary Service Manager) stated he was present on 6/23/21 and nursing staff alerted him of Resident 5 getting served ice cream with nuts when she/he was on a pureed diet and an aspiration risk. Staff 23 stated kitchen staff were to check the dietary cards as they are plating the meals to ensure the correct diet was being served and this did not occur on 6/23/21. On 1/18/22 at 9:04 AM Staff 39 (LPN) stated she was present on 6/23/21 and a CNA had delivered Resident 5's tray and heard Resident 5 making noise. Staff 39 entered the room and the resident was able to speak but was coughing and could not clear her/his throat. Staff 39 stated she could see nuts at the bottom of Resident 5's ice cream bowl and Resident 5 was on a pureed diet. Staff 39 stated Resident 5 was unable to get the remaining pecans out of her/his throat and she/he was sent out to the hospital. On 1/18/22 at 2:43 PM Staff 19 (CNA) stated she recalled the incident on 6/23/21 and Resident 5 already had her/his lunch tray in the room and she/he was coughing. Staff 19 stated Resident 5 was on a pureed diet but when she entered the room Resident 5 had ice cream and there were pecans in the bowl of ice cream, the resident was able to speak and was not in distress but was coughing. Staff 19 stated Staff 39 assessed the Resident 5 and she/he was sent out to the hospital for further evaluation. On 1/20/20 at 10:08 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 23 acknowledged dietary orders were not followed on 6/23/21 and Resident received the wrong diet.

Based on interview and record review it was determined the facility failed to ensure resident rooms were free from pests for 1 of 6 sampled residents (#22) reviewed for wounds. This placed residents at risk for pest infestation. Findings include: Resident 22 was admitted to the facility in 12/2020 with diagnoses including cancer to the left chest. Review of Work Order Reports from 6/1/21 to 7/1/21 revealed no work orders for removal of flies in the facility or in Resident 22's room. A 6/27/21 Progress Note revealed while Staff 6 (LPN) was removing Resident 22's dressing to complete daily wound care many maggots were found in the wound. On 1/14/22 at 9:34 AM Staff 4 (CNA) stated there was an issue with flies in Resident 22's room. On 1/14/22 at 10:06 AM Staff 6 (LPN) stated when he found the maggots in Resident 22's wound this was reported to Staff 2 (DNS). Staff 6 stated there was a concern with flies in Resident 22's room and he requested maintenance fix the flaps on the windows as some were missing. Also, carbon bags were added to Resident 22's room to assist with reduction of the flies. Resident 22 stated the odor of the wound was attracting the flies. A 1/14/22 email from Staff 30 to Staff 2 indicated Resident 22's maggots were first noticed on 6/27/21. Staff 30 believed it occurred no more than five instances where Resident 22 had maggots in her/his wound. On 1/18/22 at 8:32 AM Witness 12 (Former CNA) stated she had observed flies in Resident 22's room and heard about maggots in her/his wound on two instances. On 1/19/22 at 10:34 AM Staff 31 (CNA) stated in 6/2021 there were flies in the Resident 22's room and she had over 200 to 300 maggots in her/his wound which occurred at least three instances. There were fly traps in Resident 22's room, but it did not get rid of the flies. On 1/20/22 Staff 24 (Maintenance Lead) stated no one ever reported to him about a concern with flies in a resident's room in 6/2021. In an interview on 1/21/22 at 10:13 AM Staff 1 (Administrator) and Staff 2 stated a wound nurse had reported a screen was missing on the window which Staff 2 checked and it had been fixed.

1) Resident 22 has discharged. 2) Resident/s rooms have been checked for pest/s by maintenance and staff. 3) Staff will be in-serviced on the process of reporting any pest issues to maintenance through TELS and Maintenance log book. 4) Caring Partners are done by managers who have been assigned certain rooms. They will be educated to look at the environment and for pests. 5) Maintenance will be informed of any issues R/T pests identified by Caring Partners at stand-up or stand down and if not in TELS it will be put in TELS for tracking at that time. 6) Administrator or designee will audit active TELS entries weekly to ensure any pest reports are handled appropriately. Audits will continue weekly x4 weeks, then monthly for 3 months. Any issues will be brought to QAPI. 7) Administrator and DNS responsible for compliance.

Based on interview and record review it was determined the facility failed to maintain appropriate RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift seven days a week for four of 25 days and a minimum of a registered nurse for one hour per resident per week for one of four weeks reviewed for staffing. This placed residents at risk for unmet assessment and care needs. Findings include: a. The facility's Direct Care Staff Daily Reports revealed from 11/5/20 through 11/30/20 four days out of 25 days reviewed revealed the facility went without eight consecutive hours of RN coverage between the start of day shift and the end of evening shift as follows: -11/5/20, 11/11/20, 11/16/20 and 11/21/20. b. The facility's Direct Care Staff Daily Reports revealed from 6/1/21 through 6/28/21 there were four out of four weeks the facility did not have RN coverage for at least one hour per resident per week for the weeks as follows: -6/1/21 through 6/7/21 with an average of 96 residents for the week and 88 hours of RN coverage. -6/8/21 through 6/14/21 with an average of 100 residents for the week and 64 hours of RN coverage. -6/15/21 through 6/21/21 with an average of 98 residents for the week and 96 hours of RN coverage. -6/22/21 through 6/28/21 with an average of 98 residents for the week and 64 hours of RN coverage. On 1/19/22 at 8:43 AM Witness 9 (Former LPN) stated in 6/2021 the staffing shortage was "horrible" for both CNAs and nurses which would occur more than a couple of times a week. Witness 9 also stated showers and basic ADLS were not completed, medications were late, showers were not given, and meals were late. Witness 9 stated there were also staff who would disappear and take extra-long breaks. In an interview on 1/21/22 at 10:07 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would review documentation to see if a nurse was on the floor who was not counted on the report.

1) Human Resources and Administrator will continue to advertise RN openings and promote facility school reimbursement program for LPNs going to school to become RNs. 2) Staff Development will work with current RNs in facility to restructure positions to allow for increase RN oversight and support on the floor. 3) All Licensed staff and staffing team will be in-serviced on the importance of having 1 RN hour per patient per week. 4) RN staffing will be monitored by the Administrator, or designee, Mon-Fri with Sat and Sun being reviewed on Mon. This will be completed for 30 days or until compliance threshold is met. Results of the audits will be brought to the QAPI team for review. 5) Administrator and DNS responsible for compliance.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing for five of 25 days reviewed for staffing. This placed residents at risk of unmet needs. Findings include: Review of the Direct Care Staff Daily Report sheets from 11/5/20 through 11/30/20 and 6/1/21 through 6/29/21 revealed the facility did not meet minimum CNA staffing requirements for eight shifts on the following days: 11/8/20, 11/14/20, 11/16/20, 11/18/20, 11/19/20, 6/5/21, 6/22/21 and 6/29/21. On 1/19/22 at 8:20 AM Staff 3 (CNA) stated the facility was understaffed in 6/2021. She had been assigned to a bariatric hall alone and there were six residents she could not put to bed after lunch because there was not another staff member who could assist until the next shift. One resident was wet from incontinence and had to have a full clothing change. Another resident was wet and angry because she/he had to wait so long for assistance. Staff 3 stated at times some of the staff would hang out in the break room or go outside a lot to smoke. Staff 3 also stated staff would disappear and not inform their hall partner. On 1/19/22 at 8:43 AM Witness 9 (Former LPN) stated in 6/2021 the staffing shortage was "horrible" for CNAs and nurses which would occur more than a couple of times a week. Witness 9 also stated showers and basic ADLS were not completed, medications were late, showers were not given, and meals were late. Witness 9 stated there were also staff who would disappear and take extra-long breaks and smoke breaks. On 1/19/22 at 10:23 AM Witness 8 (Former CNA) stated in 6/2021 residents were not getting showers because of short staffing. Witness 8 stated some staff would document a resident received a shower if they did not have enough time to complete a shower for a resident. Witness 8 stated the level of care of the residents was not what it should be, and staff did not put the effort into improving the lives of the residents. On 1/19/22 at 10:34 AM Staff 31 (CNA) stated in 6/2021 the facility was short staffed and during that time the residents had twice as many falls, call lights were not answered and one instance when every single call light was on in one hallway and all the lights were red, after they have been on for extended period of time. Call light times would go over 30 minutes a couple of times a week. In an interview on 1/21/22 at 10:07 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would review documentation to see about coverage of CNAs during the above time frame.

1) Current Staffing Director has been trained on the importance of maintaining adequate staff and meeting the staffing minimum requirements. Staff Director will continue to use all means necessary to meet staffing minimums (Ex: Agency, incentive pay, mandating, utilizing CMAs and RAs) 2) Nursing staff will be in serviced on the mandation rules for call ins and the staffing requirements to assure appropriate number of staff to care of the residents. 3) Projected Direct Care Staff Daily Report (SDS0717) shall be brought to daily stand up meeting to ensure compliance, Mon-Fri with Sat and Sun being reviewed on Mon. Documentation of staffing discussions at the daily stand up meeting will be maintained in the staffing binder. This will be completed for 30 days to ensure continued compliance. 4) Staffing Director, or Designee will review Direct Care Staff Daily Report Mon-Fri with Sat and Sun being reviewed on Mon to ensure accurate staffing number. This will be completed for 30 days to ensure continued compliance. Results of the audits will be brought to the QAPI team for review. 5) Administrator and DNS responsible for compliance.

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

Refer to F677, F684, and F695 ***** OAR-411-086-0250: Dietary Services Refer to F804 and F808 ***** OAR-411-087-0100: Physical Environment Generally Refer to F925