Avamere Transitional Care at Sunnyside

On 11/19/25, a public complaint was received by the State Agency, which alleged the facility was understaffed resulting in longer call light wait times. On 12/29/25 at 12:46 PM, Staff 1 (Administrator) stated the facility had between six and seven bariatric residents and confirmed the facility required two additional staff to meet the state minimum bariatric CNA staffing ratios.-á A review of the facility's Direct Care Staff Daily Reports indicated the following dates did not meet the required bariatric CNA ratio for one or more shifts: -10/19/25: 13 staff were required for day shift and the facility had 12 -10/24/25: 13 staff were required for day shift and the facility had 12 -11/2/25: 13 staff were required for day shift and the facility had 12 -11/3/25: 13 staff were required for day shift and the facility had 11 -11/9/25: 13 staff were required for day shift and the facility had 11 -11/10/25: 13 staff were required for day shift and the facility had 12 On 12/30/25 at 10:27 AM, Staff 3 (Staffing Coordinator) confirmed the identified shifts were not staffed to meet the required bariatric CNA ratios.-á

All residents are at risk for this alleged deficient practice. Current staffing levels have been reviewed to ensure the facility is staffed adequately to meet current resident needs. The staffing coordinator was re-educated on appropriate staffing levels. The Administrator will perform audits of grievances, call lights and interview five residents weekly for 4 weeks, then monthly for three months.  Trends will be brought to QAPI for three months or until substantial compliance is reached.

Based on interview and record review it was determined the facility failed to ensure residents were able to be fully informed in language that she/he can understand of her/his health status and participate in health care decisions for 1 of 7 sampled residents (#39). This placed residents at risk for not being able to fully participate in their own health care. Findings include: Resident 39 was admitted to the facility in 8/2022 with diagnoses including hypertension (high blood pressure). A review of Resident 39's care plan initiated in 9/2022 revealed the resident was Spanish-speaking and stated translation services would be available to her/him. On 6/3/25 at 2:02 PM, Resident 39 stated some staff did not take the time to understand her/him and were impatient when she/he tried to communicate her/his needs. On 6/4/25 at 10:15 AM, Staff 5 (LPN) stated on the morning of 6/4/25 Staff 5 observed Staff 6 (CNA) tell Resident 39 to "stop talking" while he was attempting to take Resident 39's blood pressure. Staff 5 stated Resident 39 was trying to explain she/he wanted her/his blood pressure taken with the manual cuff rather than the tower. Staff 6 was not using the tablet translator. On 6/5/25 at 7:36 AM, Resident 39 stated she/he was not respected by staff when they did not bother to understand her/his needs or communicate with the resident when providing care. Resident 39 stated she/he was frustrated because Staff 6 did not understand Resident 39 did not like her/his blood pressure taken with the tower monitor and wanted it taken manually. On 6/6/25 at 8:57 AM, Staff 6 stated he was trying to take Resident 39's blood pressure and Resident 39 was getting very upset because the tower monitor was not reading correctly. Staff 6 stated he was "blunt and straightforward" with Resident 39 and did tell him to stop talking so he could take her/his blood pressure manually. Staff 6 stated he did not use the tablet translator. Staff 6 stated he thought it was unfair to residents that they could not easily communicate their needs when they didn't understand or speak English. On 6/6/25 at 1:04 PM, Staff 2 (DNS) stated staff were expected to use translator tablets. Staff 2 stated she did not provide any recent training on communicating with non-English speaking residents but assumed the training was part of their orientation. Staff 2 stated Staff 6 was placed on leave pending investigation for his interaction with Resident 39.

• Resident # 39 had their care plan updated to reflect interpreter access. • Staff were educated on the interpreter protocol and how to access/use interpreter iPads. • One iPad was relocated to the downstairs nursing station for better access. Residents Potentially Affected: • All residents whose primary language is not English were potentially affected. Systemic Changes: • Staff will be educated by DNS or designee on Avamere’s interpreter policy, including iPad use and storage. • All non-English primary language residents will have their care plans reviewed for interpreter documentation and updated as appropriate. Monitoring / QA: • Administrator or DON/designee will audit 5 residents and 5 staff to ensure care plan is reflective of communication needs and IPAD location and how to use it weekly for 4 weeks, then bi-monthly for 2 months, then monthly for 2 months. • Results will be reviewed in QAPI for 3 months or until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to provide a written grievance resolution or communication with a resident regarding the resolution of a resident's grievance for 1 of 1 sampled resident (#69) reviewed for dignity. This placed residents at risk for unaddressed concerns and grievances. Findings include: Resident 69 was admitted to the facility in 5/2025 with diagnoses including chronic pain and PTSD (Post Traumatic Stress Disorder). Resident 69's 5/24/25 Admission MDS indicated the resident was cognitively intact. The facilities Grievance Policy dated 1/1/17 indicated concerns will be forwarded to the grievance official and appropriate department supervisor for action. The grievance official or department supervisor will contact the concerned resident or representative to inform them of the resolution of their concern. The grievance official and administrator will review the grievance and then forward a copy to the appropriate department manager for action within 72 hours of the receipt. The grievance official and appropriate department supervisor will take immediate action towards resolution of the concern upon receiving a copy of the grievance communication form and will record this action and resolution on the bottom section of the form. The grievance official, administrator or department manager will then contact the concerned party to inform them of the resolution to their concern. On 6/2/25 at 11:02 AM, Resident 69 reported that on 5/28/25 she/he spoke with Staff 2 (DNS) regarding staff not giving her/his pain medication in a timely manner. Resident 69 stated Staff 2 responded by expressing disapproval of residents entering her office to voice complaints about staff. Staff 2 stated she did not have time for this discussion and directed the resident to leave her office. Resident 69 described Staff 2's demeanor as rude and disrespectful. Resident 69 reported feeling she/he was not treated with dignity and respect. Resident 69 stated she/he told two staff members about her/his conversation with Staff 2 and they encouraged her/him to fill out a grievance form and provided one for that purpose. Resident 69 stated she/he completed the grievance communication form handed it to Staff 25 (RN) and she slid it under the administrators office door so they would not be noticed. On 6/4/25 at 9:14 AM, Resident 69 stated staff did not follow up with her/him regarding their grievance. The resident expressed concerns Staff 2 might confront her/him and become upset. Resident 69 also stated Staff 2 did not apologize and she/he felt disrespected. Resident 69 provided a copy of the 5/28/25 Grievance Communication Form which stated the following: The resident reported being prescribed oxycodone (narcotic pain medication) every four hours and alleged nursing staff were an hour late in administering her/his medication. The resident stated they informed a CNA of her/his upcoming physical therapy session and requested the nurse be notified to administer pain medications beforehand. After waiting 45 minutes, the resident reported speaking with Staff 2, who asked the resident to leave her office and expressed disapproval of complaints about the staff. The resident also reported Staff 2 was rude. The resident expressed dissatisfaction with the facilities pain management and rehabilitation services. On 6/5/25 at 8:44 AM, Staff 22 (CNA) stated last week Resident 69 requested pain medication but waited for an hour, as the nurse was attending to another resident and the medication aid was on lunch. Staff 22 noted Resident 69 was in more pain than usual and became upset, and she/he did not want to participate in physical therapy due to the pain. On 6/5/25 at 9:46 AM, Staff 21 (CNA) stated last week Resident 69 became upset because she/he waited over an hour for her/his pain medication. Resident 69 stated she/he talked to Staff 2 and felt like she "lied" to her/him. Staff 21 encouraged Resident 69 to fill out a grievance. On 6/6/25 at 8:02 AM, Staff 24 (Social Service Director) stated she was unaware Resident 69 filled out a grievance and she would follow up with the resident. On 6/6/25 at 8:18 AM, Staff 2 confirmed last week she had a discussion with Resident 69 regarding the resident's concerns about pain medication not being administered in a timely manner. Staff 2 reported she completed a risk management form related to the concern and provided staff education. She further stated the resident did not give her a grievance form and she believed the issue was resolved. On 6/6/25 at 1:08 PM, Staff 1 (Administrator) stated he was not aware Resident 69 submitted a grievance. Staff 1 reported his expectation was for all grievances to be brought to his attention as soon as possible and the resident to be contacted or provided with the investigative conclusion to the grievance. Staff 1 stated he would follow up with Resident 69. On 6/6/25 at 1:28 PM, Staff 25 confirmed around 6:00 PM on 5/28/25, Resident 69 approached her and stated she/he was very upset after a conversation with Staff 2. The resident reported she/he was never spoken to in that manner before and felt disrespected. Staff 25 stated Resident 69 completed a grievance form. Staff 25 stated she had a key to Staff 1's office and placed the grievance form in his mailbox. Staff 25 stated staff did not follow up with her regarding any additional information. On 6/6/25 at 3:00 PM, Staff 1 stated he found the missing grievance. Staff 1 confirmed the grievance process was not followed.

Corrective Action Taken (Completed 6/07/2025): • Administrator located the grievance, met with Resident #69 and apologized. • Staff 2 received coaching on grievance handling and respectful communication. Also met with resident and apologized. • Grievance log updated. Residents Potentially Affected: • No other residents were found to have additional unaddressed grievances. Systemic Changes: • Staff re-educated on grievance policy, including timelines and written response requirements. Monitoring / QA: • Admin or DON will audit all grievances 3 X a week for follow up and conclusion ×4 weeks, Then all grievances X 4 weeks or until substantial compliance is sustained. • Results reviewed in QAPI for 3 months or until compliance is sustained.

Based on interview and record review it was determined the facility failed to provide residents with a written bed hold notification, including reserved bed hold payment, at the time of transfer to the hospital for 1 of 1 sampled resident (#18) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: A review of the facility's Bed Holds and Returns Policy dated 10/2022 stated "residents, regardless of payer source, are provided written notice about these policies [. . .] at the time of transfer." Resident 18 was admitted to the facility in 11/2017 with diagnoses including congestive heart failure, COPD (chronic obstructive pulmonary disease), and respiratory failure. A review of Resident 18's clinical record revealed she/he was transferred to the hospital on 5/27/25. No evidence was found in Resident 18's clinical record to indicate written notice of the facility's bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital. On 6/6/25 at 8:55 AM, Staff 2 (DNS) stated a written bed hold notification was not provided to Resident 18 or her/his representative at the time of transfer to the hospital because her/his payer source was Medicaid. On 6/6/25 at 10:33 AM, Staff 17 (Regional Nurse Consultant) confirmed a written bed hold policy, including reserved payment, needed to be provided to Resident 18 or her/his representative at the time she/he was transferred to the hospital.

Corrective Action Taken: • Resident # 18 has returned to the facility. Bed hold policy reviewed with staff. Residents Potentially Affected: • All residents discharged with an anticipated return are at risk. Systemic Changes: • Nursing and IDT staff will be educated by Administrator or designee on federal Medicaid bed hold standards and notification procedures. Monitoring / QA: • Admin/DON or designee will audit all patients sent to the hospital to ensure a bed hold was offerred and documented for 4 weeks, then 2 readmits weekly for 4 weeks, then 1 readmit weekly for 4 weeks. • Results tracked in QAPI for 3 months or until compliance is reached.

Based on interview and record review, it was determined the facility failed to ensure qualified staff administered medications for one of one facility reviewed for medication administration. This placed residents at risk for receiving medication errors. Findings included: The Oregon State Board of Nursing indicated the title abbreviation CMA is protected by Oregon law and means Certified Medication Aide, not Certified Medical Assistant. The abbreviation CMA could not be used by medical assistants in Oregon. Medical assistants are unregulated personnel and work in outpatient settings under the direction of a physician. The facility's Administering Medications policy, dated 4/2019, indicated only persons licensed or permitted by the state could prepare, administer, and document the administration of medications. A public complaint was received on 3/15/25, which alleged the facility failed to ensure staff were qualified to administer medications to residents. On 6/3/25 at 11:36 AM, Staff 20 (Staffing Coordinator) stated she posted on an agency website the facility needed CMAs to pass medications on day shift. Staff 19 (Agency Medical Assistant) signed up for the shift and passed medications on the first and second floors of the facility. It was not until the end of the day shift the facility realized Staff 19 was a Medical Assistant, not a CMA, and could not administer medications to residents in a nursing facility. On 6/4/25 at 11:51 AM, Staff 2 (DNS) stated Staff 19 told Staff 2 she was a medication aide. Staff 19 passed medications on 3/15/25, on day shift. Staff 2 stated Staff 19 did not pass the medications per established protocols and the nurses questioned her ability, so they looked up her license to find out she was a Medical Assistant not a CMA. On 6/5/25 at 11:06 AM, Staff 19 stated she was told she could administer medications at the nursing facility if she was working under a nurse or physician. Staff 19 stated she had worked eight hours in the facility on 3/15/25. On 6/6/25 at 1:15 PM, Staff 1 (Administrator), Staff 2, and Staff 3 (Regional Clinical Nurse) acknowledged Staff 19 administered medications to residents in the facility. Staff 2 stated the staffing agency was called, and the facility no longer used the staffing agency's services. Staff 2 stated her expectation was for nursing staff to be licensed or certified to work in the facility

Corrective Action Taken (Completed 3/15/2025): • The unqualified agency Medical Assistant was immediately removed from the schedule. • The staffing agency was notified of their mistakenly sending a medical assistant and not a certified medication aide. • Facility Decision was made to no longer utilize CMA’s, in facility from agencies. Residents Potentially Affected: • All residents on this assignment of the staff were at risk of medication errors when unqualified staff administered medications. No adverse outcomes were reported or found during that adverse event. Systemic Changes: • Staffing Coordinator now verifies and documents all credentials in a Credentials Log before scheduling agency staff. Monitoring / QA: • Admin or DNS or designee will audit agency Credential Log for all agency personnel weekly × 2 weeks, then 4 agency staff X 2 weeks, then 4 agency staff X 2 months. • Results will be reviewed in QAPI for 3 months or until full compliance is sustained.

Based on observation, interview, and record review, it was determined the facility failed to provide respiratory care and services under physician orders for 1 of 2 sampled residents (#47) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: Resident 47 was admitted to the facility in 8/2024 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease an airway disease which restricts breathing) and diabetes. The undated facility Oxygen Administration policy and procedures revealed: 1. Verify a physician's order for the procedure. Review the physicians' orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. The 12/24/24 care plan indicated Resident 47 experienced shortness of breath with decreased energy and fatigue. Interventions included learning signs of respiratory compromise, encouraging sustained deep breaths, and monitoring and documenting changes in orientation, increased restlessness, anxiety, and air hunger. Resident 47 was to have oxygen via nasal cannula PRN. O2 Sat Summary (Oxygen Saturation Summary) printed on 6/4/25 revealed from 5/1/25 through 6/3/25, Resident 47's oxygen vitals were checked 45 times, and the resident was documented as being on oxygen via nasal cannula 32 times. Resident 47's 5/16/25 Quarterly MDS indicated the resident was cognitively intact. On 6/2/25 at 12:50 PM, and 6/4/25 at 8:53 AM, Resident 47 was observed in bed with oxygen administered through a nasal cannula. On 6/3/25 at 8:08 AM, Resident 47 was observed in bed with oxygen administered through a nasal cannula. On 6/5/25 at 7:28 AM, Staff 3 (CNA) stated Resident 47 used oxygen while she/he was in bed but did not use it when she/he was up in her/his wheelchair. On 6/5/25 at 9:01 AM, Resident 47 was observed with oxygen administered through a nasal cannula. A review of the Resident 47's clinical record found no documentation of physician orders for oxygen administration, how often the oxygen filter was to be cleaned, checked, or how often the oxygen tubing was to be changed. On 6/5/25 at 10:28 AM, Staff 2 stated Resident 47 did not have any current orders for oxygen.

Corrective Action Taken: • Resident # [redacted] 47 now has an active oxygen order in place. • Full-facility audit conducted on 6/5/25—no unauthorized oxygen found. Residents Potentially Affected: • All residents using oxygen are at risk if orders are not in place. Systemic Changes: • Nurses and CNAs will receive education by the DNS or desginee on the requirement for MD orders for oxygen use. Monitoring / QA: • Admin/DON or designee, will audit all new admits/readmits and conduct weekly room-to-room oxygen use checks to ensure orders are in place for 4 weeks. • Then audit 5 random new admits/readmits for 2 months. • Results will be reviewed in QAPI for 3 months or until substantial compliance is met.

Based on interview and record review, the facility failed to provide appropriate pain management for 1 of 2 sampled residents (#55) reviewed for pain. This placed residents at risk for uncontrolled pain. Findings include: Resident 55 was admitted to the facility in 2/2025 with diagnoses including osteoarthritis of the hip and knee and chronic pain. A 4/16/25 Physician's Progress Note indicated Resident 55 experienced severe osteoarthritis. The recommendation was to continue pain management with PRN acetaminophen. A revised 4/17/25 care plan revealed Resident 55 experienced chronic pain due to gout, and bilateral severe osteoarthritis of the hip. Interventions included attempting non-pharmaceutical interventions before administering pain medications per physician orders and report to the nurse complaints of pain or requests for pain treatment. Resident 55's 5/21/25 Quarterly MDS indicated the resident was cognitively intact. Resident 55 received scheduled pain medication and no PRN pain medications. Resident 55 was in almost constant pain, which affected sleep, day-to-day activities, and therapy frequently. The resident reported a pain level of seven on a scale from 0-10. A 6/2025 MAR instructed staff to administer gabapentin 300 mg by mouth in the afternoon for pain and gabapentin 300 mg two capsules two times a day for pain at 8:00 AM and 8:00 PM. Resident 55 was also ordered to have acetaminophen 500 mg two tablets every 8 hours for pain. Both orders were administered as physician ordered. On 6/2/25 at 12:48 PM and 6/5/25 at 8:51 AM, Resident 55 stated she/he was asking for something to assist with breakthrough pain, but nothing had happened yet. Resident 55 stated there were days when she/he was very painful and needed additional medication. Resident 55 stated she/he took gabapentin and acetaminophen and did not take anything for breakthrough pain. Resident 55 stated she/he put in a request a couple of weeks ago and nothing was done. Resident 55 stated topical creams did not work. No documentation or communication with the provider about pain management was found in Resident 55's clinical record. On 6/5/25 at 11:21 AM, Staff 2 (DNS) stated she could not find any information to indicate the physician was contacted for clarification for the PRN acetaminophen. Staff 2 stated she expected staff to contact the physician to clarify the information in the physician's progress note.

Corrective Action Taken (Completed 6/06/2025): • Physician was contacted for Resident #55, and a revised PRN pain medication order was obtained. • Resident was reassessed, and updated pain interventions were added to the care plan. Residents Potentially Affected: • All residents with pain management needs were at risk if provider communication was delayed. • Facility will audit all current residents to assess for active/ unrelieved pain issues. Providers will be notified to review if issues are identified. Systemic Changes: • DNS or Designee will re-educated Nurses on timely provider notification for unresolved or breakthrough pain and Pain assessments and documentation expectations reinforced during shift report. Monitoring / QA: • DON/designee will review 5 resident pain records to ensure pain is being managed and for notification to MD if not weekly × 4 weeks, then monthly × 2 months. • All findings will be tracked and reviewed in QAPI for 3 months or until compliance is sustained.

Based on interview and record review, it was determined the facility failed to ensure narcotic drug records were in order, and an account of all controlled drugs was maintained for 4 of 4 medication carts reviewed for medication administration. This placed residents at risk for drug diversion. Findings included: On 6/4/25 at 11:14 AM, book four on the South hall's 5/2025 medication cart Narcotic log book revealed 57 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 11:30 AM, book four on the South hall's 4/2025 medication cart Narcotic log book revealed 45 times out of 180 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 11:45 AM, book seven on the North hall's 3/2025 medication cart Narcotic log book revealed 92 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 11:50 AM, book seven on the North hall's 4/2025 medication cart Narcotic log book revealed 82 times out of 180 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 11:55 AM, book seven on the North hall's 5/2025 medication cart Narcotic log book revealed 64 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 12:00 PM, book 14 on the South hall's 3/2025 medication cart Narcotic log book revealed 94 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 12:05 PM, book 14 on the North hall's 4/2025 medication cart Narcotic log book revealed 52 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 12:10 PM, book 14 on the North hall's 5/2025 medication cart Narcotic log book revealed 36 times out of 180 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 12:22 PM, Staff 2 (DNS) verified the missing signatures in the Narcotic books. Staff 2 acknowledged the Narcotic book always needed to be signed by two nurses or CMAs to verify the count was accurate.

Corrective Action Taken: • Facility identified failure in shift-to-shift narcotic count signatures;. Staff designated to pass medications will be in-serviced on requirements of counting narcotics and signing narcotic book. Residents Potentially Affected: • All residents receiving narcotic medications are at risk due to potential for diversion or miscount. Systemic Changes: • Licensed nurses and CMAs will be in-serviced on narcotic count procedures and signature protocols. Monitoring / QA: • Narcotic book audits will be conducted by DNS or designee 5x weekly for 2 weeks, 2x weekly for 3 weeks, weekly for 3 weeks, then monthly for 2 months. • Trends reviewed in QAPI for 3 months or until compliance is sustained.

Based on observation and interview it was determined the facility failed to ensure sufficient supplies were available to ensure a functional and comfortable environment for one of two floors reviewed for environment. This placed residents at risk for an uncomfortable living environment. Findings include: A public complaint received on 2/13/25 indicated the facility failed to provide enough supplies to meet resident care needs. On 6/5/25 at 9:24 AM, Staff 21 (CNA) reported since 2/2025 the facility experienced on-going shortages of bariatric sheets and towels for residents. As a result, residents often waited for clean linens before staff could change their beds. Staff 21 stated she reported these concerns to management however the issues continued to occur. On 6/5/25 at 9:25 AM, Staff 21 confirmed no bariatric sheets or towels were available for resident use in the North Hall linen closet. On 6/5/25 at 9:45 AM, Staff 29 (CNA) stated she looked for towels for a resident and was unable to find any in the North Hall linen closet. She further stated this was a common occurrence and she often searched other areas of the facility to locate linens for all residents. On 6/5/25 at 10:00 AM, Resident 43 stated the facility never had the right size sheets for her/his bariatric bed and the sheets frequently slipped off her/his mattress. Resident 43 also stated the facility frequently ran out of sheets, and she/he waited more than 20 minutes before staff could change her/his bedding. On 6/5/25 at 10:31 AM, Staff 22 (CNA) stated on weekends, the facility always ran out of bed pads and bariatric sheets. She informed the housekeeping management of the issue over the past few months however the facility still did not have enough linens for the residents. On 6/5/25 at 10:57 AM, Resident 31 stated for a period of time, the facility ran out of bariatric sheets several times a week. Resident 31 stated nine times out of 10 the CNA's were unable to make her/his bed until later in the day due to lack of bariatric sheets. On 6/5/25 at 11:16 AM, Staff 30 (CNA) stated the facility had multiple bedbound bariatric residents. Staff 30 reported the facility ran out of bariatric sheets daily, resulting in residents having to wait before their bedding could be changed. Staff 30 stated this made it difficult to provide care particularly on shower days when staff were expected to change resident sheets but often waited for supplies or searched throughout the facility to locate them. On 6/6/25 at 9:45 AM, Staff 27 (Maintenance Director) confirmed over the past several months both residents and staff expressed concerns about not having enough bariatric sheets and towels. On 6/6/25 at 1:19 PM, Staff 1 (Administrator) confirmed he was aware the facility had an ongoing issue with not having sufficient linens to meet the needs of all the residents.

Corrective Action Taken (Completed 6/08/2025): • Emergency order placed for bariatric sheets, towels, and bed pads. Inventory received and distributed to all units. Several bariatric mattresses were noted to have tight fitting sheets, and slightly larger linen was recommended and ordered. 6/19/25 Residents Potentially Affected: • All residents were checked and all beds had appropriate linen on the beds, clean and in good condition. Several bariatric mattresses were noted to have tight fitting sheets. Systemic Changes: • Central supply and housekeeping staff re-educated by administrator on linen par levels and timely restocking. • Administrator and Maintenance Supervisor ordered additional linen and included some larger various sized fitted sheets to ensure that all sizes of mattresses had properly sized linen available. Monitoring / QA: • Admin or designee will audit linen availability on each unit 2× weekly × 4 weeks, then weekly × 2 months. • Results will be reported in QAPI until sustained compliance is reached.

******************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F552 and F585 ******************************** OAR 411-088-0080 Notice Requirements Refer to F628 ******************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F659 ******************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F695 and F697 ******************************** OAR 411-086-0260 Pharmaceutical Services Refer to F755 ******************************** 411-087-0100 Physical Environment: Generally Refer to F921 ****************************************

Based on observation, interview, and record review it was determined the facility failed to ensure residents' rights to a dignified existence for 2 of 5 sampled residents (#s 3 and 15) reviewed for dignity and respect. This placed residents at risk for diminished quality of life. Findings include: 1. Resident 3 was admitted to the facility in 2020 with diagnoses including morbid obesity and depression. A care plan dated 2/1/20, revealed Resident 3 was independent with transferring herself/himself in the room, utilized a bed side commode, and required one-person assistance with toileting hygiene. A Grievance Communication Form Dated 9/30/24, revealed the following: - Resident 3 turned on the call light for help at 12:15 PM. At 12:30 PM, Resident 3 placed herself/himself on the beside commode. At 1:15 PM, her/his roommate went out and asked staff for help. At 1:20 PM, almost one hour after the resident turned on the call light, a CNA entered the room and helped Resident 3 off the bedside commode. -Staff 41 (Former CNA) stated Resident 3 indicated her/his call light was on for 45 minutes and Staff 41 told Resident 3 she was the only one answering call lights because the other CNA was providing another resident a shower after lunch. Staff 41 apologized. -Staff 2 (DNS) indicated Resident 3 was independent in her/his room for the most part and Staff 41 intended to assist Resident 3, but another resident was crying in the hall and was distraught. Staff 41 made a judgement call. -Staff 41 apologized to Resident 3 post incident. Resident 3 was upset and crying and stated, "It wasn't fair." -Staff 2 indicated the long call light did occur. Staff were not ignoring the call light, or Resident 3's needs, because the CNAs were working the best they could. On 1/2/25 and 1/3/25 attempts to contact Staff 41 were unsuccessful. On 1/2/25 at 11:20 AM, Resident 3 was observed sitting on the edge of her/his bed. The resident's bedside commode was adjacent to the bed. A call light was attached to the wall next to the bedside commode. Resident 3 stated she/he completed a grievance form regarding the 9/30/24 incident. Resident 3 stated she/he could get onto the bedside commode herself/himself but needed assistance with wiping. Resident 3 stated she/he sat on the bedside commode for almost an hour without assistance and was "in tears" because her/his bottom hurt from the hard plastic. Resident 3 stated this occurred on more than one occasion and was very frustrating. On 1/6/25 at 2:11 PM, Staff 11 (LPN-Resident Care Manager) stated he spoke with Resident 3 after the incident on 9/30/24, and she/he was upset regarding the incident. On 1/6/25 at 3:39 PM, Staff 2 stated she was aware of the incident on 9/30/24, and Resident 3 was upset from sitting on the bedside commode for an extended period. Staff 2 stated she encouraged the resident to turn her/his call light on sooner when Resident 3 knew when she/he was going to use the commode. 2. Resident 15 was admitted to the facility in 2024 with diagnoses including morbid obesity and anxiety. A care plan dated 8/15/24, and revised on 12/24/24, revealed Resident 15 needed to be supervised when smoking. Resident 15 obtained her/his smoking materials from staff, and returned them when she/he was done smoking. A review of progress notes from 8/30/24 through 9/7/24 revealed Resident 15 was found to have smoking paraphernalia on her/him and was caught smoking while unsupervised. The resident handed over her/his smoking paraphernalia to staff when asked. A Progress Noted dated 9/13/24 at 10:43 AM, revealed the following: -Staff 30 (Former Nursing Student) went into Resident 15's room to provide wound care after the resident returned from visiting with a friend. Therapy was working with the resident. -Staff 30 completed the resident's wound treatment and asked if it was ok if she checked the resident's makeup bag. Staff 30 "requested to check due to patient's friend having history of bringing patient paraphernalia." -Resident 15 agreed to have her/his bag searched, and the therapist was present. Staff 30 found a white oval pill with M367 scripted on one side and a lighter. Staff 30 confiscated the pill, took the lighter, and reported the information to Staff 9 (LPN), who then contacted Staff 2 (DNS). The items were given to Staff 2. -Staff 30 spoke with Staff 31 (Former LPN-Resident Care Manager), who requested staff to do a room search immediately and to check Resident 15 when she/he came back downstairs. -Staff 30 indicated two additional nurses went and searched Resident 15's room and belongings, but no smoking paraphernalia was found. -Resident 15 returned to her/his room and was upset, and yelled at the staff for being in her/his room, saying, "You guys need to get the fuck out of my room. You have no right to be in my fucking room. Get the hell out of here. This isn't right, you can't do this, you need to tell [Resident 15] before you search [Resident 15's] room." -Staff 31 informed Resident 15 staff were doing this per administration's direction and needed to complete a full body check on Resident 15. Staff communicated with the resident about which body part needed to be checked prior to touching the resident. The search was completed, and nothing was found on the resident. -Staff 31 let the resident know she/he did not need to yell and indicated to talk nicely to staff. Staff 31 tried to let the resident know staff already searched the room and the resident did not need to leave her/his room. -Resident 15 proceeded to go downstairs and felt she/he was being targeted by staff due to her/his room being searched without permission. On 1/6/25 at 12:10 PM, Resident 15 was observed in her/his room seated in her/his wheelchair. Resident 15 stated she recalled the 9/13/24 incident and stated a staff person "sniffed" her/his hair upon returning from outside. When the resident returned to her/his room, a staff person approached the resident and asked if she could look into Resident 15's bag, to which the resident agreed. Resident 15 stated they found a Vicodin (pain pill) and a lighter, which the staff member confiscated. Resident 15 stated she/he and the staff person left the room. Resident 15 stated when she/he returned there were multiple staff in her/his room conducting a search. Resident 15 stated "W.T.F., you searched [Resident 15's] room without [Resident 15's] permission." Resident 15 stated she/he was flustered, and staff indicated they needed to complete a "body search." Resident 15 stated she felt coerced and let Staff 31 complete the body search. Resident 15 stated Staff 31 indicated she was told by Staff 1 (Administrator) and Staff 2 the search needed to be completed. Resident 15 stated the staff found nothing on her/him or in the room. Resident 15 stated she/he felt humiliated, targeted, and angry. On 1/6/25 at 12:54 PM, Staff 9 stated she was aware of the incident on 9/13/24 and was directed by Staff 31 to search Resident 15's room and assist with a body search. Staff 9 stated she could not recall if the resident was in the room during the search or if the staff asked the resident's permission to search the room. Staff 9 stated she was not comfortable with the search but did what was asked of her. Staff 9 stated Resident 15 was extremely upset and angry about what happened and felt her/his rights were violated. On 1/6/25 at 3:05 PM, Staff 31 stated she was not involved with the incident but only heard about Resident 15's room search and body search. Staff 31 stated Staff 1 and Staff 2 were aware and followed up regarding the 9/13/24 incident. On 1/6/25 at 4:37 PM, Staff 30 stated Resident 15 had a history of being non-compliant with smoking paraphernalia and had items confiscated from her/him before the 9/13/24 incident. Staff 30 stated Staff 1 and Staff 2 told her to an keep an eye on the resident due to non-compliance with smoking. Staff 30 stated she was in Resident 15's room to provide treatment, and the resident had a purse which was unzipped, in which she saw a lighter. Staff 30 stated she asked the resident if she could search her/his purse and the resident agreed. Staff 30 stated she found a pill and lighter in the resident's purse, confiscated them, and informed Staff 31. Staff 30 indicated she and a couple other staff members were told to search the resident's room and had done so without permission. Resident 15 was out of the room during the search, and no one asked permission to search her/his room. Staff 30 stated upon Resident 15's return, she was extremely upset, stating, "You should not be going through my stuff without my permission." Staff 30 stated Staff 31 informed the resident a body search needed to be completed and Staff 31 conducted the body search. Staff 30 stated Resident 15 was very upset, cursed, and nothing was found in the resident's room or on her/his body. Staff 30 stated the incident made her "very uncomfortable" and she never experienced anything else like it. On 1/6/25 at 4:13 PM and 5:37 PM, Staff 1 and Staff 2 were present for an interview. Staff 1 and Staff 2 stated Resident 15 was non-compliant with smoking paraphernalia, and both were aware of the incident that occurred on 9/13/24. However, both staff stated they were unaware Resident 15's room was searched, or a body search was completed without the resident's permission. Staff 1 stated she expected staff to ask permission prior to searching the resident's room or when conducting a body search.

All residents are at risk for this alleged deficient practice. Residents 3 and 15 still reside in the facility. A facility wide audit will be conducted to ensure that residents feel that their privacy is being honored. Education to be provided to staff regarding resident privacy on 1/20/25. Admin/designee will interview five residents weekly regarding privacy being honored for 4 weeks, then monthly for three months. Trends will be brought to QAPI for three months or until substantial compliance is reached.

Based on observation, interview, and record review it was determined the facility failed to accommodate residents with the correct fit of incontinence briefs for 4 of 13 sampled residents (#s 1, 6, 13 and 15) reviewed for dignity and respect and accommodation of need. This placed residents at risk skin breakdown and discomfort. Findings include: 1. Resident 1 was admitted to the facility in 2015 with diagnoses including diabetes and renal disease. A care plan dated 9/5/23, and revised on 12/5/24, revealed Resident 1 was incontinent of bowel and bladder, and used a brief with tabs, size three extra-large. Staff were to ensure the brief tabs were secure, so they did not scratch the skin, and use barrier cream between skin if tab contact was anticipated. Resident 1 required two-person assistance for bed mobility and one or two-person assistance for a brief change. On 12/27/24 at 1:30 PM, Witness 20 (Complainant) stated Resident 1 was recently switched to a different brief size for incontinence care, and the brief was too small, was tight, and caused red marks on the resident's skin. Witness 20 stated the resident reported concerns to staff, but the resident was still in the smaller brief. Interviews were conducted on 12/30/24 from 12:32 PM through 3:35 PM, with Staff 12 (CNA), Staff 43 (CNA), and Staff 13 (CNA). Staff 12, Staff 43, and Staff 13 stated Resident 1 was incontinent of bowel and bladder and required one or two persons to provide incontinence care. Staff 12, Staff 43, and Staff 13 stated residents were changed over to new brief sizes and Resident 1 complained the new brief was too small, cut into her/his skin, and rubbed uncomfortably. Staff 13 stated Resident 1's previous brief went over the top of the resident's pannus area, but the new sized brief went under the pannus, causing the tabs to rub, and resulting in red skin around the area. Staff 12 stated the new briefs were decided based on height and weight only, and nothing else about Resident 1 was considered. On 12/30/24 at 3:53 PM, Resident 1 was observed in bed. Resident 1 stated she/he was provided a new brief size, and the brief was way too small. The resident pulled down her/his blankets, and lifted her/his pannus, and the brief was visible along with where the tabs attached to the brief. Resident 1 stated the brief was too tight around her/his legs, rubbed on her/him, and was very uncomfortable. Resident 1 further stated she/he spoke with Staff 2 (DNS) and Staff 11 (LPN/Resident Care Manager), but both staff indicated the brief was the correct size based off her/his height and weight and did not allow her/him a different size. On 1/6/25 at 1:48 PM, Staff 11 stated Resident 1 was sized for a new brief based off the resident's height and weight. The brief she/he was fitted for did not recommend a larger brief size, according to the chart. Staff 11 stated he was aware Resident 1 was not comfortable in the new brief and the resident preferred a brief that went over the top of her/his pannus. On 1/6/25 at 3:13 PM, Staff 2 stated all residents were sized for new briefs and she was not sure what size Resident 1 wore prior to the brief change, but the old brief was place over the resident's pannus area. The new sized brief was based on height and weight, and staff were trained on the new brief sizes. Staff 2 stated she was unaware there were concerns regarding Resident 1's new brief size. 2. Resident 13 was admitted to the facility in 2021 with diagnoses including a stroke and anxiety. A care plan dated 3/10/21, and revised on 12/5/24, revealed Resident 13 was frequently incontinent of urine, and used a brief with tabs, size three extra-large. Staff were to assist Resident 13 with incontinent care after each episode. Resident 13 required substantial/maximum to dependent assistance with toileting hygiene. On 12/30/24 at 10:57 AM, Resident 13 stated she/he was very upset due to being placed in a new brief size. Resident 13 stated the brief she/he was fitted for was too small, and was tight around the thighs, and crotch area. Resident 13 stated CNAs could not supply her/him with a bigger brief size because of what her/his care plan indicated. Resident 13 stated, "This is just not right." On 12/31/24 at 9:35 AM Witness 23 (Complainant) stated Resident 13 was recently switched to a different brief size for incontinence care and the brief was too small, tight, and uncomfortable for Resident 13. Witness 23 stated the resident was very upset regarding the new brief and asked for a different size brief but was told the brief fit her/him appropriately and was based off her/his height and weight. Witness 23 stated upper management did not consider Resident 13's waist size or lower body size. Witness 23 further stated upper management told residents they needed to buy their own briefs if the residents were unhappy with the size of brief provided. On 12/31/24 at 2:13 PM, Staff 16 (CNA), and on 1/3/25 at 2:13 PM, Staff 28 (CNA) stated Resident 13 was frequently incontinent of bladder, and required one staff person to assist with her/his incontinent care needs. Staff 16 and Staff 28 stated Resident 13 was extremely upset about the new brief sizes because the new brief was tight around her thighs, and crotch area. Staff 16 and Staff 28 stated to their knowledge, Resident 13 did not have redness or skin breakdown. On 1/2/25 at 2:35 PM, Staff 7 (LPN) stated Resident 13 was very upset regarding her/his brief size change and felt the brief was too small. Staff 7 stated a brief specialist was in the building and assisted with determining the correct brief size for each resident, which was based off height and weight. On 1/6/25 at 3:57 PM Staff 2 (DNS) stated she was aware Resident 13 was upset about the new brief sizing and was focused on the color of the brief. Staff 2 stated the new briefs were determined by height and weight for each resident. Staff 2 stated she was unaware Resident 13 had concerns regarding the brief being too small and uncomfortable. 3. Resident 15 was admitted to the facility in 2024 with diagnoses including morbid obesity and anxiety. A care plan dated 8/15/24, and revised on 12/4/24, revealed Resident 15 required one-person assistance with toileting, and used size two extra large briefs "without tabs." Staff were to ensure the brief was securely fastened. On 12/31/24 at 9:35 AM Witness 23 (Complainant) stated Resident 15 was recently switched to a different brief size for incontinence care and the brief was too small, tight, and uncomfortable for Resident 15. Witness 23 stated the resident was very upset regarding the new brief and asked for a different size brief but was told the brief fit her/him appropriately and was based off her/his height and weight. Witness 23 stated upper management did not consider Resident 15's waist size or lower body size. Witness 23 further stated upper management told residents they needed to buy their own briefs if the residents were unhappy with the size of brief provided. On 1/3/25 at 10:50 AM, Resident 15 was observed sitting in her/his wheelchair, well groomed with no odors. Resident 15 stated she/he required one staff person to assist with toileting and pulling up her/his clothing. Resident 15 stated she/he was switched to a "smaller" brief than her/his prior size and the new brief was way too small. Resident 15 stated it was tight and rubbed on her/his thighs. Resident 15 stated she/he reported concerns to upper management, and was told to buy her/his own briefs and would not be supplied with a larger brief size. Resident 15 stated it was very upsetting. On 1/3/25 at 11:30 AM, Staff 16 (CNA) and at 11:57 AM, Staff 29 (CNA) stated Resident 15 was a one- person assist with toileting but was known to self-transfer. Staff 16 and Staff 29 stated the resident complained of the new brief size change and indicated the briefs were too tight, pinching her/him and the tabs that attach to the brief do not stay adhered. Staff 16 and Staff 29 stated the resident was informed to buy her/his own supplies from upper management because Staff 2 (DNS) would not supply the resident with a larger brief. On 1/6/25 at 4:13 PM, Staff 2 and at 5:37 PM, Staff 1 (Administrator) stated all residents were sized for new briefs and was not sure what size Resident 15 wore prior to the brief change. Staff 1 and Staff 2 stated the new sized brief was based on height and weight, and staff were trained on the new brief sizes. Staff 1 and Staff 2 stated they were unaware Resident 15 was uncomfortable in her/his brief and did not know the resident was buying her/his own supply. , 4. Resident 6 admitted to the facility in 5/2019 with diagnoses including Guillain-Barre Syndrome (a neurological disorder which causes muscle weakness, tingling, and paralysis). A 7/23/24 Wound Evaluation revealed Resident 6 had a Stage 4 pressure wound (a wound that extends completely through all layers of the skin, exposing muscle, tendon, or bone) on her/his coccyx (tailbone). An 8/2/24 Progress Note revealed Resident 6 complained to staff about facility staff using "face towels" to do wound care and the Resident Care Manager requested an order for wet wipes due to Resident 6's skin breakdown. A review of Resident 6's orders revealed no orders for staff to use wet wipes instead of washcloths for incontinence care and wound care on the coccyx. On 12/31/24 at 1:50 PM and on 1/2/25 at 12:58 PM Resident 6 stated the facility staff used washcloths to clean the area around her/his coccyx wound. Resident 6 stated Staff 2 (DNS) had the facility staff use washcloths instead of wet wipes. Resident 6 stated the facility staff used the washcloths for incontinence care currently when the facility ran out of wet wipes and it was painful due to the wound on her/his coccyx area. On 1/2/25 at 2:12 PM Staff 46 (CNA) stated the staff did not have access to enough wet wipes for all the personal care provided daily and the staff were to fill out a slip to request wipes to be delivered by Staff 2 once a day. Staff 46 stated the staff were to use washcloths to do incontinence care for Resident 6 and she/he complained about it being very rough because her/his skin was delicate. On 1/2/25 at 3:49 PM Staff 37 (CNA) stated the facility staff were required to use washcloths for incontinence care and on resident wounds. Staff 37 stated Resident 6 complained about the washcloths being uncomfortable. On 1/6/25 at 12:54 PM Staff 2 stated the facility moved to using washcloths for residents rather than wet wipes for all residents except those with skin breakdown; and those with skin breakdown were added to a list and approved for use of wet wipes. On 1/6/25 at 2:30 PM Staff 2 provided an undated Resident Approved for Wet Wipes List of residents who were approved for wet wipes for incontinence care and stated the facility moved to washcloths on 7/16/24. The Resident Approved for Wet Wipes List revealed Resident 6 was not approved to receive incontinence care with wet wipes until 8/2/24. Staff 2 confirmed Resident 6 should have always been on the list of residents to use wet wipes instead of wash cloths but there was a time staff used wash cloths for incontinence care. Staff 2 reviewed the orders for residents with approval for wet wipes and confirmed Resident 6 did not have an order for the staff to use wet wipes instead of wash cloths.

All residents are at risk for this alleged deficient practice. Residents 1, 6, 13 and 15 still reside in the facility. A facility-wide audit will be conducted to ensure that all residents have been sized correctly for briefs and have an adequate par level for briefs. Education to be provided to staff on checking par levels at the beginning of their shifts on 1/20/25. DNS/designee will stock resident rooms Fridays with wipes with enough supply for the weekend. Emergency backup supply of dry wipes available at all times. DNS/designee will interview five residents weekly regarding sufficient supplies for 4 weeks, then monthly for three months. Trends will be brought to QAPI for three months or until substantial compliance is reached.

Based on interview and record review it was determined the facility failed to notify the physician regarding a change in condition for 1 of 4 sampled residents (#5) reviewed for change of condition. This placed residents at risk for lack of physician involvement. Findings include: The facility's Change in a Resident's Condition or Status Policy Statement dated 2/2021 directed the nurse to notify the resident's attending physician or the on-call physician of a significant change in the resident's physical condition. Resident 5 was admitted to the facility in 10/2023 with diagnoses including Congestive Heart Failure (a chronic condition in which the heart does not pump blood as well as it should) and a below the knee amputation. Review of Resident 5's clinical record revealed the following: - On 10/27/24 Resident 5 had a 4.9 pound weight gain in 24 hours. No evidence was found to indicate the physician was notified. - On 10/29/24 Resident 5 had a 10.2 pound weight gain in the past seven days. No evidence was found to indicate the physician was notified. - On 11/1 Resident 5 had a 4 pound weight gain in 24 hours. No evidence was found to indicate the physician was notified. - On 11/3 Resident 5's had a 3.2 pound weight gain in 24 hours. No evidence was found to indicate the physician was notified. A Nursing Care Note dated 11/10/24 revealed the provider was notified of Resident 5's weight gain - to188.2 pounds [8.4-pound gain in one week]. Resident 5 was sent to the hospital and admitted for evaluation of lower extremity swelling. On 1/2/25 at 2:50 PM Staff 32 (LPN-Resident Care Manager) stated when daily weights were ordered for patients with CHF the nurse was expected to report a weight gain of two pounds in 24 hours or five pounds in a week. Staff 32 stated she did not notify the provider of any weight changes. On 1/2/25 at 3:56 PM Staff 34 (LPN) stated she recalled Resident 5 being upset about her/his weight gain but could not recall the exact date. Staff 34 stated she did not notify the provider of any weight gains. On 1/6/25 at 11:18 AM Staff 2 (DNS) confirmed the physician was not notified for dates identified. Staff 2 stated she expected nursing staff to notify the physician when a resident had weight gain of two or three pounds within a 24-hour period, or if a resident had a five-pound increase within a week. On 1/6/25 at 3:10 PM Staff 42 (Medical Director) stated staff should follow the American Heart Association recommendations and notify the provider regarding a resident who had weight gain of two or three pounds within a 24-hour period, or if a resident had a five-pound increase within a week, which could be a potential sign of worsening heart failure.

All residents are at risk for this alleged deficit practice. Resident #5 has been discharged from the facility. All residents residing in the facility will be reviewed for significant weight gain/loss and that PCP was notified. DNS/Designee to review weights no less than three times a week. Nurses will be educated on the importance of notifying the physician when residents have a change in condition on 1/20/25. DNS/designee will audit multiple residents who have had a change in condition to ensure that the MD was notified. Audits will continue weekly for 4 weeks, then monthly for three months. Trends will be brought to QAPI for three months or until substantial compliance is reached.

Based on observation, interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 4 of 7 sampled residents (#s 1, 2, 3, and 13) and 2 of 2 floors reviewed for call light wait times and staffing. This placed residents at risk for lack of ADL care needs. Findings include: 1. Resident 1 was admitted to the facility in 2015 with diagnoses including diabetes, and renal disease. A care plan dated 9/5/23, and revised on 12/5/24, revealed Resident 1 was incontinent of bowel and bladder. Resident 1 required one or two-person assistance for all ADL care needs and required a mechanical lift for transfers. On 12/27/24 at 1:30 PM, Witness 20 (Complainant) stated Resident 1 had concerns regarding long call light response times, which were 30 minutes or longer. Witness 20 stated the resident called him on multiple occasions when she/he was sitting in a wet and soiled brief. Witness 20 stated ongoing concerns with staffing and long call light response times dated back to July 2024. On 12/30/24 at 12:32 PM, Staff 12 (CNA) and at 3:35 PM, Staff 13 (CNA) stated the resident was dependent on ADL care needs and had concerns with not enough staff to answer call lights. Staff 12 stated Resident 1 sat in wet and soiled briefs for 20 minutes or longer on more than one occasion. On 12/30/24 at 3:53 PM, Resident 1 was observed in bed. Resident 1 stated the facility did not have enough CNAs, which was a concern since the beginning of summer and continued to be an issue. Resident 1 stated call lights were long, at times up to 30 plus minutes. Resident 1 further stated she/he sat in a wet and soiled brief on multiple occasions. On 1/6/25 at 1:48 PM, Staff 11 (LPN-Resident Care Manager) stated Resident 1 had concerns of long call light wait times, since the summer months and was due to being short staffed. On 1/6/25 at 5:22 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware of call lights being a concern and it was an ongoing issue. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner. Staff 1 and Staff 2 acknowledged the facility struggled with appropriate CNA staffing ratios. 2. Resident 2 was admitted to the facility in 2024 with diagnoses including a stroke and depression. A care plan dated 6/28/24, and revised on 7/13/24, revealed Resident 2 was on a toileting program due to mixed bowel and bladder incontinence. Resident 2 required one-person assistance for all ADL care needs. On 12/27/24 at 12:30 PM, Resident 2 indicated she/he needed assistance with toileting due to her/his left sided weakness. Resident 2 stated there were concerns with long call light response times and she/he had sat in a wet and soiled brief for 20 plus minutes once when she/he was first admitted and another episode towards the beginning of December 2024. Resident 2 stated long call light wait times were 20 to 30 plus minutes and was an ongoing concern. On 12/30/24 at 12:32 PM, Staff 12 (CNA) and on 12/31/24 at 2:13 PM, Staff 16 (CNA) stated Resident 2 required assistance with toileting but at times soiled herself/himself because of long call light response times. Staff 12 and Staff 16 stated long call light response times and being short staffed were an ongoing concern. On 12/31/24 at 9:45 AM, Staff 9 (LPN) stated Resident 2 concerns regarding long call light response times and had wet herself/himself on more than one occasion. Staff 9 stated the long call light response times were due to lack of staff which was an ongoing concern. On 1/6/25 at 5:22 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware of call lights being a concern and it was an ongoing issue. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner. Staff 1 and Staff 2 acknowledged the facility struggled with appropriate CNA staffing ratios. 3. Resident 3 was admitted to the facility in 2020 with diagnoses including morbid obesity and depression. A care plan dated 2/1/20, revealed Resident 3 was independent with transferring herself/himself in the room, utilized a bed side commode, and required one-person assistance with toileting hygiene. On 12/27/24 at 10:44 AM, and 1/2/25 at 11:20 AM, Resident 3 was observed sitting on the edge of her/his bed, well groomed. Resident 3 stated there were ongoing concerns with long call light wait times and the facility was short staffed from July 2024 to present. Resident 3 stated she/he could get onto the bedside commode herself/himself but needed assistance with wiping. Resident 3 stated she/he sat on the bedside commode for greater than 20 minutes to almost an hour without assistance, which occurred on more than one occasion and was very frustrating. On 12/30/24 from 11:00 AM, through 3:01 PM, Staff 22 (CNA), Staff 12 (CNA), and Staff 43 (CNA) were interviewed and stated Resident 3 needed assistance with wiping after she/he was on the bedside commode. Staff 22, Staff 12, and Staff 43 stated the resident sat on her/he bedside commode on multiple occasions for greater than 30 minutes. Staff 43 stated Resident 3 was frustrated and upset on those occasions because the bedside commode was uncomfortable. On 1/6/25 at 2:11 PM, Staff 11 (LPN-Resident Care Manager) stated he was aware Resident 3 had concerns with long call light wait times and sat on her/his bedside commode for extended periods of time due to being short staffed. Staff 11 stated call lights and staffing was an ongoing issue. On 1/6/25 at 5:22 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware of call lights being a concern and it was an ongoing issue. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner. Staff 1 and Staff 2 acknowledged the facility struggled with appropriate CNA staffing ratios. 4. Resident 13 was admitted to the facility in 2021 with diagnoses including a stroke and anxiety. A care plan dated 3/10/21, and revised on 12/5/24, revealed Resident 13 was frequently incontinent of urine. Staff were to assist Resident 13 with incontinent care after each episode. Resident 13 required substantial/maximum to dependent assistance with toileting hygiene. On 12/30/24 at 10:57 AM, and 1/2/25 at 12:30 PM, Resident 13 stated call light response times were terrible, CNAs passed by her/his room without answering the call lights, and took upwards of 40 minutes or longer. Resident 13 stated she/he sat in a wet brief on more than one occasion. Resident 13 stated every shift was terrible, but weekends were the worst. On 12/31/24 at 2:13 PM, Staff 16 (CNA) and on 1/3/25 at 2:13 PM, Staff 28 (CNA) were interviewed. Staff 16 and Staff 28 stated Resident 13 reported concerns with sitting in wet briefs on multiple occasions due to long call light response times of 20 to 30 minutes. Staff 16 and Staff 28 stated the resident was upset because it occurred on all shifts, but especially on the weekends. On 1/6/25 at 5:22 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware of call lights being a concern and it was an ongoing issue. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner. Staff 1 and Staff 2 acknowledged the facility struggled with appropriate CNA staffing ratios. 5. A review of the Direct Care Staff Daily Reports from 7/4/24 through 1/1/25 revealed state minimum bariatric CNA staffing requirements were not maintained for 74 of 90 days reviewed for staffing. On 12/27/24 the facility provided lists of residents who: -Required assistance with eating and were considered an aspiration risk: 13 -Required two-person assistance with transfers or mechanical lift: 35 -Required assistance with toileting: 41 -Residents who were incontinent: 52 -Residents who required behavioral healthcare needs: 9 -Residents who required bariatric healthcare needs: 10 Review of Resident Council Notes revealed the following concerns from 6/2024 through 12/2024: June 2024: Call lights were too long on evening shift. July 2024: Call lights response times were horrible especially on weekends. August 2024: Not enough staff on the weekends "so terrible." Call light response times up to an hour wait. September 2024: Call light response time on swing shift were on average 30 to 45 minutes. October 2024: Call light response time on evening shift were 40 plus minutes. Resident 3 utilized call light for assistance off her/his bedside commode and just waits because no CNAs come to assist her/him. November 2024: Long call light response times on evening and swing shift. Residents called out for CNAs and they walked by the room and ignored the residents' call lights. December 2024: Long call lights on evening shift and a resident waited 80 minutes for assistance. CNAs made excuses as to why they were unable to answer call lights timely. Showers were not completed at the scheduled time. Interviews with staff revealed the following: On 12/27/24 at 9:41 AM, Staff 23 (CNA) and at 11:00 AM, Staff 22 (CNA) both stated staffing was terrible. The facility was short staffed all the time since 7/2024 and continued to be a struggle. Staff 22 and Staff 23 stated call lights could be 45 minutes or longer, and residents sat in wet and soiled briefs on multiple occasions. Staff 22 and Staff 23 further stated there was high acuity residents, including bariatric residents, which took more time. Staff 23 and Staff 22 stated wet wipe and briefs were difficult to access, because those supplies were no longer stored in the linen closets and had to be requested and turned into Staff 2 (DNS), which took time away from resident care. On 12/30/24 at 12:32 PM, Staff 12 (CNA) and at 2:20 PM, Staff 21 (CNA), and at 3:35 PM, Staff 48 (CNA) were interviewed. Staff stated they worked on both floors and staffing was not great. Staff 12, Staff 21 and Staff 48 stated the facility was short staffed constantly, as far back as 7/2024 and continued to be short staffed. Both floors had high acuity residents, as well as bariatric residents. Staff 12, Staff 21 and Staff 48 stated residents complained constantly regarding long call light response times, which ranged from 30 to 40 minutes, and residents sat in wet and soiled briefs due to lack of staffing. Staff 12, Staff 21 and Staff 48 stated the linen closets no longer had wet wipes or briefs and they had to request for additional wet wipes when running low or out and request more briefs, which at times made it difficult to provide timely care because CNAs had to turn in a form to Staff 2 (DNS) to receive the supplies, which resulted in longer call light wait times. Staff 12, Staff 21, and Staff 48 stated at times it was difficult to assist with getting residents up timely for meals and showers. Staff 12, Staff 21 and Staff 48 stated the facility was constantly short staffed, management was aware, and weekends were awful. On 12/31/24 at 9:45 AM Witness 23 (Complainant) stated the facility was constantly short staff dating back to 7/2024 and continued struggling to meet the acuity of residents in the building. Witness 23 stated call lights were greater than 25 to 30 minutes at times, depending on how short staffed the facility was. Witness 23 stated residents were very upset regarding lack of care and sitting in soiled briefs. Staff 23 further stated CNAs had to request wet wipes and brief supplies which slowed staff down because CNAs were to turn in a form to Staff 2 before acquiring more wet wipes or briefs. If Staff 2 was not available, the nursing staff had to access the supply room to retrieve more briefs for residents which took away from resident care. On 12/31/24 at 2:13 PM, Staff 16 (CNA) stated he worked on both floors and the lack of staffing went back to during the summer months, and was ongoing. Staff 16 stated the facility was constantly short staffed and call light response times were 15 minutes on a good day. Staff 16 stated residents complained of sitting in wet and soiled briefs and were very upset about lack of staff. Staff 16 stated the summer months were worse. On 1/2/25 at 10:00 AM, Staff 6 (RN) stated the facility struggled with staffing since 7/2024 and it was an ongoing concern. Staff 6 stated call light response times were long, and residents were very upset regarding call light response times. Staff 6 indicated it was difficult for her at times with CNAs not having access to wet wipes or briefs. If a CNA ran out of wet wipes and briefs, they completed a form and turned the form into Staff 2, to receive more supplies. If Staff 2 was not available, she would be responsible to retrieve more briefs from central supply for CNAs, which took time away from her resident care. Staff 6 stated she had never experienced anything like this. On 1/2/25 at 2:03 PM, Staff 19 (CNA) stated being short staffed and long call light response times were an ongoing issue as far back as 7/2024. Staff 19 stated residents sat in wet and soiled briefs for 30 minutes or longer due to being short staffed. Staff 19 stated many residents required two-person assistance or were dependent on ADL care. Staff 19 further stated residents were very upset regarding lack of care being provided. Staff 19 stated management was aware but it continued to be an issue. On 1/6/25 at 5:22 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware CNA staffing shortages dating back to 7/2024 and they continued to work on hiring more CNAs and meeting the appropriate ratios. Staff 1 and Staff 2 acknowledged there were concerns regarding call light response times. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner.

All residents are at risk for this alleged deficit practice. Resident 1, 2, 3, 13 and 15 still reside in the facility. Current staffing levels have been reviewed to ensure facility is staffed adequately to meet current resident needs. The Staffing Coordinator was re-educated on appropriate staffing levels. The Administrator or designee will perform audits of grievances, call lights and interview five residents weekly for 4 weeks, then monthly for three months. Trends will be brought to QAPI for three months or until substantial compliance is reached.

Based on observation, interview, and record review it was determined the facility failed to ensure residents food preferences were honored for 1 of 3 sampled resident (#3) reviewed for food. This placed residents at risk for food lessened quality of life. Findings include: Resident 3 was admitted to the facility in 2020 with diagnoses including morbid obesity and diabetes. A 12/27/24 meal ticket revealed Resident 3 ordered barbecue country ribs, scalloped potatoes, mixed vegetables, fruit salad, two strawberry kiwi juices and two diet lemon sodas. On 12/27/24 at 12:21 PM, Resident 3 was observed eating lunch in her/his room and the meal consisted of barbecue country ribs, scalloped potatoes, and mixed vegetables. The resident received one strawberry kiwi juice and one diet lemon lime soda. There was only one beverage each and no fruit salad delivered with the meal. On 12/27/24 at 12:25 PM, Resident 3 stated she/he did not receive what she/he requested which occurred often. Staff 12 (CNA) was present and acknowledged the resident did not receive what she/he requested, and which was a common occurrence. On 12/31/24 at 8:14 AM, Staff 12 (CNA) delivered Resident 3's breakfast which included a Belgian waffle with syrup, oatmeal, Canadian bacon, scrambled eggs, coffee and one milk. Nothing on the meal ticket was circled and Resident 3 stated she/he did not order any of the breakfast items because the resident was never given the menu on 12/30/24 to be completed. Staff 12 confirmed this happened often because residents were not always given menus the day before. On 12/31/24 at 8:25 AM, Staff 12 stated Resident 3's preferences were often not honored. The resident liked to receive two bowls of Cheerios, a yogurt, and a cup of hot chocolate. On 12/21/24 at 1:26 PM, Staff 25 (Dietary Manager) stated CNAs were responsible to ensure residents completed menus for the next day's meal and turn the menu selection in the day before to ensure residents' preferences were honored. Staff 25 stated she was not aware Resident 3 did not receive what she/he ordered on 12/27/24. Staff 25 stated when a menu selection was not submitted, residents received whatever printed out on the meal ticket. Staff 25 acknowledged she was unaware of Resident 3's preference because she was new to the position and was learning the dietary meal ticket system on the computer.

All residents are at risk of this alleged deficient practice. Resident #3 still resides in the facility. A facility wide audit will be conducted to ensure that residents feel that their food preferences are honored. The Dietary Manager will attend food committee. Staff will be educated on residents right to food preferences on 1/20/25. Admin/designee will interview five random residents regarding food preferences being honored weekly for 4 weeks, then monthly for three months. Trends will be brought to QAPI for three months or until substantial compliance is reached.

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing requirements were maintained for 74 of 90 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: On 12/27/24, Staff 1 (Administrator) provided a list of 10 residents approved for the bariatric rate. Review of the Direct Care Staff Daily Reports from 7/4/24 through 1/1/25 revealed the following dates when state bariatric staffing ratios were not met: -7/4/24 through 7/18/24 for 26 of 45 shifts. -8/13/24 through 8/31/24 for 20 of 54 shifts. -9/20/24 through 9/30/24 for 10 of 33 shifts. -10/1/24 through 10/20/24 for 22 of 60 shifts. -11/15/24 through 11/29/24 for 20 of 42 shifts. -12/20/24 through 1/1/25 for 19 of 36 shifts. On 1/3/25 at 1:45 PM Staff 1 and Staff 3 (Staffing Coordinator) were present for an interview. Staff 1 and Staff 2 acknowledged the failure to meet the state minimum bariatric CNA staffing ratios.

All residents are at risk for this alleged deficit practice. Resident 1, 2, 3, 13 and 15 still reside in the facility. Current staffing levels have been reviewed to ensure facility is staffed adequately to meet current resident needs. The Staffing Coordinator was re-educated on appropriate staffing levels. The Administrator or designee will perform audits of grievances, call lights and interview five residents weekly for 4 weeks, then monthly for three months. Trends will be brought to QAPI for three months or until substantial compliance is reached.

*************************** OAR 411-085-031 Residents' Rights: Generally Refer to F550 *************************** OAR 411-086-0360 Resident Furnishing, Eqyuipment Refer to F558 *************************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 *************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 *************************** OAR 411-086-025 Dietary Services Refer to F806 ***************************

Based on observation, interview, and record review it was determined the facility failed to ensure residents' rights to a dignified existence and self-determination for 1 of 1 sampled resident (#56) reviewed for dialysis. This placed residents at risk for a diminished quality of life. Findings include: Resident 56 was admitted to the facility in 12/2023 with diagnoses including diabetes and end stage kidney disease. On 1/24/24 at 11:50 AM Resident 56 was observed in her/his wheelchair in the hallway talking to Resident 11. Both residents decided to eat lunch together and Resident 56 moved her/his bedside table next to Resident 11's door. Resident 11 received her/his lunch at 11:53 AM and started eating, but Resident 56's meal did not arrive. Resident 56 stated "I never get my meals with the other residents." At 12:00 PM Resident 56 asked Staff 9 (CNA) and Staff 14 (LPN) about her/his lunch and stated "I did not get my breakfast this morning either." Staff 9 told Resident 56 the kitchen lost her/his meal slip and asked Resident 56 what she/he wanted for lunch. Resident 56 requested a burger and tater tots. Resident 11 stated "I want some tater tots too." Staff 9 brought tater tots for Resident 11 at 12:05 PM, but Resident 56 still had no lunch. Resident 56 stated she/he was "hungry" and "frustrated" because she/he wanted to eat her/his lunch with Resident 11. Resident 56 received her/his burger and tater tots At 12:15 PM after Resident 11 was almost finished with her/his lunch. On 1/24/24 at 12:15 PM Staff 9 and Staff 14 stated Resident 56's meal slip was misplaced in the kitchen, which caused her/his breakfast and lunch delivery to be delayed. Staff 9 stated Resident 56 was "upset" about missing her/his meals and not eating lunch with Resident 11. On 1/24/24 at 2:05 PM Staff 13 (Dietary Manager) stated Resident 56's meal slip was misplaced and thought it was on her desk. Staff 13 stated the meal trays and meal slips were supposed to be arranged by room numbers for the hall carts. Staff 13 stated she expected meals to be served timely.

Resident 56 is still in the facility. Residents 56 was interviewed to ensure that dining experience is suitable and did not diminish their quality of life. Current residents are at risk of this alleged deficient practice. Managers were educated on the Meal Manager Program. The Administrator or designee will be doing a daily audit for four weeks and then once a month to make sure that a quality dining experience is being provided. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on interview and record review it was determined the facility failed to promptly respond to grievances and recommendations from the resident council for 4 of 4 months reviewed and ensure clothing and missing personal property were addressed timely for 2 of 3 sampled residents (#s 53 and 56) reviewed for personal property. This placed residents at risk for unresolved quality of life and care issues. Findings include: 1. The 6/2004 Grievance Policy indicated the Activities Director or designee was to complete a grievance form when a global issue was raised at a resident council meeting. The form was to be given to the appropriate department head for follow up and departments were to respond within five days. During a resident group meeting on 1/24/24 at 1:30 PM residents stated facility staff did not consistently respond to suggestions timely or concerns offered by the resident council. Residents indicated they did not feel staff communicated with them effectively and did not feel fully informed of the actions taken in response to their concerns. Resident Council Minutes from 9/2023, 10/2023, 11/2023 and 12/2023 revealed the following resident issues: 9/2023: -Residents felt the return of missing clothing was improved, but there was still a long delay for items to be returned. Laundry services responded a new staff person would start in 10/2023 to assist with laundry services. -Residents reported call light wait times were too long, and CNAs ignored call lights if not "assigned" to them. The staffing coordinator indicated call light audits would be completed, and CNAs were re-educated regarding call light response times and the responsibility of all CNAs to answer call lights. -Residents requested more board games and physical games, such as ping pong. The activities department did not respond regarding the suggestion. 10/2023: -Residents reported call light response times were "sometimes 45 minutes" and CNAs told residents they did not have enough staff in the building. The staffing coordinator indicated they were actively recruiting to help with appropriate coverage. They also sent out alerts in staff meetings and staff huddles to remind CNAs about call light response times. 11/2023: -Residents reported clothing items were missing for a few residents. Laundry services indicated they would be on the lookout for the clothing items. -Residents felt like call light wait times were "still too long." CNAs stated "they are not your CNA and can't help." The staffing coordinator indicated CNAs would be re-educated regarding answering call lights timely, and all CNAs were to answer call lights even if not assigned to the resident/section. 12/2023: -Residents reported ongoing concerns about not getting clothing items back and their clothing items not being labeled. Laundry services indicated they were short-staffed and doing their best to get clothing items returned as quickly as possible. On 1/24/24 at 1:54 PM Staff 15 (Social Services Director) stated a grievance was to be completed for missing clothing items and she then attempted to locate the missing items. If a missing clothing item was not found it was replaced, and grievances were addressed within five days. Staff 15 stated residents complained about delays in getting their clothes back timely and Staff 12 (Account Manager) handled laundry services. On 1/24/24 at 2:20 PM Staff 12 stated she was in charge of laundry services and was short-staffed for a couple of months. Staff 12 stated she had trouble with laundry services, including residents' clothing items. Staff 12 stated clothes should be sorted, washed and returned to residents in two or three days, but clothes took more than seven days to return to residents. Staff 12 further stated she had some racks of unidentified clothes in laundry services, but did not have time to sort them. On 1/25/24 at 10:26 AM Staff 11 (Activities Director/Central Supply) stated she took notes during resident council and placed the completed forms with identified concerns in each department heads' mail box to address, and each department had three to five days to respond to the concern. Staff 11 stated once a response was completed from each department, the forms were given to Staff 1 (Administrator) to review. On 1/25/24 at 12:32 PM Staff 1 and Staff 2 (Interim DNS) stated they were aware of concerns with laundry services. Staff 1 stated they were collaborating with laundry services to resolve the staffing concern and the delays in returning clothes to residents. Staff 1 stated he expected grievances, including resident council concerns, to be followed up on as soon as possible, but typically it took five business days to complete. Staff 1 and Staff 2 stated they were aware of staffing issues and were actively working on ensuring call light response times were addressed and all staff were responsible for answering call lights, not just CNAs. 2. Resident 56 was admitted to the facility in 12/2023 with diagnoses including diabetes and end stage kidney disease. On 1/22/24/24 at 10:30 AM and 1/24/24 at 9:09 AM Resident 56 stated laundry services was short staffed and she/he had missing clothing items for approximately three weeks including shirts, pants and bras. Resident 56 stated she completed paperwork regarding the missing items but no one followed up with her/him and the clothing items had not been returned. On 1/24/24 at 9:33 AM Staff 9 (CNA) stated Resident 56 reported she/he was missing shirts, pants and bras. Staff 9 stated laundry services were slow and there were concerns with clothing items not being returned timely for Resident 56. On 1/24/24 at 1:54 PM Staff 15 (Social Director) stated she was unaware of Resident 56's missing clothing items and a grievance was to be completed for the missing items. Staff 15 stated residents complained about delays in getting their clothes back timely and Staff 12 (Account Manager) handled laundry services. On 1/24/24 at 2:20 PM Staff 12 stated she was in charge of laundry services and was short staffed. Staff 12 stated she had trouble with laundry services, including residents' clothing items. Staff 12 stated clothes should be sorted, washed and returned to residents in two or three days, but clothes took more than seven days to return for residents. Staff 12 further stated she had some racks of unidentified clothes in laundry services, but did not have time to sort them. On 1/25/24 at 12:32 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated they were aware of concerns with laundry services. Staff 1 stated they were collaborating with laundry services to resolve the staffing concern and the delays in returning clothes to residents. 3. Resident 53 admitted to the facility in 4/2023 with diagnoses including malnutrition. On 1/22/24 at 11:23 AM Resident 53 stated three to four months ago her/his property was placed in the hallway while the flooring was replaced. During that time she/he saw two residents going through her/his property. Resident 53 stated she/he was missing a cell phone when the property was returned to her/his room. Resident 53 stated a grievance form was completed and she/he did not receive a response from facility staff regarding the missing cell phone. Resident 53's 4/16/23 Inventory of Personal Property indicated the resident had a cell phone. On 1/25/24 at 1:52 PM Staff 15 (Social Services Director) stated when she received a grievance form from a resident who was missing a personal property item she delegated the grievance to the appropriate facility staff, such as Staff 12 (Account Manager) or Staff 1 (Administrator). Staff 15 stated she received a grievance form from Resident 53 about a missing cell phone. Staff 15 stated she delegated the grievance form regarding Resident 53's missing cell phone to Staff 1. Staff 15 stated she was unable to locate the grievance form related to Resident 53's missing cell phone. On 1/25/24 at 1:57 PM Staff 1 (Administrator) stated he was unaware of Resident 53's missing cell phone, had not received a grievance form, and therefore the resident's missing item was not investigated.

Resident 53 has had their clothing returned/reimbursed. Resident 56 has had their cell phone replaced. Resident council issues identified previously are currently being monitored and improved through IDT processes. Current residents are at risk of this alleged deficient practice. The facility is utilizing a labeling machine for resident clothes to prevent them from going missing. Social Services and Activities were educated on the policies and procedures for both Resident Council and Grievances. The Administrator or designee will be doing audits of grievances and call lights weekly for four weeks and then monthly to ensure that grievances are being followed up on timely. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on interview and record review it was determined the facility failed to report results of abuse investigations to the State Survey Agency within the required time frame for 2 of 4 sampled residents (#s 34 and 49) reviewed for abuse. This placed residents at risk for abuse. Findings include: A 9/18/23 FRI for abuse involving a verbal abuse altercation when Resident 13 yelled at Resident 34 and Resident 49. The investigation was completed and submitted to the State Agency on 9/26/23 (three days late). On 1/25/24 at 1:59 PM Staff 2 (Interim DNS) acknowledged the facility investigation was not reported to the State Survey Agency within five working days.

Investigation for the altercation between residents 34 and 49 had been submitted to ODHS for review. Current investigations have been reviewed to ensure appropriate reporting and investigation submissions have been completed within required timeframes. Clinical managers were educated on the abuse reporting policy and timeframes for investigations. The Administrator or designee will be doing audits for four weeks and then monthly to ensure that abuse allegations are reported, investigated and turned into the state within the 5 day timeframe. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on interview and record review it was determined the facility failed to provide bowel medications as ordered for 1 of 1 sampled resident (#16) reviewed for bowel care. This placed residents at risk for constipation. Findings include: The facility 10/2020 Bowel Care Protocol indicated the following: -If a resident has not had a bowel movement for three consecutive days, then evening shift was to run a report for residents who did not have a bowel movement. -Day shift was to administer milk of magnesia and if no results, then evening shift was to administer a suppository, if no results then, night shift was to administer a Fleets enema. Resident 16 admitted to the facility in 2019 with diagnoses including dementia. The 12/21/23 physician orders indicated Resident 16 was to receive a bisacodyl suppository every 24 hours PRN for constipation. Resident 16's 12/2023 and 1/2024 bowel records indicated the following days with no bowel movement: -12/29/23 -12/30/23 -12/31/23 -1/1/24 -1/2/24 -1/3/24 (Six days without a bowel movement) -1/8/24 -1/9/24 -1/10/24 -1/11/24 (Four days without a bowel movement) Resident 16's 12/2023 and 1/2024 MARs indicated the following: -12/29/23 through 12/31/23 there was no indication a bisacodyl suppository was offered or administered. -1/1/24 a bisacodyl suppository was not administered because Staff 19 (RN) did not have time to administer it. -1/2/24 a bisacodyl suppository was not administered because Staff 19 did not have time to administer it. -1/3/24 a bisacodyl suppository was administered at 10:49 PM and it was ineffective. -1/8/24 through 1/11/24 there was no indication a bisacodyl suppository was offered or administered. On 1/23/24 at 2:16 PM Staff 19 stated she did not administer the bisacodyl suppository as ordered on 1/1/24 and 1/2/24 because she did not have time. On 1/24/24 at 11:12 AM Staff 2 (Interim DNS) acknowledged Resident 16 did not have a bowel movement from 12/29/23 through 1/3/24 (six days) and 1/8/24 through 1/11/24 (four days), and acknowledged physician orders were not followed and the bowel protocol was not implemented.

Resident 16 has been reviewed for constipation and appropriate changes to bowel care regimen. Current residents on the bowel care list have been reviewed for constipation and appropriate changes to bowel care regimen. Clinical staff will be educated on the importance of monitoring for constipation and following bowel care policy and orders. DNS or designee will audit the bowel care process weekly x4 weeks then monthly. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on interview and record review it was determined the facility failed to address recommendations to promote wound healing for 1 of 2 sampled residents (#37) reviewed for pressure ulcers. This placed residents at risk for delayed healing and worsening of wounds. Findings include: The facility's 8/2020 Wound Management Policy and Guidelines indicated after the initial referral was sent to the Registered Dietitian, facility staff were to follow up on recommendations provided by the Registered Dietitian. Resident 37 admitted to the facility in 9/2020 with diagnoses including dementia and diabetes. The 9/6/23 Annual MDS indicated Resident 37 was at risk for pressure ulcer development. The resident's care plan for pressure ulcers, last updated 1/15/24, indicated the resident was at risk for pressure ulcers due to decreased mobility, incontinence of bowel, and comorbidities including diabetes. A 1/15/24 Progress Note indicated the resident was found to have two open areas on her/his coccyx (tail bone). 1/16/24 and 1/23/24 wound provider notes indicated the resident was assessed for two open areas on the coccyx. The wound provider recommended a house protein supplement twice a day. Resident 37's 1/17/24 Nutrition Review completed by Staff 17 (Registered Dietitian) recommended a house protein supplement twice a day. A review of Resident 37's medical record revealed the house protein supplement was not addressed. On 1/25/24 at 2:21 PM Staff 16 (LPN Resident Care Manager) acknowledged the recommendations on 1/16/24, 1/17/24, and 1/23/24 from the wound provider and Staff 17 were not addressed for Resident 37.

RD recommendations for resident #37 have been implemented. Current residents with wounds and RD recommendations have been reviewed to ensure implementation as appropriate. Clinical managers have been educated about importance of implementing RD recommendations timely when received. DNS or designee will conduct weekly audits for four weeks and then monthly. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on observation, interview, and record review it was determined the facility failed to put services in place to eliminate the risk of elopement for 1 of 1 sampled resident (#48) reviewed for accidents. This placed residents at risk for elopement from the facility. Findings include: Resident 48 was admitted to the facility in 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing problems). A review of Resident 48's progress notes revealed Resident 48 had two prior elopement incidents at the facility on 8/26/22 and 8/27/23. On 9/1/23 Resident 48 received a new diagnosis of vascular dementia. A 9/4/23 Smoking Safety Evaluation revealed Resident 48 was independent to smoke and went to the designated smoking area outside. A FRI submitted on 9/11/23 revealed on 9/10/23 at 2:56 PM Resident 48 eloped from the facility from the smoking area at the back of the building. Resident 48 was located approximately 45 minutes later at a grocery store parking lot adjacent to the facility by Staff 16 (LPN RCM). Resident 48's 9/12/23 Care Plan indicated the resident was at risk for elopement related to high level cognition deficits, and lack of awareness regarding safety of oneself. Interventions included a WanderGuard (wearable monitoring device) on her/his right lower extremity. On 1/22/24 at 2:07 PM Staff 18 (CNA) stated Resident 48 required supervision because she/he attempted to elope in the past. Staff 18 was not sure if Resident 48 wore a WanderGuard, and thought she/he had the WanderGuard attached to her/his wheelchair. Staff 18 was not able to locate the WanderGuard on the wheelchair. On 1/22/24 at 2:12 PM the Surveyor observed Resident 48 did not have a WanderGuard on her/his ankles, wrists, or wheelchair. On 1/22/24 at 2:27 PM Staff 19 (RN) stated she was not sure if Resident 48 was an elopement risk. Staff 19 stated she was unaware of how the WanderGuard system worked and how she would be alerted if the alarm went off. A 1/22/24 progress note by Staff 2 (Interim DNS) revealed Resident 48 did not have a WanderGuard on her/his ankles, wrists, or wheelchair. On 1/26/24 at 11:12 AM Staff 2 acknowledged Resident 48 was a risk for elopement. Staff 2 stated she expected staff to ensure Resident 48 had her/his WanderGuard on her/his right lower ankle per the care plan.

Resident 48 has discharged from the facility. Current residents who wander have been assessed to ensure appropriate interventions are in place. Clinical staff and IDT managers have been educated about elopement mitigation processes including Wander Guard system, Code Pink and how to identify what residents are at highest risk. Maintenance Director or designee will do weekly audits to make sure the Wander Guard system is working. Unannounced elopement drills will occur periodically over the next three months. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on observation, interview, and record review it was determined the facility failed to ensure physician orders related to an ileostomy were followed and implemented for 1 of 1 sampled resident (#53) reviewed for ostomy care. This placed residents at risk for skin breakdown. Findings include: Resident 53 was admitted to the facility in 4/2023 with diagnoses including the presence of an Ileostomy (an artificial opening on the abdominal wall through which waste material passes out of the body from the bowel). Resident 53's 11/21/23 Care Plan indicated the resident was at risk for a potential infection related to an open wound on her/his abdomen, fistula and ileostomy status. Resident 53's Bowel Documentation records from 12/1/23 through 1/25/24 indicated the resident had output from her/his ileostomy which was loose or a diarrhea consistency. The Physician Order Summary as of 1/26/24 included the following order: - Change midline pouch, ileostomy pouch, and mucous fistula (attaches part of the intestine to a surgically created opening on the abdomen) dressing twice a week. - Remove old pouch using adhesive remover. - Clean skin with warm water and wash cloth and pat dry. - Apply skin barrier spray to surrounding intact skin and let air dry. - Cover open wound with silver alginate and 4 x 4 hydrocolloid (dressing that promotes wound healing). - Apply ostomy paste around fistula. - Remove paper backing from fistula pouch, apply and be sure to cut to fit the wound. - Cover the fistula and ileostomy with gauze and tape. On 1/22/24 at 9:35 AM Resident 53 was observed to have a towel covering her/his abdomen taped around the edges. The resident stated she/he used the last ostomy pouch the day before and the facility did not have ostomy pouches available. On 1/22/24 at 1:05 PM a Trauma and Acute Care Surgery wound and ostomy nurse note indicated when Resident 53 managed the pouch change, it leaked and required multiple pouch changes. On 1/23/24 at 1:08 PM Resident 53 stated the facility "still" did not have ostomy pouches available and she/he was noted to have a towel covering her/his abdomen secured with tape. The resident stated the output from the ostomy was burning her/his skin. A review of Resident 53's medical record revealed no indication the resident had: - ostomy supplies available and the resident was without an ostomy bag from 1/21/24 through 1/23/24. - been assessed or educated on the ability to provide self-care and pouch changes for the ileostomy and fistula. - a physician order for PRN changes of the ileostomy and fistula pouches. On 1/23/24 at 1:45 PM Staff 14 (LPN) stated Resident 53 was adamant about performing her/his own ileostomy and fistula care and used up to 12 pouches a week. Staff 14 stated ostomy pouches were not available for the ostomy and kept a towel over her/his abdomen because the facility was out of ostomy pouches. A nursing progress note dated 1/23/24 at 2:04 PM revealed Resident 53 complained of increased abdominal cramps and the pain was not relieved with medications. The doctor was contacted and ordered labs and a urinary analysis. The resident was sent to the hospital at her/his request. A review of hospital records dated 1/23/24 at 10:46 PM revealed Resident 53 was admitted to the hospital with a recurrent bowel obstruction. The hospital records did not indicate the resident had an infection to her/his ostomy, fistula or the skin surrounding these areas. On 1/24/24 at 9:54 AM Staff 16 (LPN) stated Resident 53 independently performed her/his wound care including the change of the ileostomy and fistula pouches. Staff 16 stated the ostomy wound center indicated the resident was only to change the ostomy pouch a few times a week. Staff 16 stated he assessed the resident's wound on 1/23/24 and the wound bed had "a little more slough (contributes to delayed wound healing) this week." Staff 16 stated the resident did not have an ostomy pouch on at the time of the assessment as the facility was out of the ostomy pouches. On 1/24/24 at 11:43 AM Staff 11 (Activities Director/Central Supply) stated Resident 53 went though ostomy pouches and other ostomy supplies quickly. The facility was out of ostomy pouches and was waiting for supplies for the resident. On 1/25/24 at 1:41 PM Staff 6 (LPN) stated Resident 53 did not want nurses to change her/his ileostomy or fistula pouches, and wanted to change them out herself/himself. Staff 6 stated the resident changed the pouches frequently and went through supplies quickly. Staff 6 stated Resident 53 removed the last pouch the facility had on 1/21/24 and used towels to cover her/his ostomy site. Staff 6 stated the use of a towel to cover the resident's ileostomy and fistula was unsanitary. Staff 6 stated the resident placed the towel herself/himself and was not instructed by the nurse to do so. On 1/26/24 at 10:32 AM Staff 2 (Interim DNS) stated she was unable to locate education and assessment related to Resident 53's ability to perform her/his ileostomy and fistula care and pouch changes on her/his own. Staff 2 stated the resident refused to allow facility nurses to provide ileostomy and fistula care. Staff 2 confirmed Resident 53 had a treatment order for the pouch to be changed twice a week and the resident changed the pouch up to 10 times a week without a PRN order for the pouch change. Staff 2 verified there was not a physician's order for the resident's ileostomy and fistula care to be completed by the resident. Staff 2 confirmed Resident 53 ran out of ostomy pouches on 1/21/24 (two days without ostomy supplies before the resident was sent to the hospital) and expected staff to notify her and the ostomy nurse for a viable option. Staff 2 stated she was not notified about the lack of resident ostomy supplies and the use of a towel was not a viable option.

Ostomy supplies for resident 53 have been assessed to ensure there is a sufficient supply and orders are appropriately followed. Current residents with a colostomy, urostomy or ileostomy have been assessed to ensure there is a sufficient supply of appliances and current orders are correct. Central Supply and Clinical Managers were educated about importance of maintaining needed supplies and appliances. Nurses have been educated about importance of following provider orders as it relates to ostomy changes. DNS or designee will conduct a weekly audit to ensure that supplies are on hand and orders are being followed as written. This will be done weekly for four weeks and then monthly. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on observation, interview, and record review it was determined the facility failed to ensure oxygen equipment was properly maintained for 1 of 1 sampled resident (#265) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 265 admitted to the facility in 1/2024 with diagnoses including chronic kidney disease. Observations from 1/22/24 through 1/25/24 revealed Resident 265 used an oxygen concentrator (generates medical-grade oxygen from surrounding air) through a nasal cannula (tubing with two prongs placed in nostrils). Resident 265's 1/2024 TAR indicated: - Oxygen one to four liters via nasal cannula PRN for comfort or shortness of breath. - Oxygen concentrator filters were to be changed or cleaned every four weeks for oxygen maintenance. - Change and date the oxygen nasal cannula tubing once weekly. Observations of the oxygen concentrator and oxygen tubing from 1/22/24 through 1/25/24 revealed: - the oxygen concentrator had a built-up layer of dust on the machine. - the two external filters on the oxygen concentrator were dislodged at the upper and lower aspects of the machine. - the nasal cannula tubing was not labeled with the date to indicate when the tubing was last changed. On 1/25/24 at 8:26 AM Staff 26 (LPN) stated resident oxygen tubing was to be changed as indicated on the TAR and labeled with a piece of tape which indicated the date the tubing was changed. She verified Resident 265's oxygen tubing was not dated. Staff 26 stated the filters on the resident's oxygen concentrator were "out a bit" on both sides of the concentrator. Staff 26 confirmed the concentrator was dusty and stated it was time for a "deep clean." On 1/25/24 at 10:12 AM Staff 2 (Interim DNS) verified the resident's oxygen tubing was to be changed weekly and dated when changed. Staff 2 stated she expected the oxygen concentrator to be maintained and cleaned.

Resident 265 has discharged from the facility. Current residents utilizing oxygen have been assessed to ensure equipment is clean and oxygen tubing is dated appropriately. Nurses were educated about importance of maintaining oxygen equipment cleanliness and changing tubing as scheduled. DNS or designee will audit process weekly for four weeks and then monthly. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 4 of 4 halls reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 1/25/24 the facility provided lists of residents who: -Required assistance with eating: 5 -Required assistance with dressing: 49 -Required assistance with bathing: 58 -Required assistance with toileting: 52 -Required two-person assistance with transfers: 10 -Required mechanical lift transfers: 21 -Required incontinence care: 32 -Had wandering behaviors: 4 -Had behavioral healthcare needs: 18 Resident Council Notes were reviewed and indicated the following: 9/2023: call light response times were up to one hour and there were not enough staff to give showers. A lot of CNAs turned off call lights and stated they would be back, but never returned. 10/2023: Call light response times were still too long, staff indicated they would be back in a minute and never came back. 11/2023: Call light response was still an issue. 12/2023: Call light response still took too long and there were CNAs who did not help. A review of the facility Direct Care Staff Daily Reports from 12/23/23 through 1/21/24 revealed the facility had insufficient CNA staff for one or more shifts to meet the state minimum staffing requirement on the following dates: -12/23/23 -12/28/23 -1/5/24 -1/6/24 -1/8/24 -1/12/24 -1/17/24 Interviews with residents revealed the following concerns: -On 1/22/24 at 1:05 PM Resident 56 stated the facility was short-staffed on evenings and weekends. She/he stated it took 30-45 minutes to get assistance and "sometimes it's too late, I go in my briefs and I have to get changed." -On 1/22/24 at 10:22 AM Resident 6 stated she/he got up to the wheelchair by her/himself because she/he waited too long for assistance. Resident 6 stated it took up to one hour to get help. Interviews with staff revealed the following concerns: -On 1/23/24 at 2:16 PM Staff 19 (RN) stated she did not have time to administer Resident 16's ordered bowel medications on 1/1/24 and 1/2/24 because there was not enough staff and she had to prioritize the other residents' needs. Staff 19 further stated if a resident was critically ill or if there were new admissions it was difficult to get everything done. -On 1/24/24 at 10:07 AM Staff 21 (CNA) stated several residents required mechanical lifts which made it difficult to complete showers because it took up to 40 minutes to complete a shower for those residents. Staff 21 further stated she was not always able take a lunch because she was too busy. -On 1/24/24 at 10:14 AM Staff 14 (LPN) stated morning medication pass was "heavy." Staff 14 further stated there were some treatments including dressing changes which she was not able to complete during her shift and often passed treatments to the next shift. -On 1/24/24 at 12:43 PM Staff 22 (RN) stated medication pass was difficult for one person to complete and she often had to do both medication pass and treatments. Staff 22 stated medications were given up to an hour late due to the heavy workload. Staff 22 further stated the 100 hall had residents that required a lot of care, CNAs often reported they were not able to get everything done, and she often had to help the CNAs with resident care. -On 1/25/24 at 10:00 AM Staff 23 (CNA) stated prior to 1/2024 staff were not able to complete showers. Staff 23 stated residents were often given a bed bath instead of a shower due to time constraints. Staff 23 stated meals were given late and the food was served cold due to being short staffed. On 1/25/24 at 10:46 AM and 1/26/24 at 11:27 AM Staff 1 (Administrator) acknowledged staffing concerns included nursing staff not being able to administer ordered medications due to not having enough time. Staff 1 acknowledged the facility had a lot of residents with high acuity needs and the facility continued to work on staffing issues. Refer to F684.

Current staffing levels have been reviewed to ensure facility is staffed adequately to meet current resident needs. The Staffing Coordinator was re-educated on appropriate staffing levels. The Administrator or designee will perform audits of grievances, call lights and interview multiple residents weekly for four weeks and then monthly to ensure care needs are being met. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 1 of 3 sampled residents (#14) reviewed for medication administration. The facility's medication error rate was 6.67%. This placed residents at risk for adverse medication consequences. Findings include: Resident 14 admitted to the facility in 4/2023 with diagnoses including respiratory failure and COPD (chronic obstructive pulmonary disease). Resident 14's 1/2024 physician orders included the following orders: - Advair Diskus (an inhaled combination medication to treat COPD) one puff two times a day; rinse mouth after every application. - Incruse Ellipta (an inhaled medication to treat COPD) one puff once a day; rinse mouth after every application. Advair Diskus manufacturer instructions indicated the user was to rinse their mouth with water without swallowing following inhalation to help reduce the risk of thrush (fungal infection in the mouth). On 1/24/24 at 7:05 AM Staff 25 (CMA) was observed to give Resident 14 the Advair Diskus and Incruse Ellipta inhalers for the resident to self-administer the medications. Staff 25 did not instruct, assist, or remind Resident 14 to rinse her/his mouth with water and spit it out after inhalation of Advair Diskus and Incruse Ellipta inhaled medications. On 1/24/24 at 12:43 PM Staff 25 stated his process was to offer residents water and encourage residents to swish and spit after the use of an inhaler. Staff 25 verified he did not instruct, assist, or remind Resident 14 to rinse and spit after the administration of the resident's inhalers. On 1/25/24 at 10:06 AM Staff 2 (Interim DNS) was informed of the inhaler medication errors observed during a medication administration observation. Staff 2 stated her expectation was for staff to administer medications as the physician ordered and staff were expected to encourage Resident 14 to swish and spit after the use of her/his inhalers.

Resident 14 was assessed for adverse reaction to inhaler use. Other residents using inhalers were also assessed for adverse reaction with use. Nursing staff administering medications will be educated on importance of following orders. DNS or designee will periodically observe inhaler administration weekly for four weeks and then monthly. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained for 2 of 2 medication storage refrigerators reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: 1. On 1/24/24 at 12:48 PM the medication refrigerator on the 200 hall was observed with Staff 27 (RN). Review of the refrigerator temperature log indicated temperatures were to be maintained between 36 to 46 degrees. The Logs from 1/1/24 through 1/24/24 revealed 20 instances with no temperatures logged. The medication refrigerator contained tuburculin (used for testing and diagnoses of Tuburculosis) and influenza vaccines (vaccines which require refrigeration). On 1/24/24 at 1:20 PM Staff 2 (Interim DNS) stated the medication refrigerator was to be checked twice a day (AM/PM). Staff 2 further stated there was not to be any "holes" in the temperature logs "especially" with vaccines in the medication refrigerators. 2. On 1/24/24 at 1:16 PM the medication refrigerator on the 100 hall was observed with Staff 27 (RN). Review of the refrigerator temperature log indicated temperatures were to be maintained between 36 to 46 degrees. The logs from 1/1/24 through 1/24/24 revealed 12 instances with no temperatures logged. The medication refrigerator contained Tuburculin (used for testing and diagnoses of Tuburculosis) and influenza vaccines (vaccines which require refrigeration). On 1/24/24 at 1:20 PM Staff 2 stated the refrigerator was to be checked twice a day (AM/PM). Staff 2 further stated there was not to be any "holes" in the temperature logs "especially" with vaccines in the medication refrigerators.

Current refrigerators in use for medication and vaccination storage have been assessed to ensure appropriate temperature checks are being performed and documented. Clinical staff have been educated about importance of checking refrigerator temps as appropriate and documenting results. The DNS or designee will be doing weekly audits for four weeks and then monthly to check for labeling and temperatures. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 1 facility kitchen reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include: 1. On 1/22/24 at 9:23 AM during the initial tour of the main kitchen, the following was observed regarding refrigerator two: -One plastic carton of moldy strawberries. -One container with a lid of sliced lemon wedges with no date. -One bag of sliced bread with a date, but not sealed. On 1/22/24 at 9:27 AM Staff 13 (Dietary Manager) confirmed the identified items were not appropriately stored. 2. On 1/24/24 at 11:31 AM Staff 24 (Cook/Dietary Aide) was observed to pick up a hamburger bun with ungloved hands and place it on the plate. She was observed to place a hamburger patty on the bun with tongs and then proceeded to move aside the hamburger bun with ungloved hands. The surveyor stopped Staff 24 and questioned why she was not wearing gloves. Staff 24 stated she forgot to put a pair on. Staff 13 (Dietary Manager) was present during this observation and interview. On 1/24/24 at 2:25 PM Staff 13 acknowledged Staff 24 was not wearing gloves while handling food during the lunch service on 1/24/24. She stated it was her expectation for staff to wear gloves when directly handling food items.

Current residents are at risk from this deficient practice. Dietary staff will be educated on appropriate food handling and food storage practices. The Administrator or designee will be doing weekly audits of proper food storage and sanitary practices for four weeks and then monthly. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on observation, interview, and record review it was determined the facility failed to ensure proper placement of a resident's urinary catheter bag and appropriate infection control practices were in place for 2 of 2 sampled residents (#s 2 and 53) reviewed for infection control. This placed residents at risk for cross-contamination and infection. Findings include: 1. Resident 53 was admitted to the facility in 4/2023 with diagnoses including presence of an ileostomy (an artificial opening on the abdominal wall through which waste material passes out of the body from the bowel). On 1/22/24 at 9:35 AM Resident 53 was observed to have a towel covering her/his abdomen taped around the edges. On 1/23/24 at 1:08 PM Resident 53 stated the facility still did not have ostomy pouches available and she/he was noted to have a towel covering her/his abdomen secured with tape. On 1/23/24 at 1:45 PM Staff 14 (LPN) stated the resident kept a towel over her/his abdomen because the facility was out of ostomy pouches. On 1/25/24 at 1:41 PM Staff 6 (LPN) stated Resident 53 removed the last pouch the facility had on 1/21/24 and used towels to cover her/his ostomy site. Staff 6 stated the use of the towel was unsanitary. Staff 6 stated the resident placed the towel herself/himself and was not instructed by the nurse to do so. On 1/26/24 at 10:32 AM Staff 2 (Interim DNS) confirmed Resident 53 ran out of ostomy pouches on 1/21/24 (two days without ostomy supplies before the resident was sent to the hospital). Staff 2 stated she was not notified of the lack of resident ostomy supplies and the use of a towel was not a viable option and put the resident at risk for skin damage. Refer to F691. , 2. Resident 2 admitted to facility in 2023 with diagnosis of obstructive uropathy (blockage of normal urine flow). On 1/22/24 at 11:14 AM Resident 2 was observed lying in bed with her/his catheter bag sitting on the bottom cross bar leg of an over bed table without a privacy bag. On 1/24/24 at 1:45 PM Resident 2 was observed lying in bed with her/his catheter bag laying on the floor without a privacy bag. On 1/24/24 at 1:56 PM Staff 4 (CNA) confirmed Resident 2's catheter bag was on the floor, and acknowledged catheter bags were not to be laid on the floor. Staff 4 stated Resident 2's urinary catheter bag was to be placed in a privacy bag. On 1/25/24 at 11:07 AM Staff 19 (LPN) stated catheter bags should be in a privacy bag attached to the bed. On 1/25/24 at 11:37 Staff 2 (Interim DNS) stated she expected staff to ensure Resident 2's urinary catheter bag was placed in a privacy bag and was not to be laid on the floor when the resident was in bed.

Resident 53 has been assessed to ensure ostomy supplies are available and in place as ordered. Resident 2 has been assessed to ensure catheter drainage bag is maintained following infection control practices with privacy cover in place. Current residents using catheters or ostomy appliances have been assessed to ensure equipment is maintained following infection control practices. Clinical staff were educated about importance of following standard infection control practices as it relates to ostomies and urinary catheters. The DNS or designee will be doing a weekly audit for four weeks and then once a month. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained for 8 of 30 days reviewed for staffing. This placed residents at risk for delayed resident care. Findings include: A review of the Direct Care Staff Daily Reports from 9/1/23 through 9/30/23 as part of a public complaint revealed the following days when state minimum CNA staffing requirements were not met: -Day shift: 9/2/23, 9/3/23, 9/21/23, 9/24/23, 9/26/23, and 9/27/23. -Night shift: 9/10/23 and 9/23/23. On 1/25/24 at 2:02 PM Staff 2 (Interim DNS) acknowledged there were CNA staffing shortage for identified dates.

Current staffing levels have been reviewed to ensure facility is staffed adequately to meet current resident needs. The Staffing Coordinator was re-educated on appropriate staffing levels. The Administrator or designee will perform audits of grievances, call lights and interview multiple residents weekly for four weeks and then monthly to ensure care needs are being met. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing requirements were maintained for 7 of 30 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: On 1/25/24 at 10:30 AM Staff 1 (Administrator) provided a list of four bariatric residents. A review of the Direct Care Staff Daily Reports from 12/22/23 through 1/21/24 revealed the following days when the state minimum bariatric CNA staffing requirements were not met for one or more shifts: -12/23/23 -12/28/23 -1/5/24 -1/6/24 -1/8/24 -1/12/24 -1/17/24 On 1/25/24 at 10:46 AM Staff 1 acknowledged the CNA staffing shortages on the identified dates.

Current staffing levels have been reviewed to ensure facility is staffed adequately to meet current resident needs. The Staffing Coordinator was re-educated on appropriate staffing levels. The Administrator or designee will perform audits of grievances, call lights and interview multiple residents weekly for four weeks and then monthly to ensure care needs are being met. Audits will continue until substantial compliance is achieved. Any issues will be brought to QAPI.

********** OAR 411-085-0310 Residents' Rights: Generally Refer to F550 ********** OAR 411-085-0310 Residents' Rights: Generally Refer to F565 ********** OAR 411-085-0360 Abuse Refer to F609 ********** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684, F691, F695 and F759 ********** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686 and F689 ********** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ********** OAR 411-086-0260 Pharmaceutical Services Refer to F761 ********** OAR 411-086-0250 Dietary Services Refer to F812 ********** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 **********

Based on observation and interview it was determined the facility failed to have the required Long Term Care Ombudsman (LTCO) poster posted for 1 of 2 floors observed for the LTCO poster. This placed residents and visitors at risk for not knowing how to reports concerns. Findings include: On 10/5/23 at 8:36 AM an observation of the first floor revealed the LTCO poster was not posted. On 10/5/23 at 8:36 AM Staff 9 (LPN) stated the first floor used to have the LTCO poster poster and verified the LTCO poster was no longer posted.

This Plan of Correction is the center’s credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/ or executed solely because it is required by the provisions of federal and state law. This provider respectfully requests that the 2567 Plan of Corrections be considered the Letter of Credible Allegation and requests a post survey review on or after 10/19/2023. F575 – Required Postings 1. Ombudsman resident visitor contact posting was not on first floor of facility. 2. This placed residents and visitors at risk for not knowing how to report concerns. 3. Systemic Change to Meet Compliance Human Resources Director placed Ombudsman contact posting on first floor hallway across from the nursing station in full view of residents. Human Resources Director will audit the posting of Ombudsman contact posting 1 x weekly, X4 weeks. Results will be reported to the QAPI Committee. 4. Administrator or designee will be responsible for this facilities compliance with the regulation and practice. 5. Date of alleged compliance 10/19/2023

Based on observation and interview it was determined the facilty failed to ensure a minimum of one week supply of staple foods and two-day supply of perishable foods was on the premises for 1 of 1 kitchens reviewed for dietary services. This placed residents at risk of unmet nutritional needs. Findings include: On 10/5/23 an observation was completed of the dry food storage area, the freezers and the refrigerators. The quantity of food was minimal. The kitchen did not have a two-day supply of perishable foods or a one week supply of staple foods. On 10/5/23 at 7:30 AM and 9:32 AM Staff 5 (Cook) stated the day prior serving staff had to "skimp on the chicken" because there was not enough, verified portions sizes were smaller due to the lack of food, stated residents were sometimes unable to get "seconds" if requested, verified there was no yogurt in the building (resident request) and the residents were not served the food on the posted menus. Staff 5 stated the facility did not have two days worth of food on hand and "if we had a fire or a flood we would not be able to feed everyone." On 10/5/23 at 10:04 AM Staff 15 (Dietary Manager) verified the facility did not have two days of food on hand that followed the prepared menus and verified the facility did not have two days worth of perishable food or a one week supply of staples.

M320 OAR – OAR 411-086-0250 (4) Dietary Services: Diets M320 and Menus 1. The facility failed to provide a backup food storage area. 2. This placed all residents of the center at risk back up food supply. 3. Dietary Director identified a storage room in the dietary services area for storing back up food supply. Systemic Change to Meet Compliance a. Quantity of food was placed in storage to ensure a minimum of one week supply of staple foods and a two-day supply of perishable foods are on the premises. b. Dietary Director will audit the storage area 1x weekly, X4weeks. 4. Administrator or designee will be responsible for this facilities compliance with the regulation and practice. 5. Date of alleged compliance 10/19/2023

************ OAR 411-085-0030 Required Postings Refer to F575 ************

Based on interview and record review it was determined the facility failed to notify the resident representative of a hospital transfer for 1 of 3 sampled residents (#1) reviewed for notifications. This placed resident representatives at risk for being uninformed of current resident status. Findings include: Resident 1 admitted to the facility in 2015 with diagnoses including end stage renal disease. The 7/12/23 Discharge Summary indicated Resident 1 was transferred to the hospital from the dialysis facility. Review of Resident 1's medical record revealed no evidence Resident 1's representative was notified of the hospital transfer on 7/12/23. On 8/23/23 at 5:00 PM Witness 1 (Complainant) stated Resident 1 was transferred to the hospital and she/he was not notified. On 8/23/23 at 11:30 AM Staff 4 (LPN Resident Care Manager) verified Resident 1's representative was not notified of the hospital transfer on 7/12/23.

Family member for resident #1 was provided notification of hospital transfer. Residents sent to the hospital in the last week have been reviewed to ensure appropriate family members have been notified. Nurses have been educated on the importance of notifying identified Emergency Contacts when residents are transferred out for acute care needs. DNS or designee will audit multiple residents who have been transferred out for acute care needs to ensure Emergency Contacts were notified. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on observation, interview and record review it was determined the facility failed to provide a safe, comfortable and homelike environment for 2 of 2 floors reviewed for environment. This placed residents at risk for an unclean and unsafe environment. Findings include: 1. The 4/27/23 and 5/31/23 Resident Council Notes revealed the residents verbalized concerns related to unclean bathrooms, cob webs, odor and sticky floors. On 8/30/23 at approximately 8:30 AM an environmental observation of the facility was started with Staff 20 (Infection Preventionist). The following concerns were identified: Second Floor: *205 - The floor was dirty, had black tire track marks throughout room and dirt marks on wall. *206 - The floor and wall was dirty, black marks all over the floor, duct tape on floor and paint peeling off wall behind both beds. *208: The floors were dirty with black lines on floor and the windowsill was scratched up. *210: There were black lines on floor. *212: The floors were dirty with cracked linoleum and one linoleum square by the bed missing 1/3 of the square. *213: The floors were extremely dirty, especially near the closet and the bathroom door. the linoleum was in disrepair and there was paint off of the wall behind both beds and door. *217: The floors were dirty and the linoleum was in disrepair especially by the bathroom. *218: There were black marks on floor and the linoleum in disrepair. *220: There was a paint spot (rectangle shape) on the wall of a different color. *221: The floors were dirty and had black marks. The paint on the walls was scuffed up. The bathroom door stuck on the floor when it opened and closed. The shared bathroom was very dirty. The door needed to be repainted on both sides. *222: The floors were dirty with black marks. There was missing flooring under the closets. * The family/staff room had dirty floors with part of the floor missing. The freezer was dirty and sticky. There were paint scratches on the walls and the door. * The OT Kitchen had dirty floors with cracked linoleum and the floor trim was dirty. * The lab supply door had peeling pain and the bottom of the door was very dirty. * The south shower room had a black, mold-like substance on the floor, the floor tile had cracks and overall, the floors were dirty. The wall Sharps container had two razors sticking out of the top opening. The back of door was all scratched up and had paint off of it. * the north shower room floors had a black, mold-like substance and there was paint scratched off interior the door. * The common bathroom 1 had pain coming off of the outside door and multiple areas inside the room that needed paint. The interior bathroom, especially the sink was very dirty. * The common bathroom 2 had paint scratches off of the door, the painted wall had a rectangle painted area of a different color and the garbage overflowing. * The common dining room needed paint touched up in multiple areas, the outside windows were filthy and hard to see through. There were scattered floor pieces peeling up on their ends which created a tripping hazard and the wheelchair scale and shred cart were placed in a large corner of the room which created a non-homelike environment. First Floor: *103: There were black lines on the floor. *105: There was old duct tape on the floor and gaps in linoleum. *106: The linoleum tile spacing had gaps and was not a cleanable surface. *108: The corner drywall was scuffed, the toilet had an active leak with towels all over floor, the resident stated toilet leaked for the past four days and there were cracks in linoleum. *109: The floormats by the bed were not a cleanable surface due to disrepair. The linoleum was cracked and there was paint off of the wall, especially behind the bed. *111: The call light did not work, the linoleum was cracked and there were multiple areas where the paint was off the walls. *112: There were black marks on the floor and the edge of wall and trim were in disrepair. *120: There were discolored white spots on the floor. *121: The floors were dirty and in disrepair. *122: The floor had black lines on it. *124: The walls and floor trim were dirty and the floors had black marks. * The resident activity room had dirty floors which were disrepair, especially under the ice machine. The floor under the ice machines was very dirty. * The dining room contained a shred cart and wheelchair scale which created a non-homelike environment. The linoleum had scuffs and cracks, the windows were dirty and difficult to see through. * The common bathroom 1 had multiple paint scuffs on the door and the floor was extremely dirty. * The common bathroom 2 had tile floor spacing with gaps and black substance in the gaps. There was paint off of the outside of door. *The north shower room door needed paint touch-ups and the floor had a black substance in tile cracks. * The south linen door had paint off both sides, especially interior side. On 8/29/23 at 10:42 AM Staff 9 (Housekeeping Account Manager) stated the facility was very under-staffed and were unable to keep up general housekeeping. On 8/30/23 at 9:45 AM the environment tour with Staff 20 was completed. Staff 20 verified all findings were correct. 2. The following overhead announcements were observed which created a non-homelike environment: *8/30/23 8:07 AM: "CNA's, your hall cart is here, north." *9/1/23 8:23 AM: "Second hall north hall is out, second hall your north hall is out." *9/7/23 7:29 AM: "First floor, your hall cart is here." *9/7/23 8:02 AM: "Second hall, your food cart is out." On 8/30/23 at approximately 8:30 AM Staff 20 (Infection Preventionist) acknowledged the overhead announcements for the dietary carts did not create a home-like environment. 3. Observations of facility linen closets on 9/1/23 revealed the both the first and second floor had minimal linen present. On 8/29/23 at 10:42 AM Staff 9 (Housekeeping Account Manager) stated the facility was very under-staffed and were unable to keep up with the laundry. On 8/29/23 at 10:57 Staff 10 (CNA) stated the facility routinely ran out of both linen and slings. Staff 10 stated the night shift CNA's used to do some laundry so the day shift would have linen at the start of the shift but new locks were put on the door so they no longer had access to the laundry. On 9/7/23 at 7:20 AM Staff 24 (CNA) verified the facilty ran out of linen and stated it was a common problem on the weekend.

On 9/11/23 a housekeeping team completed a facility-wide inspection and cleaning of all areas identified. Par levels of linens will be completed to ensure resident needs are met. Schedules for housekeeping staff will be reviewed to verify coverage of positions. Areas identified throughout property needing repair have been corrected. Overhead paging has been minimized for routine use. Previous Housekeeping Manager is no longer employed by facility. New Housekeeping Manager continues with onboarding and training related to staffing, laundry and cleaning services, routine linen par levels and quality oversight. Nurses and facility managers have been educated on minimizing overhead paging. All staff have been educated on communicating environmental concerns through proper channels. Administrator or designee will audit environmental cleanliness and linen availability weekly. Administrator or designee will audit for overhead paging frequency multiple times a week. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation for 4 of 6 sampled residents (#s 2, 16, 17 and 18) reviewed for abuse. This placed residents at risk for financial abuse. Findings include: Resident 2 was admitted to the facility in 2021 with diagnoses including dementia. Resident 16 was admitted to the facility in 2022 with diagnoses including hypertension. Resident 17 was admitted to the facility in 2022 with diagnoses including diabetes. Resident 18 was admitted to the facility in 2022 with diagnoses including convulsions. The 8/17/23 facility records indicated Resident 2 reported she/he and three other residents loaned Staff 21 (CNA) money and did not get paid back. The 8/17/23 Facility Investigation indicated Resident 2 loaned Staff 21 twenty dollars and did not get the money back. Resident 16 indicated Staff 21 asked her/him for one hundred dollars as he did not have money for food, Resident 16 loaned it to him but did Staff 21 did not pay the money. Resident 17 requested Staff 21 give twenty dollars to "someone" and not sure if Staff 21 did. Resident 18 indicated she/he loaned money to Staff 21 but did not get the money back. On 8/29/23 Staff 21 stated the allegation he took money from four residents was false. On 8/29/23 at 8:54 AM Staff 3 (Regional RN) verified the Facility Investigation was correct and misappropriation of resident funds was substantiated. On 8/29/23 at 10:35 AM Resident 16 stated Staff 21 "came to us with a sob story all the time, I have cancer, I have this, I've been sick" and "asked for money and said he couldn't pay us back." On 8/29/23 at 10:39 AM Resident 17 verified she/he gave money to Staff 21.

Resident #2, 16, 17 and 18 have been reimbursed for the full amount loaned to staff. Staff member identified was terminated from the facility and has been reported to the licensing board. Residents with capacity to loan money were interviewed to ensure no additional residents were affected. Any residents identified were reimbursed for the full amount loaned to staff. All staff were educated about abuse prohibition including freedom from misappropriation. Administrator or designee will interview random residents weekly about potential misappropriation concerns. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on interview and record review it was determined the facility failed to revise a residents plan of care for 1 of 2 sampled residents (#18) reviewed for dining. This placed residents at risk for lack of food. Findings include: Resident 18 re-admitted to the facility in 2022 with diagnoses including depression. The current Nutrition Care Plan revealed an 11/24/20 intervention which indicated Resident 18's family would bring in lunch and dinner. The 11/27/20 intervention instructed staff to check with Resident 18 to ensure her/his family brought in lunch and dinner, if not to notify the kitchen daily. Records revealed Resident 18's family was out of state and unable to bring the resident lunch and dinner. On 9/7/23 at 2:12 PM Staff 2 (DNS) stated the family member lives out of state every summer and the care plan needed to be updated.

Resident 18’s care plan has been reviewed and updated with current information about family bringing in meals. Dietary care plans for current residents have been reviewed and revised as needed to reflect current information regarding dietary plans and/or preferences. Nurses and managers were educated about importance of reviewing and updating care plans to reflect current preferences and information. DNS or designee will audit multiple care plans weekly to ensure resident-centered information reflects current practice. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on interview and record review it was determined the facility failed to ensure services provided met professional standards of quality for 5 of 7 sampled residents (#s 2, 3, 16, 17 and 18) reviewed for medications and abuse. This placed residents at risk for missed medications and financial abuse. Findings include: 1. Resident 3 admitted to the facility in 2022 with diagnoses of diabetes and glaucoma. The 7/17/23 Facility Records indicated Resident 3 requested her/his medications, Staff 22 (LPN) did not understand Resident 3's Spanish so told the resident to return to their room and to speak English, not Spanish. Resident 3 stated Staff 22 did not administer the medications and documented she/he refused the medications which she/he did not. The July 2023 MARs revealed the following 8:00 PM and 9:00 PM medications documented as refused: *Lidocaine External Patch 4%, remove per schedule (pain patch) *Systane Nighttime Ophthalmic Ointment. (artificial tears eye drops) *Xalantan Ophthalmic sol 0.005% (glaucoma eye drops) *Brimonidine Tartrate Ophthalmic sol 0.2% (glaucoma eye drops) *Cosopt Ophthalmic sol 22.3-6/8 mg/ml (glaucoma eye drops) *metformin HCL (diabetes medication) *Senna (bowel medication) *gabapentin (nerve pain medication) *Refresh plus ophthalmic 0.5% (artificial tears eye drops) The 7/17/23 12:31 AM Progress Note revealed Resident 3 requested her/his 8:00 PM and 9:00 PM medications when she arrived on shift 7/16/23 which was refused on swing shift. The medication was administered after contacting the Resident Care Manager for guidance. The 7/17/23 Facility Investigation indicated Resident 3 approached Staff 22 and requested her/his evening medications. Staff 23 (CNA) indicated Staff 22 instructed Resident 3 to go back to her/his room and stated "I can't think with you talking and breathing down my neck". Resident 3 stated she/he was told "if you don't speak English then nothing". Documentation revealed Staff 22 documented Resident 3 refused the medications. On 8/23/23 at 8:20 AM Resident 3 stated she/he usually got her/his evening medications between 8:00 PM and 8:30 PM. Resident 3 stated at almost 9:00 PM she/he went to then nurse's station to find out who was passing the medications. Staff 22 "showed up, it was overwhelming and talking crazy". Staff 22 went to the medication cart, she/he followed and requested her/his medicaitons. A CNA translated the conversation. Resident 3 further stated Staff 22 told her/him she would not give me my pills unless I talked in English. Resident 3 stated Staff 22 then went back to the nurse's station, she/he followed her and explained all she/he wanted was her/his medicaitons. The staff member who translated earlier asked for her/him to return to her/his room which she/he did. At 10:30 PM Resident 3 stated she/he asked for her/his medications again and the night shift nurse said I had refused them. Resident 3 stated she/he finally got the medications around midnight. Resident 3 stated she/he reported the incident the next morning. Two unsuccessful attempts were made to contact Staff 22 on 8/28/23 and 8/29/23. On 8/29/23 at 9:40 AM Staff 2 (DNS) verified Staff 22 did not administer Resident 3's medications as ordered, falsely documented the medication was refused, abuse was substantiated and Staff 22 was terminated. Refer to F684. 2. Resident 2 was admitted to the facility in 2021 with diagnoses including dementia. Resident 16 was admitted to the facility in 2022 with diagnoses including hypertension. Resident 17 was admitted to the facility in 2022 with diagnoses including diabetes. Resident 18 was admitted to the facility in 2022 with diagnoses including convulsions. The 8/17/23 facility records indicated Resident 2 reported she/he and three other residents loaned Staff 21 (CNA) money and did not get paid back. The 8/17/23 Facility Investigation indicated Resident 2 loaned Staff 21 twenty dollars and did not get the money back. Resident 16 indicated Staff 21 asked her/him for one hundred dollars as he did not have money for food, Resident 16 loaned it to him but Staff 21 did not pay the money. Resident 17 requested Staff 21 give twenty dollars to "someone" and not sure if Staff 21 did. Resident 18 indicated she/he loaned money to Staff 21 but did not get the money back. On 8/29/23 Staff 21 stated the allegation he took money from four residents was false. On 8/29/23 at 8:54 AM Staff 3 (Regional RN) verified the Facility Investigation was correct and misappropriation of resident funds was substantiated. On 8/29/23 at 10:35 AM Resident 16 stated Staff 21 "came to us with a sob story all the time, I have cancer, I have this, I've been sick" and "asked for money and said he couldn't pay us back." On 8/29/23 at 10:39 AM Resident 17 verified she/he gave money to Staff 21. Refer to F602.

Resident #2, 16, 17 and 18 have been reimbursed for the full amount loaned to staff. Staff member identified was terminated from the facility and has been reported to the licensing board. Medical record for resident #3 has been reviewed to ensure documentation accurately reflects not receiving medications on 7/17/23. Residents with capacity to loan money were interviewed to ensure no additional residents were affected. Any residents identified were reimbursed for the full amount loaned to staff. Current resident routine medications were reviewed to verify orders are being followed as written. All staff were educated on professionalism, ethics and employee conduct. Administrator or designee will interview random residents weekly about staff interactions and professionalism. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on interview and record review it was determined the facility failed to administer medications as ordered for 2 of 3 sampled residents (#s 1 and 3) reviewed for medications. This placed residents at risk for worsening medical symptoms. Findings include: 1. Resident 1 admitted to the facility in 2015 with diagnoses including hypertension and end stage renal disease. The 7/20/23 Physician Order instructed to administer Midodrine HCL 10 mg tablet every six hours and to hold for systolic blood pressure greater than 110. The July 2023 MARs revealed the Midodrine was administered as ordered on 7/28/23. The medication instructed to administer one 10 mg tablet (not two tablets). The 7/28/23 Facility Investigation revealed Staff 5 administered two tablets instead of one of Midodrine to Resident 1 on 7/28/23. The bubble pack (medication dispensing form) for the Midodrine had 2 tablets inside each bubble pack. The directions indicated to give 10 mg; it did not indicate the dosage of each tablet. The CMA immediately reported the medication error, and both the pharmacy and physician were notified. Monitoring began and there was no identified adverse outcome. On 8/23/23 11:40 AM Staff 2 (DNS), Staff 3 (Regional RN) and Staff 4 (LPN Resident Care Manager) verified Resident 1 was given twice the ordered dose of Midodrine. Staff 2 further verified if the seven medication rights were completed when the medication was prepared then Staff 5 would have caught the labeling discrepancy prior to making the medication error. 2. Resident 3 admitted to the facility in 2022 with diagnoses of diabetes and glaucoma. The 7/17/23 Facility Records indicated Resident 3 requested her/his medications, Staff 22 (LPN) did not understand Resident 3's Spanish so she told the resident to return to their room and to speak English, not Spanish. Resident 3 stated Staff 22 did not administer the medications and documented she/he refused the medications which she/he did not. The July 2023 MARs revealed the following 8:00 PM and 9:00 PM medications documented as refused: *Lidocaine External Patch 4%, remove per schedule (pain patch) *Systane Nighttime Ophthalmic Ointment. (artificial tears eye drops) *Xalantan Ophthalmic sol 0.005% (glaucoma eye drops) *Brimonidine Tartrate Ophthalmic sol 0.2% (glaucoma eye drops) *Cosopt Ophthalmic sol 22.3-6/8 mg/ml (glaucoma eye drops) *metformin HCL (diabetes medication) *Senna (bowel medication) *gabapentin (nerve pain medication) *Refresh plus ophthalmic 0.5% (artificial tears eye drops) The 7/17/23 12:31 AM Progress Note revealed Resident 3 requested her/his 8:00 PM and 9:00 PM medications when she arrived on shift 7/16/23 which was refused on swing shift. The medication was administered after contacting the Resident Care Manager for guidance. The 7/17/23 Facility Investigation indicated Resident 3 approached Staff 22 and requested her/his evening medications. Staff 23 (CNA) indicated Staff 22 instructed Resident 3 to go back to her/his room and stated "I can't think with you talking and breathing down my neck". Resident 3 stated she/he was told "if you don't speak English then nothing". Documentation revealed Staff 22 documented Resident 3 refused the medications. On 8/23/23 at 8:20 AM Resident 3 stated she/he usually got her/his evening medications between 8:00 PM and 8:30 PM. Resident 3 stated at almost 9:00 PM she/he went to then nurse's station to find out who was passing the medications. Staff 22 "showed up, it was overwhelming and talking crazy". Staff 22 went to the medication cart, she/he followed and requested her/his medicaitons. A CNA translated the conversation. Resident 3 further stated Staff 22 told her/him she would not give me my pills unless I talked in English. Resident 3 stated Staff 22 then went back to the nurse's station, she/he followed her and explained all she/he wanted was her/his medicaitons. The staff member who translated earlier asked for her/him to return to her/his room which she/he did. At 10:30 PM Resident 3 stated she/he asked for her/his medications again and the night shift nurse said I had refused them. Resident 3 stated she/he finally got the medications around midnight. Resident 3 stated she/he reported the incident the next morning. Two unsuccessful attempts were made to contact Staff 22 on 8/28/23 and 8/29/23. On 8/29/23 at 9:40 AM Staff 2 (DNS) verified Staff 22 did not administer Resident 3's medications as ordered.

Resident #1 and 3 were assessed for adverse effects of not receiving medications as ordered and appropriate providers notified. Current resident routine medications were reviewed to verify orders are being followed as written. Nursing and Med Aides were educated on the rights of medication administration. DNS or Designee will audit med pass weekly to ensure ongoing compliance. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on observation and interview it was determined the facility failed to maintain the exterior safety railing for 1 of 1 buildings reviewed for accident hazards. This placed residents, visitors and staff at risk for serious injury. Findings include: On 8/23/23 at approximately 9:00 AM two residents were observed to be in the sitting in their wheelchairs on the front sidewalk. The residents did not touch the safety railing. On 8/23/23 at 11:30 AM Resident 3 was observed in her/his wheelchair on the front sidewalk. The resident did not touch the safety railing. From 8/23/23 through 9/7/23 the outside metal staircase to walk down to the first floor (and is attached to the safety railing) had yellow caution tape around it. On 9/7/23 at 8:18 AM the safety railing parallel to the parking lot and alongside the sidewalk was found to have two large sections where the railing was not secure and able to be easily pushed in toward the hill that it was protecting residents, visitors and staff from falling down. The north side of the building had approximately six to seven loose sidewalk sections and the south side of the building had four sidewalk sections which were loose. On 9/7/23 at 7:20 AM Staff 24 (CNA) stated the safety rails in the parking lot and side of the building were falling apart, they would fall if pushed on and if a resident, visitor or staff fell against it they would fall down the hill.

Immediate area around the railing on North side of the building was blocked off from use using cones and caution tape on 9/8/23 until further repairs could be made. Arrangements were made with a construction vendor for initial visit on 9/11/23 and construction began on iron railing repairs. Sidewalk was inspected and areas needing repairs will be completed. In-servicing for all staff on how to report broken equipment and environmental concerns, including steps for immediate action will be completed. Maintenance plan will be reviewed by Regional Maintenance Director and used to train new Facility Maintenance Director on correct processes. Administrator or designee will perform routine weekly inspections of exterior railing to ensure repairs are successful and no additional areas are found to be in need of repair. Until repairs can be completed, daily inspection will be made to ensure hazardous section of railing remains blocked from public use. Results of exterior inspections will be shared with QAPI team to identify trends and additional corrective action.

Based on observation, interview and record review it was determined the facility failed to ensure enough dietary personal was assigned each shift for 31 of 31 days reviewed for dining. This placed residents at risk for not getting preferences honored, being served the incorrect food and incorrect food textures. Findings include: A review of the August 2023 Dietary Staff Timecards revealed the following number of shifts worked over eight hours: *Staff 12 (Dietary Aide) - 15 shifts up to 14.75 hours * Staff 13 (Dietary Aide) - 9 shifts up to 8.5 hours * Staff 14 (Cook) - 10 shifts up to 13.75 hours * Staff 15 (Dietary Aide) - 4 shifts ranging up to 9 hours * Staff 17 (Hospitality Aide) - partial month, 2 shifts up to 10.5 hours * Staff 19 (Cook) - partial month, 3 shifts up to 8.75 hours * Staff 28 (Cook) - 16 shifts up to 15 hours * Staff 29 (Dietary Aide) - 19 shifts up to 15.25 hours On 8/30/23 at approximately 8:30 AM an observation with Staff 20 (Infection Preventionist) of the resident refrigerators on both the first and second floor revealed the temperatures were not checked in August 2023. Staff 20 stated this was the job duty of the kitchen staff. On 8/30/23 at 9:40 AM Staff 11 (Cook) stated the facility did not have a current dietary manager, only had two full-time cooks, she had worked multiple double shifts, came in on previously scheduled days off and had to do the food ordering and scheduling. Staff 11 stated due to lack of staff they had sent out food with the wrong tray tickets, residents did not always get the correct ordered food texture and they served food not on the posted menu because the food was not available. Staff 11 further stated they would get a cook from another facility come and help occasionally but it was not enough. On 8/30/23 at 12:12 PM Staff 2 (DNS) verified the Dietary Manager was on leave since 8/16/23. On 9/7/23 at 7:20 AM Staff 24 (CNA) stated resident trays came out with the wrong tray cards on the food trays and resident preferences and dislikes were missed. Staff 24 stated Resident 18 was supposed to get chocolate or vanilla ice cream on her/his tray but the kitchen almost always forgot it. If they did remember, they would serve strawberry ice cream. Staff 24 further stated Resident 8 consistently received green beans when she/he disliked them and Resident 6 did not eat for a week because she/he wanted a grilled cheese sandwich which the kitchen refused to make. On 9/7/23 at 7:35 AM Staff 25 (LPN) verified residents were not getting their food preferences and Resident 6 went on a hunger strike because she/he wanted a grilled cheese sandwich. On 9/7/23 at 7:45 AM Staff 16 (CNA) stated a resident who was prescribed a regular, puree diet was served the wrong texture earlier in the week but the CNA recognized the error prior to the resident eating. Staff 16 further stated, residents who prefer to have their food cut up no longer get the food cut for them in the kitchen. On 9/7/23 at 2:23 PM Staff 27 (Payroll) verified the listed shifts above when staff worked over eight hours in a shift.

Dietary staffing and schedules have been evaluated and identified needs communicated to Recruiting. Administrator will work with facility and regional resources to continue filling open dietary shifts. Administrator or designee will audit dietary schedule 2x/week to verify dietary shifts have been filled with appropriate staff. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on observation, interview and record review it was determined the facility failed to follow posted menu's for 2 of 2 meals observed for dining. This placed residents at risk for unmet dietary needs. Findings include: On 8/30/23 at 9:40 AM Staff 11 (Cook) stated she was not able to order the food she needed because she had to stay within budget which resulted in the facility not serving the food on the menus because they did not have the needed food. Staff 11 stated the days menu listed chicken carbonara but the facility did not have the sauce or tortilla's so they would substitute chicken alfredo with rice and refried beans instead. Staff 11 further stated the residents were tired of the food offerings and wanted more of a variety. Staff 11 stated residents mostly received broccoli or green beans for vegetables. On 9/1/23 at 8:25 AM Staff 10 (CNA) verified the breakfast tray ticket listed pancakes, syrup, oatmeal, bacon strips, mixed fruit cup and drinks as the menu items. Staff 10 verifed the resident food trays did not include bacon and the mixed fruit cup was substituted with mandarin oranges. On 9/7/23 at 8:10 AM Staff 10 compared the food on the breakfast trays to the meal tickets and stated none of the trays included the mixed fruit cup which was listed on the meal tickets. On 9/7/23 at 8:30 AM Staff 11 (Cook) stated the previous day's food order was denied "because it was too much money." Staff 11 stated she had to reorder, get less food and the following week she would not be serving everything on the menu and menu substitutions would made.

Posted menus for the coming week have been reviewed to ensure there is a sufficient supply of food items needed to follow menu. Education provided to Dietary Manager and Administrator about importance of reviewing/approving dietary orders to ensure food items needed for posted menus are received timely. Education provided to dietary staff about importance of preparing meals per the posted menu and verifying correct items at time of service. Administrator or designee will audit for meals being prepared per posted menu, multiple times weekly. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on interview it was determined the facility failed to serve residents the correct texture food for 1 of 1 kitchens reviewed for dining. This placed residents at risk for aspiration. Findings include: On 8/30/23 Staff 11 (Cook) due to staffing concerns residents were sent out food with the wrong tray tickets and not getting the correct texture as ordered. Staff 11 offered an example from the day prior when a resident was given taquitos and the tray was returned to the kitchen because it was the wrong texture. On 9/7/23 at 7:45 AM Staff 10 (CNA) stated dietary gave a resident who was on a regular puree diet the wrong textured food. The CNA discovered the error before the resident started to eat. On 9/7/23 at 8:26 AM Staff 18 (Dietary Aide) verified residents were sometimes getting the wrong tray card on their tray and occasionally trays were sent out with the incorrect texture.

Dietary staffing and schedules have been evaluated and identified needs communicated to Recruiting. Administrator will work with facility and regional resources to continue filling open dietary shifts. Education provided to dietary staff about importance of preparing textures per resident orders and verifying correct items at time of service. Administrator or designee will audit for correct textures as ordered, multiple times weekly. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on interview and record review it was determined the facility failed to ensure a residents food preferences were honored for 2 of 3 sampled residents (#s 6 and 18) reviewed for dining. This placed residents at risk for weight loss and malnutrition. Findings include: 1. Resident 18 was readmitted to the facility in 2022 with diagnoses including depression. The current Nutrition Care Plan revealed a 9/7/21 revision for the resident to have vanilla or chocolate ice cream at every meal. The 8/5/22 Nutrition Assessment indicated Resident 19 received two ice creams with each meal. On 8/30/23 Staff 11 (Cook) stated the dietary staff was understaffed, they were not getting the food they needed because they had to stay within budget and verified food was sent out with the wrong try tickets/food. On 9/7/23 at 7:20 AM Staff 22 (CNA) stated the dietary staff are frequently making mistakes on the food trays. Staff 22 stated the resident dislikes were missed or the residents did not receive what they asked for. Staff 22 verified Resident 18 rarely received the chocolate or vanilla ice cream on her/his food tray. Staff 22 further stated, if she/he did receive any ice cream, which was rare, she/he would be given strawberry. On 9/7/23 at 11:42 AM Staff 26 (RD) stated Resident 18's tray tickets and Kardex (care plan) indicated the resident was to have vanilla or chocolate ice cream at every meal. Staff 26 stated the facility does not always follow her recommendations and had to request things two to three times before the facility would implement them. Additionally, Staff 26 stated, she completed an audit the previous month, notified management of the concerns that need fixed or changed, "sounded the alarms," but it appeared that the management did not want to hear it. 2. Resident 6 readmitted to the facility in 2023 with diagnoses including malnutrition. Resident 6's meal monitor indicated Resident 6 frequently refused meals. On 9/7/23 at 7:20 AM Staff 22 (CNA) stated Resident 6 quit eating the facility food for about a week because she/he wanted a grilled cheese and the kitchen refused to make it for her/him. Additionally, Staff 22 stated, the kitchen would send up old, rotted banana's for the CNA's to give to the residents. On 9/7/23 at 7:35 AM Staff 25 (LPN) verified Resident 6 went on a food strike because she/he wanted a grilled cheese sandwich and many of the residents did not receive their food preferences. On 9/7/23 at 8:26 AM Staff 18 (Dietary Aide) verified food preferences were not always honored.

Resident #6 and 18 have been interviewed about satisfaction with meals received in the last 2 days, with corrections made as appropriate. Audit for dietary preferences completed to ensure those identified were honored and diet card updated. Education provided to dietary, clinical and management staff about importance of honoring resident preferences with each meal. Administrator or designee will interview random residents weekly about meal satisfaction and preferences being honored. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on interview and record review it was determined the facility failed to accurately document in the medical record for 1 of 3 sampled residents (#3) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 3 admitted to the facility in 2022 with diagnoses of diabetes and glaucoma. The 7/17/23 Facility Records indicated Resident 3 requested her/his medications, Staff 22 (LPN) did not understand Resident 3's Spanish so told the resident to return to their room and to speak English, not Spanish. Resident 3 stated Staff 22 did not administer the medications and documented she/he refused the medications which she/he did not. The July 2023 MARs revealed the following 8:00 PM and 9:00 PM medications documented as refused: *Lidocaine External Patch 4%, remove per schedule (pain patch) *Systane Nighttime Ophthalmic Ointment. (artificial tears eye drops) *Xalantan Ophthalmic sol 0.005% (glaucoma eye drops) *Brimonidine Tartrate Ophthalmic sol 0.2% (glaucoma eye drops) *Cosopt Ophthalmic sol 22.3-6/8 mg/ml (glaucoma eye drops) *metformin HCL (diabetes medication) *Senna (bowel medication) *gabapentin (nerve pain medication) *Refresh plus ophthalmic 0.5% (artificial tears eye drops) The 7/17/23 12:31 AM Progress Note revealed Resident 3 requested her/his 8:00 PM and 9:00 PM medications when she arrived on shift 7/16/23 which was refused on swing shift. The medication was administered after contacting the Resident Care Manager for guidance. The 7/17/23 Facility Investigation indicated Resident 3 approached Staff 22 and requested her/his evening medications. Staff 23 (CNA) indicated Staff 22 instructed Resident 3 to go back to her/his room and stated "I can't think with you talking and breathing down my neck". Resident 3 stated she/he was told "if you don't speak English then nothing". Documentation revealed Staff 22 documented Resident 3 refused the medications. On 8/23/23 at 8:20 AM Resident 3 stated she/he usually got her/his evening medications between 8:00 PM and 8:30 PM. Resident 3 stated at almost 9:00 PM she/he went to then nurse's station to find out who was passing the medications. Staff 22 "showed up, it was overwhelming and talking crazy". Staff 22 went to the medication cart, she/he followed and requested her/his medicaitons. A CNA translated the conversation. Resident 3 further stated Staff 22 told her/him she would not give me my pills unless I talked in English. Resident 3 stated Staff 22 then went back to the nurse's station, she/he followed her and explained all she/he wanted was her/his medicaitons. The staff member who translated earlier asked for her/him to return to her/his room which she/he did. At 10:30 PM Resident 3 stated she/he asked for her/his medications again and the night shift nurse said I had refused them. Resident 3 stated she/he finally got the medications around midnight. Resident 3 stated she/he reported the incident the next morning. Two unsuccessful attempts were made to contact Staff 22 on 8/28/23 and 8/29/23. On 8/29/23 at 9:40 AM Staff 2 (DNS) verified Staff 22 falsely documented Resident 3 refused her/his medications.

Medical record for resident #3 has been reviewed to ensure documentation accurately reflects not receiving medications on 7/17/23. Current resident routine medications were reviewed to verify orders are being followed as written. Nurses were educated about importance of medical records being comprehensive and accurate based on actual events that occur. DNS or designee will review medical record documentation for complete and accurate information. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on observation, interview and record review it was determined the facility failed to ensure clean, safe drinking water was served to the residents on 1 of 2 floors (2nd floor) observed for dining services. This placed residents at risk of food-borne illness. Findings include: The 4/27/23 and 5/31/23 Resident Council Notes revealed cobwebs in the bathrooms and overall the bathrooms "need attention." On 8/30/23 at 8:05 AM a general observation of the second resident rooms was conducted. The bathrooms were dirty and in need of cleaning. On 9/7/23 at 7:35 AM Room 218 was observed to have plastic, disposable water bottles in the room. On 9/7/23 at 7:40 AM an observation of the second floor revealed no public drinking water station and no sinks to obtain water from in the public areas. On 9/7/23 at 7:35 AM Staff 10 (CNA) and Staff 24 (CNA) stated the only place staff could get water for the residents was the bathroom sink. Staff 10 stated the facility previously had a water station but staff were told it was too expensive so the residents had to drink water from the bathroom sink. Staff 10 further stated the residents in rooms 218 and 222 bought their own water because they did not want to drink bathroom sink water. Staff 10 stated this option was too expensive for the other residents so many of the other residents switched to juice. Staff 10 stated when a new resident was admitted and asked for water, staff would take their cup out of the room and fill it up in another bathroom so they would not know.

Arrangements have been made with a vendor to provide a water cooler/dispenser and maintain routine service/supply on both the first and second floors. Education provided to all staff regarding locations of appropriate drinking water sources and consequences of refilling water from inappropriate locations. DNS or designee will audit staff practices for obtaining resident drinking water multiple times each week. Audits will continue weekly x4 weeks, then monthly until substantial compliance is achieved. Audit results will be shared with QAPI committee to identify trends for further correction.

Based on observation, interview and interview it was determine the facilty failed to ensure resident equipment was in good working order for 2 of 2 floors reviewed for equipment. This placed residents at risk for accidents and injuries. Findings include: 1. The August 2023 maintenance records revealed Resident 19's bed had multiple work order requests for the bed to be fixed. On 8/29/23 at 10:57 AM Staff 10 (CNA) stated Resident 19's bed was broken, the foot of the bed would not go up, the resident would slide down and need to get boosted up three to four times each shift. The issue was put into the maintenance event log system several times but the bed had still not been fixed. On 8/29/23 at 11:07 an observation was completed of Resident 19's bed with Staff 3 (Regional RN). The bottom of the bed was at a lower angle. An unsuccessful attempt was made to move the foot of the bed up. Staff 3 verified Resident 19's bed was not in good working order as the foot of the bed was not level with the rest of the bed and not able to move upward. 2. On 8/29/23 at 10:57 AM Staff 10 (CNA) stated Resident 20 was supposed to go to an appointment the previous week however the wheelchair was broken so the transportation company refused to transport her/him. Staff 10 stated the maintenance director never fixed things and could always be found outside the building. On 8/29/23 at 11:11 AM an observation of Resident 20's wheelchair was completed with Staff 3 (Regional RN) and the back right wheel was not sitting on the wheelchair correctly. The resident was unable to say how long the wheel was broken. Staff 3 verified the right back wheel was broken and needed repair. 3. On 8/29/23 at 11:14 AM an unidentified CNA stated the bed in room 105B had a bed remote that "sometimes works, sometimes doesn't." The CNA stated staff had to crawl under the bed to take out the bed plug and than put it back in to get the remote to work again. On 8/29/23 at 11:15 AM Staff 3 (Regional RN) acknowledged the concern with Bed 105B's bed remote. 4. Request to review facility maintenance records for mechanical lifts revealed no documentation of any regular maintenance or calibration checks. On 9/7/23 at 9:07 AM Staff 24 (CNA) stated the facility stopped maintaining the mechanical lifts and were no longer being checked monthly like they were supposed to. Staff 24 said there was one mechanical lift that staff had to wiggle the wires to get it to work. On 9/7/23 at 7:45 AM Staff 28 (CNA) stated one mechanical lift did not work, the battery was fine, but staff had to "wiggle it up and down to get it to work". On 9/7/23 at 8:05 AM Staff 29 (Maintenance Director) stated he thought the mechanical lifts received maintenance and calibration every six months. Staff 29 stated "they just called one day, said we were due and came out the next day." Staff 29 stated he was unsure what the maintenance and calibration schedule was supposed to be and did not have any documentation when the maintenance check last occurred. .

Resident 19’s bed was immediately taken out of service and replaced with a new bed on 8/29/23. Wheelchair for resident #20 was removed from service (with resident’s approval) and replaced with a new wheelchair on 8/29/23. Bed in 105B was serviced and verified as working correctly on 8/29/23. Hoyer identified as non-functional was taken out of service on 8/29/23. All residents are at risk r/t broken hoyers, beds and/or wheelchairs. Facility-wide audit of all hoyers, wheelchairs and beds in use was completed 9/11/23 to ensure they are all in good working order. Maintenance Director at time deficiencies were identified is no longer employed by the facility. New Maintenance Director has been hired and training plan created. In-servicing for all staff on how to report broken equipment or environmental concerns and steps for immediate action will be completed. Maintenance plan will be reviewed by Regional Maintenance Director and used to train new Facility Maintenance Director on correct processes. Administrator or designee will randomly audit equipment within the facility to ensure proper functioning. Administrator or designee will audit maintenance logs weekly to ensure identified equipment or environmental concerns posing an immediate danger are pulled from service or repaired promptly. Results of equipment and maintenance audits will be shared with QAPI team to identify trends and additional corrective action.

******** OAR 411-086-0130 Nursing Services: Notification Refer to F580 ******** OAR 411-087-0100 Physical Environment: Generally Refer to F584 ******** OAR 411-085-0360 Abuse Refer to F602 ******** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ******** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658 and F684 ******** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689 ******** OAR 411-086-0250 Dietary Services Refer to F802, F803, F805 and F806 ******** OAR 411-086-0300 Clinical Records Refer to F842 ******** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ******** OAR 411-087-0100 Physical Environment Generally Refer to F908 ********

Based on interview and record review it was determined the facility failed to process physician laboratory orders timely for 1 of 3 sampled residents (#2) reviewed for UTIs (Urinary Tract Infection). This placed residents at risk for UTIs. Findings include: Resident 2 admitted to the facility in 7/2022 with diagnoses including schizoaffective (mood fluctuations which could cause symptoms, such as hallucinations or delusions) disorder and obesity. A physician order dated 8/3/22 indicated staff were to obtain a UA (urinalysis) with culture and sensitivity for Resident 2 every shift and staff were to discontinue the order once completed. A review of Resident 2's clinical record from 8/3/22 through 8/12/22 revealed the following: -8/3/22 a t 4:54 PM the physician was notified because Resident 2 reported ongoing frequent urination. The physician implemented a UA order. -8/3/22 a t 8:00 PM Resident 2's UA could not be completed until 8/8/22, then the lab would pick up the UA. -8/7/22 UA was collected but there were no specimen cups and tube to reserve the sample. -8/8/22 No UA cups were available. Supply request form was completed and faxed to the lab for delivery. -8/9/22 a t 4:14 PM UA and culture sensitivity was not collected and at 11:59 PM UA with culture and sensitivity was awaiting the lab. -8/10/22 Facility staff called the lab to inquire if Resident 2's UA had results and the lab clinical staff indicated they had not received any specimens for Resident 2. Facility staff explained the urine sample had been sent along with a fax but the lab clinical staff stated they had not received the specimen or a fax. A new UA was needed and awaiting collection of the new UA sample for Resident 2. A Urinalysis Culture Lab result dated 8/10/22 (eight days later) revealed a UA was completed for Resident 2 and was negative. The result was faxed back to the facility on 8/12/22 (10 days later). On 12/28/22 at 8:55 AM Staff 1 (Regional Interim DNS) acknowledged the UA was not obtained timely because in 8/2022 they transitioned to a new laboratory clinic and struggled receiving supplies from the new laboratory clinic.

1.) Resident 2 has been discharged from the facility. 2.) Resident/s in similar situation for labs services were reviewed and no issues noted. 3.) In-service of LN on lab processing and collecting UA’s, storage of UA and lab delivery by the DNS or designee. Process is available in LAB services book for agency or new LN to review. Labs will be audited and reviewed weekly by the DNS or designee for 4 weeks and then monthly for 90 days for timeliness. 4.) Any issues will be brought to QA for review and root cause analysis. 5.) Administrator and DNS responsible for compliance and F/U.

OAR-411-086-0010: Administrator

Refer to F770

Based on observation and interview it was determined the facility failed to keep a bathroom call light at accessible length for 1 of 1 sampled resident (#40) reviewed for environment. This placed residents at risk for not being able to call for assistance in the event of a fall. Findings include: Resident 40 admitted to the facility in 2022 with diagnoses including post-traumatic stress disorder. Resident 40 resided in room 104. The 9/2/19 Care Plan indicated Resident 40 was independent to moderate assistance with toileting. The Care plan indicate the resident was a moderate risk for falls related to weakness. On 10/31/22 at 12:30 PM the call light cord in the bathroom between rooms 104 and 102 was observed to be about eight inches long and not able to be reached from the floor level. On 11/4/22 at 11:45 AM the call light cord in the bathroom was observed to be short and frayed at the end. The cord measured seven inches long. Staff 20 (CNA) stated Resident 40 used the bathroom independently. Staff 20 stated she was not aware the call light string was short. Staff 20 confirmed the call light cord was not long enough and if a resident were to fall the cord could not be reached from ground level.

Resident 40 call light cord length has been adjusted to ensure it can be accessible Bathroom call lights in the facility have been audited to ensure they can be accessible Maintenance has been reeducated to validate resident call light lengths are appropriate and ensure they are accessible Administrator and/or designee to complete audits of 5 bathrooms weekly x4 and monthly x3 to validate call lights are accessible for residents. Results will be reviewed in QAPI Administrator and/or designee to ensure compliance

Based on interview and record review it was determined the facility failed to provide a written notification to 2 of 4 sampled residents (#s 53 and 264) reviewed for Beneficiary Protection Notices. This placed residents at risk for unknown financial liabilities. Findings include: 1. Resident 53 was admitted to the facility with Medicare Part A services (skilled services including therapy) on 7/21/22. The resident's last covered day of Part A services was 10/5/22 with the facility issuing a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) letting the resident know of potential financial liability because Resident 53 remained in the facility after Medicare Part A ended. There was no documentation indicating Resident 53 was issued a Notice of Medicare Non-Coverage (NOMNC) which notified the resident skilled services were ending and their right to an appeal. On 11/2/22 at 1:58 PM Staff 5 (Social Services) stated she issued both the NOMNC and SNF ABN at the time of Resident 53's discharge from skilled services however she was unable to provide documentation the NOMNC was issued as required. 2. Resident 264 was admitted to the facility with Medicare Part A services (skilled services including therapy) on 7/16/22. The resident's last covered day of Part A services was 8/10/22 and the facility initiated a discharge from Part A services before benefit days were exhausted. The resident remained in the facility. A review of Resident 264's record indicated a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) was not issued. On 11/3/22 at 12:57 PM Staff 5 (Social Services) stated she was not aware a Notice of Medicare Non-Coverage (NOMNC) and SNF ABN were both required to be issued to a resident if the resident remained in the facility if the skilled benefits were not exhausted.

Resident 53 and 264 have discharged Reviewed residents discharged in the last 30 days to validate NOMNC and ABN was issued as appropriate Social Services has been reeducated to the process of NOMNC and ABN Administrator and or designee to complete audits of residents discharging weekly x4 and monthly x3 to validate NOMNCs and ABNs are issued as appropriate. Results will be reviewed in QAPI Administrator and or designee to ensure compliance

1.

Based on observation and interview it was determined the facility failed to ensure comfortable sound levels were maintained in 1 of 2 halls (North Hall) for 3 residents (#s 13, 29 and 44) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include: From 10/31/22 through 11/3/22 the following observations were made from the hall and with residents present both in the hallway and in rooms with open doors: - 10/31/22 at 11:30 AM Resident 21 was sitting up in a wheelchair and was yelling out while in her/his room. One staff came into room and the resident continued to yell once the staff left the room. -10/31/22 at 12:04 PM the resident was yelling. -11/2/22 from 11:13 AM to 11:20 AM the resident was up in the wheelchair yelling off and on in a high pitch with periods of laughing. A staff was observed attempting to distract the resident, once the staff left the resident continued to yell. -On 11/2/22 at 11:13 AM Resident 13 was in her/his room (next to Resident 21) and heard Resident 21 yelling out and told the resident to "shut up." Resident 13 stated she/he did not care who "fucking" heard her/him yell at the resident. -11/3/21 at 11:19 AM Resident 21 was assisted to the wheelchair. Resident 21 started yelling and laughing intermittently in a high-pitched level. The following resident and staff interviews were completed: - On 10/31/22 at 11:30 AM Resident 29 stated Resident 21 yelled all day, and it was difficult to "live like this." Resident 29 stated she/he stayed up stairs most of the time due to the noise. Resident 29 stated the yelling did not help her/his mental health. - On 11/3/22 at 9:17 AM Resident 13 stated she/he heard Resident 21 yelling for hours at a time day and night. Resident 13 stated she/he was woken up during the night because of the yelling and it took her a while to go back to sleep. Resident 13 stated the resident yelled at different times during the night and even made her/him "jump" due to the noise. - On 11/3/22 at 9:14 AM Staff 11 (Personal Care Assistant) stated she did not know much about Resident 21 but was told the yelling due to anxiety. Staff 11 stated Resident 21 yelled on and off and sometimes the resident was quieter than other days. - On 11/3/22 at 9:34 AM Staff 12 (CNA) stated Resident 21's yelling had gotten worse. Staff 12 stated she believed the resident was not able to control the yelling. Staff 12 stated Resident 21 yelled during the night and woke up the other residents on the hall. Staff 12 stated residents do get upset with Resident 21's yelling and will tell the resident to "shut up." On 11/3/22 at 12:12 PM Staff 2 (DNS) and Staff 3 (Cooperate RN) confirmed Resident 21's yelling affected other resident's homelike environment. Refer to F740 2. Based on interview and record review it was determined the facility failed to ensure resident reported missing property was addressed and followed up on in a timely manner for 2 of 2 sampled residents (#s 12 and 49) reviewed for personal property. This place residents at risk for lost personal items. Findings include: The facility's 2004 Lost Item Policy indicated items brought to the facility were marked with the resident's name and recorded on a personal inventory sheet. If an item is noted to be missing, the resident or responsible party is expected to inform a staff member. A Lost item form is completed and forwarded to social services. If items are not recovered in initial search (three business days after receipt of the Lost Item form), then Administrator would determine further action needed or means of restitution. a. Resident 12 admitted to the facility in 3/2022 with diagnoses including diabetes. The 9/19/22 Quarterly MDS indicated Resident 12 was cognitively intact. Review of Resident 12's undated and unsigned inventory sheet indicated she/he had a night gown. On 10/31/22 at 1:49 PM and 11/1/22 at 1:16 PM Resident 12 stated she/he had lost several items a few months ago, including a small mirror, two pairs of black pants, a blue silk night gown with flowers and a white long summer dress. Resident 12 stated she/he reported the missing items, but nothing had come of it. The resident stated the items had not been found nor was she/he reimbursed for the items. Resident 12 stated she/he reported the missing items to Staff 4 (LPN Resident Care Manager Assistant) and recalled completing a missing item form. On 11/4/22 at 9:46 AM laundry staff indicated they were not aware of reported missing clothing for Resident 12. The unclaimed clothing rack was observed to not have Resident 12's missing clothing. On 11/4/22 at 11:15 AM Staff 5 (Social Services) stated she was not aware of reported clothing items or receiving a missing item form from Resident 12. On 11/4/22 at 12:51 PM Staff 4 (LPN Resident Care Manager Assistant) stated she recalled speaking to Resident 12 about missing clothing and other items. Staff 4 stated the resident was going to fill out the missing item form. Staff 4 stated the process was for her to obtain the completed form and work with laundry in looking for the missing items. Staff 4 stated she did not follow up with Resident 12 to ensure the form was completed or follow up to locate the missing reported items. , b. Resident 49 was admitted to the facility in 2020 with diagnoses including kidney disease. On 10/31/22 at 5:11 PM Witness 1 (Significant Other) stated Resident 49 had two white blankets with multi-colored stripes and both blankets were missing. Witness 1 stated one month prior she/he notified staff, including Staff 4 (LPN Resident Care Manager Assistant), but Witness 1 did not receive any follow-up from staff. On 11/3/22 at 9:27 AM Staff 5 (Social Services) stated if a resident or family reported a missing item a Missing Item form was filled out. Staff would verify if the resident had the item in the facility, would look for the item and if the item was not found, staff would communicate with the resident or family in order to agree on a resolution. Staff 5 stated she was not aware Resident 49 had missing blankets. On 11/3/22 at 11:23 AM Staff 4 stated she recalled Witness 1 mentioned missing blankets and she asked a CNA to look for the blankets. Staff 4 indicated she may have asked Witness 1 to fill out a Missing Item form but did not follow up with her/him.

Interventions have been put in place for behavioral resident. Resident 13, 29, and 44 have been interviewed to validate comfortable sound levels. Resident 12’s missing items have been investigated and replaced. Resident 49 has discharged. Residents in the center have been interviewed to validate there is comfortable sound levels and they do not have any missing personal items. Nursing and Interdisciplinary team have been reeducated to ensure there are comfortable sound levels and missing items are reported and investigated timely. Five resident interviews will be completed weekly x4 and monthly x3 to validate residents have comfortable sounds levels and any missing items have been reported and investigated. Results will be reviewed in QAPI. Administrator and or designee to ensure compliance

Based on interview and record review it was determined the facility failed to accurately code the MDS for 2 of 3 sampled residents (#s 19 and 62) reviewed for hospitalizations and vision. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 19 admitted in 2022 with diagnoses including diabetes. Resident 19's 9/2022 admission MDS indicated she/he had mild cognitive impairment, and her/his vision was adequate with corrective lenses. On 11/2/22 at 12:55 PM Staff 9 (LPN Resident Care Manager Assistant) stated she was unaware Resident 19 had glasses and did not believe she/he wore glasses. On 11/4/22 at 2:00 PM Staff 2 (DNS) and Staff 3 (Corporate RN) were provided this information and affirmed the MDS was likely coded in error. , 2. Resident 62 admitted to the facility in 2022 with diagnoses including adult failure to thrive. The 8/7/22 Discharge Return not Anticipated MDS coded Resident 62 as discharging to an acute hospital. An 8/7/22 progress note indicated Resident 62 discharged home. On 11/3/22 at 2:50 PM Staff 6 (RN, MDS Coordinator) confirmed 62's MDS was coded incorrectly, and the resident did not discharge to the hospital.

MDS for Residents #19 and #62 have had errors modified and transmitted. MDS completed in the last 14 days will be reviewed to ensure accuracy with regards to vision and MDS submission type. Education has been provided to the MDS coordinator regarding accuracy of assessments and accuracy of data input into MDS. DNS or designee will audit 5 MDS completed each week for accuracy in areas identified. Audits will continue weekly x4 weeks and then monthly. Audit results will be submitted to QAPI committee for review.

Based on observation interview and record review it was determined the facility failed to address vision needs in a timely manner for 1 of 2 sample residents (#19) reviewed for vision needs. This placed residents at risk impaired interaction with staff and the environment. Findings include Resident 19 admitted in 2022 with diabetes. Resident 19's 9/2022 admission MDS indicated she/he had mild cognitive impairment, and her/his vision was adequate with corrective lenses. On 10/31/22 at 11:00 AM Resident 19 stated she/he needed a vision appointment, but no one talked to her/him about this. A review of Resident 19's medical record revealed no documentation that indicated any steps were taken including offering services, contacting family, or making an appointment, to manage her/his vision needs. On 11/2/22 at 12:55 PM - Staff 9 (LPN Resident Care Manager Assistant) stated normally we try to schedule residents with services promptly. Staff 9 confirmed this did not occur for Resident 19.

Resident 19 has a vision appointment scheduled. Residents have been interviewed to validate vision services are provided as appropriate Interdisciplinary team has been reeducated to the process of vision services. Administrator and or designee to complete 5 resident interviews weekly x4 and monthly x3 to validate residents are receiving vision services as appropriate. Results will be reviewed in QAPI. Administrator and or designee to ensure compliance

Based on observation, interview and record review it was determined the facility failed to ensure the facility applied a splint for a resident with impaired ROM for 1 of 2 sampled residents (#28) reviewed for ROM. This placed residents at risk for pain. Findings include: Resident 28 was admitted to the facility in 2020 with diagnoses including dementia. A 1/2/22 OT Evaluation and Plan of Treatment form revealed the resident had a contracture of the left hand. The goal was for the resident to tolerate daily positioning with custom splinting to reduce contractures. On 10/31/22 at 11:48 AM a sign was observed to be posted in Resident 28's room above her/his bed. The sign was dated 1/2/22 and indicated the resident was to have a left hand splint. The splint was to be worn for four hours and was to be removed for one hour during the day or if the splint was not used gauze was to be placed under the fingers. A 10/2022 TAR revealed a left hand splint was applied at 8:00 AM on 10/1/22 and removed at 8:00 PM on 10/1/22. The treatment was discontinued after 10/1/22. A Care Plan updated on 10/2/22 indicated the resident had limited ROM and a splint was to be applied to the left hand in the morning and removed at bedtime. On 11/2/22 at 9:05 AM Resident 28 was observed in a wheel chair and was observed without a splint or gauze to the left hand. On 11/2/22 at 12:11 PM Staff 10 (CNA) stated she did not apply the resident's splint since her day shift started. Staff 10 indicated she was not aware the CNA staff were to apply the splint because at one time the nurses were putting the splint on the resident's hand and this was the first time she worked with the resident in a long time. On 11/02/22 at 10:38 AM Staff 8 (Restorative Aid) stated the nurses applied the splint but at times she helped the nurses. On 11/2/22 at 12:00 PM Staff 4 (LPN Resident Care Manager Assistant) stated the resident's contractures did not worsen since admission. The resident was not on a restorative program and the CNA staff were to apply the brace. Staff 4 acknowledged there was no task in the plan of care to direct the CNA staff to apply the splint. Staff 4 acknowledged there was no documentation to verify if the splint was applied after 10/2/22. Staff 4 also acknowledged the information from therapy which was dated 1/2/22 was not the same as what was on the resident's care plan and was not sure which treatment plan was accurate.

Splint use for resident #28 has been updated in the care plan and daily use documented. Current residents with splints for contractures have been reviewed to ensure appropriate care planning and documentation of use is in place. Education provided to clinical staff about importance of splint placement to prevent contractures, following care plans and documenting use. DNS or designee will audit 5 residents using splints weekly to ensure splint is in place and use is documented. Audits will continue weekly x4 weeks, then monthly. Audit results will be submitted to QAPI committee for review.

Based on interview and record review it was determined the facility failed to ensure resident received sufficient fluid intake and failed to follow RD recommendations for nutritional supplements for 3 of 4 sampled residents (#s 1, 25 and 49) reviewed for hydration and nutrition. This placed residents at risk for dehydration and weight loss. Findings include: 1. Resident 1 was admitted to facility in 2/2019 with diagnoses including diabetes and functional quadriplegia (complete immobility due to severe physical disability or frailty). The 9/26/22 Annual MDS indicated Resident 1 required extensive assistance, one-person with eating/drinking and had range of motion impairment to both her/his upper and lower extremities. Resident 1's 10/5/22 Care Plan included potential for fluid deficit related to dependence on staff for fluids. Interventions included hydration pass and assistance with intake. On 10/31/22 at 11:36 AM Witness 2 (Family) reported Resident 1's skin and lips were often dry and stated a request was made to the facility to offer Resident 1 hydration in between meals. When family visited Resident 1 and offered fluids to Resident 1, she/he would drink fluids quickly and wanted more. Resident 1 was observed on 10/31/22 at 11:16 AM and on 11/1/22 at 2:02 PM with dry, flaky skin around her/his cheeks and lips. On 11/1/22 between 9:10 AM to 11: 05 AM and 11/3/22 between 1:18 PM to 3:13 PM Resident 1 was observed to not have any fluids on her/his bedside table for hydration. On 11/2/22 at 10:24 AM Staff 18 (CNA) reported she was aware Resident 1 needed extra hydration, and usually gave her/him a drink during a snack pass but that intervention was not on the Kardex. Staff 18 stated Resident 1 would drink all the fluids when offered. On 11/4/22 at 12:32 PM Staff 9 (LPN Resident Care Manager Assistant) reviewed the resident's Care Plan and hydration pass task and acknowledged there was no documentation for the past 30 days. She stated the original order started in March 2022 and restarted in July 2022 with no associated documentation to indicate the intervention was ever implemented. Staff 9 stated the order was entered into the electronic health record incorrectly and did not show up in the Kardex for the staff to follow. , 2. Resident 25 was admitted to the facility in 2016 with diagnoses including traumatic brain injury. A 5/29/22 Nutrition Assessment indicated the resident was assisted by staff to eat and was supervised for meals. The resident required 1800 to 2400 ml/day. The resident's hydration status was assessed to be good. A Care Plan revised 2/2020 indicated the resident was at risk for aspiration and required staff to assist the resident with fluids. Fluids were not to be left at the bedside. The Care Plan also indicated the resident was at risk for dehydration, was on a Fluid Enhancement Program (scheduled fluids) and staff were to provide the resident 120 ml of fluids three times a day. The resident's 10/2022 MAR and TAR did not indicate fluids were provided to the resident three times a day. Resident 25's CNA Hydration Pass documentation for the last 30 days revealed no data. On 11/3/22 at 9:51 AM Staff 14 (CNA) stated the resident at times could drink on her/his own but had to sit upright and had to be supervised. The resident usually drank at meals. If the resident wanted fluids between meals they would provide the resident fluids. On 11/3/22 at 9:53 AM Staff 13 (LPN) stated if fluids were scheduled between meals it was often documented on the MAR or TAR, but other times the CNAs documented if fluids were provided between meals. On 11/3/22 at 10:45 AM Staff 4 (LPN Resident Care Manager Assistant) stated the resident at times could drink independently but staff supervised the resident when she/he drank fluids. The resident usually drank plenty of fluids with meals while in the dining room. Staff 4 stated if a resident was on a Fluid Enhancement Program it was usually documented on the MAR or TAR. Staff 4 acknowledged the resident's Care Plan had interventions for staff to provide extra fluids three times a day. When Resident 25 was hospitalized 5/2022 the intervention was not re-implemented. 3. Resident 49 was admitted to the facility in 2020 with diagnoses including kidney disease. A Care Plan initiated 8/15/20 revealed Resident 49 went to dialysis (treatment which filters wastes/toxins from blood due to kidney failure) on Tuesdays, Thursdays and Saturdays with a start time of 7:15 AM. A September 2022 MAR revealed the resident was to be administered a nutritional supplement daily at 8:00 AM. The resident was not administered the supplement on Tuesdays, Thursdays and Saturdays because the resident was out of the facility. At times on non-dialysis days the resident refused the supplement. A 9/30/22 RD Progress Note indicated the resident was overweight but had undesired weight loss despite interventions. The resident was to be provided a nutritional supplement daily and the resident did not receive the supplement three times a week because the resident was at dialysis. The recommendations was to change the administration times of the supplements to ensure it was administered when the resident was not at dialysis. Review of the October 2022 MAR revealed the supplement administration time was not changed. On 11/3/22 at 11:08 AM Staff 4 (LPN Resident Care Manager Assistant) stated after the RD made a recommendation the facility staff were to implement the changes. Staff 4 acknowledged the 9/30/22 RD recommendations were not implemented.

Resident 49 has expired. Resident #1, #25 and #49 care plans have been updated to reflect hydration pass and capture staff documentation of amounts consumed. Other residents care planned for hydration pass have been reviewed to ensure documentation is occurring. Education provided to clinical staff about importance of hydration pass being completed and documenting amount consumed. DNS or designee will audit 5 residents with hydration pass to ensure care plan is being followed and documentation is occurring. Audits will continue weekly x4 weeks, then monthly. Audit results will be submitted to QAPI committee for review.

Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to ensure call lights were answered timely and bathing was completed for 1 of 2 floors (first floor) reviewed for staffing. This placed residents at risk for lack of hygiene and delayed care. Findings include 1. Resident Council Notes for 9/2022 and 10/2022 were reviewed with Staff 17 (Activities) and revealed the residents reported long call light response times. On 11/2/22 at 3:15 PM room 114's call light was activated by the resident. At 3:30 PM non-nursing staff entered the resident's room and the resident stated she/he was waiting for her/his CNA. At 3:47 PM, 32 minutes later, Staff 15 (CNA) entered the resident's room. At 11/2/22 at 3:54 PM Staff 15 stated she was assisting another resident with bathing and she was not able to answer the call light for room 114. Staff 15 stated her/his hall partner was split between the first and second floor and the hall partner was not available to answer the light when she was bathing the other resident. Staff 15 stated when there were only four staff scheduled on the evening shift on the first floor it was very difficult to ensure call lights were answered timely. On 10/31/22 at 10:19 AM Resident 3 (9/21/22 MDS-Cognitively Intact) stated on the evening shift it took up to 30 minutes for the call light to be answered. Resident 3 denied negative outcomes with the long wait times. On 10/31/22 at 11:36 AM Resident 39 (8/26/22 MDS-Cognitively Intact) stated she/he waited up to 40 minutes on evening shift because there was not enough staff. On 11/1/22 at 3:06 PM Staff 16 (LPN) stated staffing was difficult for the first floor. There were many residents who required mechanical lifts and two staff for cares. Staffing ratios did not always seem to be based on acuity. On 11/3/22 at 1:06 PM findings were reviewed with Staff 2 (DNS). Staff 2 stated call lights ideally should be answered within 15 minutes. 2. a. Resident 30 was admitted to the facility in 2016 with diagnoses including chronic lung disease. Resident 30's bathing record revealed the resident refused a bath on 10/29/22. On 11/2/22 at 9:31 AM and 11/2/22 at 10:49 AM Staff 7 (CNA) stated the facility was short staffed on 10/29/22 and she was not able to give a bath to Resident 30. It was documented as refused but she did not know how else to document, but verified she did not provide the resident bathing because she did not have time. On 11/3/22 at 1:06 PM findings were reviewed with Staff 2 (DNS). No additional information was provided. b. Resident 24 was admitted to the facility in 2021 with diagnoses including heart disease. Resident 24's bathing record revealed she/he refused bathing on 10/29/22. On 11/2/22 at 9:31 AM and 11/2/22 at 10:49 AM Staff 7 (CNA) stated the facility was short staffed on 10/29/22 and she was not able to give a bath to Resident 24. It was documented as refused, but she did not know how else to document, but verified she did not provide the resident bathing because she did not have time. On 11/3/22 at 1:06 PM findings were reviewed with Staff 2 (DNS). No additional information was provided.

Current Residents were interviewed about call light response times. Current residents not receiving a bath or shower in the last week were interviewed to ensure the opportunity was provided. If not, they were offered a bathing at that time. Education was provided to clinical staff about bathing as scheduled. Bathing schedule was reevaluated for optimal distribution across days and shifts and resident preferences taken into account. Education has been provided to Staffing Coordinator about staffing ratios for CNAs, NAs and PCAs. Daily staffing meeting has been scheduled between the Administrator, DNS and Staffing Coordinator to review coverage and potential gaps. Acuity of census and planned admits will be evaluated during staffing meeting to ensure current and planned staff coverage is adequate to meet resident needs. DNS or designee will audit daily for refusals of showers and reason refused or not given. The call light alert system will be checked daily to see that it is functioning appropriately. A weekly call light audit will be done by Administrator or designee. After 4 weeks, audits will continue monthly. Any issues will be reviewed and reported to QA

Based on observations, interview and record review it was determined the facility failed to re-evaluate, assess and implement interventions of behavioral needs for 1 of 1 sampled resident (#21) reviewed for behavior/emotional health. This placed residents at risk for unmet psychosocial well being. Findings include: Resident 21 admitted to the facility in 2018 with diagnoses including Alzheimer's Disease, schizophrenia, depression and altered mental status. From 10/31/22 through 11/3/22 the following observations were made from the hall and with residents present both in the hallway and residents' room: -10/31/22 at 11:30 AM Resident 21 was sitting up in a wheelchair and was yelling out while in her/his room. One staff came into the room and the resident continued to yell once the staff left the room. - 10/31/22 at 12:04 PM the resident continued to yell. - 11/2/22 from 11:13 AM to 11:20 AM the resident was up in the wheelchair yelling off and on in a high pitch with periods of laughing. Staff were observed attempting to distract the resident. Once the staff left the resident continued to yell. - On 11/2/22 at 11:13 AM Resident 13 was in her/his room (next to resident 21's room) and Resident 21 was heard yelling out and told the resident to "shut up." Resident 13 stated she/he did not care who "fucking" heard her/him yell at the resident. - 11/3/21 at 11:19 AM Resident 21 was assisted to the wheelchair. Resident 21 started yelling and laughing intermittently in a high-pitched tone. Resident and staff interviews revealed the following: - On 10/31/22 at 11:30 AM Resident 29 stated Resident 21 "yelled all day" and it was difficult to "live like this." Resident 29 stated she/he stayed upstairs most of the time due to the noise. Resident 29 stated the yelling did not help her/his "mental health." - On 11/3/22 at 9:17 AM Resident 13 stated she/he heard Resident 21 yelling for hours at a time day and night. Resident 13 stated she/he was woken up during the night because of the yelling and it took her a while to go back to sleep. Resident 13 stated the resident yelled at different times during the night and even made her/him "jump" due to the noise. - On 11/3/22 at 9:14 AM Staff 11 (Personal Care Assistant) she did not know much about Resident 21 but was told the yelling was due to anxiety. Staff 11 stated Resident 21 yelled on and off and sometimes the resident was quieter than other days. - On 11/3/22 at 9:34 AM Staff 12 (CNA) stated Resident 21's yelling had gotten worse. Staff 12 stated she believed the resident was not able to control the yelling. Staff 12 stated Resident 21 yelled during the night and woke up the other residents on the hall. Staff 12 stated residents would get upset with Resident 21's yelling and would tell the resident to "shut up." The 10/24/18 Care Plan indicated Resident 21 displayed ineffective coping with displays of verbal aggression and hallucinations related to mental illness. Resident 21 was noted to be resistive to cares at times with staff. Interventions included keep schedules and routines, notify the physician if behaviors interfere with functioning and to refer to mental health evaluation as needed. There was no indication the care plan was updated related to Resident 21's behaviors of yelling out and laughing with interventions to alleviate the behaviors. Review of progress notes revealed the following: - 7/25/22 care conference summary indicated Resident 21 often yelled, "hooted" and laughed inappropriately when up in chair at times. - 8/15/22 physician visit indicated Resident 21 had a reduction in psychotropic medications but continued to be loud, laugh, "woo/hoo very loud." Resident showed no signs of distress or anxiety. - 9/10/22 Resident 21 continued to yell and make loud noises when up in wheelchair and when taken to dining room or the hallway. Resident was noted to have behaviors related to being overstimulated. - 9/12/22 Resident 21 denied pain or discomfort but still called out when overstimulated. - 10/23/22 Resident 21 remained in her/his room and hollered out of anxiety and did not like lots of noise or people as it caused stress. Resident 21 was noted to like to watch movies. Social Services noted the resident "whoops". The resident no longer ate in the dining room related to distress. - 10/25/22 Resident 21 was alert with confusion, called out more often and appeared anxious when awake. The resident was noted to call out with "hysterical" laughing at times. Hospice was discussed with Resident 21's family. - 10/29/22 Resident 21 continued to yell impulsively. A 9/28/22 Mental Health evaluation indicated Resident 21 demonstrated inappropriate laughter. Resident 21's medications were recently changed, and it was unable to be determined if psychotic symptoms were related to the resident's mental health, overall, cognitively decline or multifactorial. A neurological consult was recommended for worsening dementia symptoms and behaviors. There was no indication in Resident 21's medical record of any specific interventions implemented related to the behaviors, behavior monitoring, documented follow up related to the recommendation for a neurological consult or assessments related to how to address the residents' behaviors. On 11/3/22 at 12:12 PM Staff 2 (DNS) and Staff 3 (Cooperate RN) confirmed Resident 21's behaviors were not reflected on the care plan. Staff 3 stated there was no behavior monitoring in place and both staff confirmed Resident 21's behaviors were not being addressed adequately.

Resident #21 has been assessed for appropriate interventions and care plan updated with changes. Current residents displaying disruptive behaviors in the last 2 weeks have been reviewed to ensure interventions are effective. Education provided to clinical staff about importance of identifying and controlling disruptive behaviors, including proper assessment for unmet needs. Residents displaying behaviors will be discussed during daily clinical reviews to ensure behaviors are addressed in the care plan and Kardex, with appropriate interventions in place. DNS or designee will review 5 behavioral residents weekly x4 and then monthly to validate resident behaviors are documented with interventions, outcomes and care plans match. Audit results will be submitted to QAPI committee for review.

Based on observation, interview and record review it was determined the facility failed to ensure a resident was assisted in obtaining timely dental services for 2 of 4 sampled residents (#s 19 and 32) reviewed for dental services. This placed residents at risk for worsening dental status. Findings include: 1. Resident 32 was admitted to the facility in 2022 with diagnoses including heart disease. A 5/21/21 Significant Change MDS indicated the resident was discharged from hospice. The resident was assessed to have broken front teeth, likely had cavities but denied pain. The resident was able to eat as desired. A Care Plan initiated in 2020 indicated the resident had dental health problems related to missing and broken teeth and staff were to coordinate arrangements for dental care as needed. The resident's record revealed dental services were not provided until 10/13/22. Resident 32's 10/13/22 dental visit summary note revealed the plan was to remove non-fixable decayed teeth and make a partial. On 11/3/22 at 9:24 AM Staff 5 (Social Services Director) stated if a resident was assessed to have dental issues a referral was made for the dentist. Staff 5 stated she was not sure the reason Resident 32 was not provided dental services prior to 10/2022. On 11/3/22 at 10:58 AM a request was made to Staff 4 (LPN Resident Care Manage Assistant) to provide documentation if dental services were offered to Resident 32 prior to 10/2022. No additional information was provided. , 2. Resident 19 admitted in 2022 with diagnoses including diabetes. Resident 19's 9/2022 admission MDS indicated she/he had mild cognitive impairment and had obvious or likely cavities or broken natural teeth. On 10/31/22 at 11:00 AM Resident 19 stated she/he needed a dental appointment and wanted dentures, but no one had done anything. A review of Resident 19's medical record revealed no documentation that indicated any steps were taken including offering services, contacting family, or making an appointment, to manage her/his dental needs. On 11/2/22 at 12:55 PM Staff 9 (LPN Resident Care Manager Assistant) stated normally we will try and get residents scheduled with services promptly. Staff 9 confirmed this did not occur for Resident 19.

Resident 19 has a dental appointment scheduled. Resident 32 has recently been seen by a dentist. Residents in the facility have been interviewed to validate dental services are provided as appropriate. Interdisciplinary team has been reeducated to the process of dental services. Administrator and or designee to complete 5 resident interviews weekly x4 and monthly x3 to validate residents are receiving dental services as appropriate. Results will be reviewed in QAPI. Administrator and or designee to ensure compliance

Based on interview and record review it was determined the facility failed to ensure residents' medical records were complete and accurate for 2 of 7 sampled residents (#s 15 and 19) reviewed for care planning and unnecessary medications. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 15 admitted in 2022 with diagnoses including major depression. Resident 15 had a prescription for Aripiprazole 5 mg which was reduced via gradual dose reduction (GDR) from 10 mg on 7/4/2021. Documentation revealed there was no subsequent GDR attempted. On 11/4/22 at 11:30 AM Staff 9 (LPN care manager) located documentation that indicated Resident 15 was not on Aripiprazole from 4/29/22 through 5/3/22. On 11/4/22 at 1:30 PM Staff 3 (Corporate RN) located documentation indicating a GDR attempt that was not carried out due to Resident 15 discharging to the hospital in 4/2022. Staff 3 confirmed none of the information provided by Staff 9 or herself was locatable in the medical record. 2. Resident 19 admitted in 2022 with diagnoses including major depressive disorder. A review of Resident 19's medical record revealed a physician's order for Zyprexa (an antipsychotic) with an indication for use of Major depression. On 11/3/22 at 1:50 PM Staff 4 (LPN Care Manager) located a 9/22/22 pharmacy review signed by the physician on 9/28/22 and noted by her. The 9/22/22 pharmacy review indicated the major depressive disorder diagnosis was not an appropriate diagnosis for the use of Zyprexa. The physician signed in agreement to change the diagnosis to "mood disorders (e.g. bipolar... and/or psychotic features)". Staff 4 stated she did not know why the diagnosis change was not input into Resident 19's chart but it should have been. 3. Resident 19 admitted in 2022 with diagnoses including chronic pain. Resident 19's 9/2022 Admission MDS indicated she/he had mild cognitive impairment and was frequently in moderate pain. On 10/31/22 at 11:00 AM Resident 19 stated the facility changed her/his medication orders without involving her/him. Resident 19 further stated there was no problem with the prior order, so she/he did not understand why the order was changed. Resident 19 indicated her/his PRN order had changed from every 6 hours to every 8 hours. A review of Resident 19's medical record indicated she/he admitted with a PRN pain control order to be administered no more often than every six hours. The medical record provided no indication when Resident 19 was made aware the order was changed to every eight hours. On 11/4/22 at 2:45 PM Staff 4 (LPN Resident Care Manager Assistant) stated she spoke with the resident's physician and resident about adjusting her/his pain control and the physician stated to change the interval to every eight hours. Staff 4 confirmed that information was not in Resident 19's medical record.

Medical record for resident #19 has been updated for diagnosis updates per provider instructions. Resident #15 is no longer being recommended for a GDR of antipsychotic use. Current residents utilizing psychotropic medications have been reviewed to ensure diagnosis identified is appropriate for use. Attempts for Gradual Dose Reductions not yet addressed by the provider have been documented in resident charts. Education provided to RCMs about importance of timely and accurate diagnosis updates. Education also provided about documenting attempts to reach providers for Gradual Dose Reductions and timely follow-up. DNS or designee will audit pharmacy recommendation responses to ensure updates are made to the EMR. Audits will be weekly x4 as pharmacy recommendations are received, then monthly. Audit results will be submitted to QAPI committee for review.

Based on interview and record review it was determined the facility failed to ensure CNA minimum ratios were maintained for 19 of 30 days reviewed. This placed residents at risk for unmet care needs. Findings include: Review of the 10/1/22 through 10/30/22 Direct Care Staff Daily Report forms revealed the following shifts were short at least one CNA: -10/2/22 day shift -10/7/22 evening shift -10/8/22 day and evening shift -10/12/22 day and evening shift -10/13/22 day and evening shift -10/14/22 day and evening shift -10/15/22 evening shift -10/17/22 day and evening shift -10/18/22 day shift -10/19/22 evening shift -10/20/22 day and evening shift -10/21/22 day and evening shift -10/22/22 evening shift -10/23/22 day shift -10/24/22 day shift -10/26/22 day and evening shift -10/27/22 day, evening and night shift -10/29/22 evening shift -10/30/22 day shift On 11/3/22 at 1:06 PM the above findings were reviewed with Staff 2 (DNS). Staff 2 indicated the facility used agency staff as needed and tried to ensure there were enough staff to meet resident needs. A request was made to Staff 2 to provide documentation to verify minimum CNA ratios were met on the above dates. No additional information was provided.

Education has been provided to Staffing Coordinator about staffing ratios for CNAs, NAs and PCAs. Daily staffing meeting has been scheduled between the Administrator, DNS and Staffing Coordinator to review coverage and potential gaps. Facility continues with weekly retention and hiring meeting. Administrator or designee will audit daily staffing sheets 5x/week to verify staffing ratios were met. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

OAR 411-086-0360 Resident Furnishings, Equipment

Refer to F558 *************** OAR 411-085-0320 Residents' Rights: Charges and Rates Refer to F582 *************** OAR 411-085-031 Residents' Rights: Generally Refer to F584 *************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F641 ************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F685 *************** OAR 411-086-0150 Nursing Services: Restorative Care Refer to F688 *************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to 692 *************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ************** OAR 411-086-0240 Social Services Refer to F740 *************** OAR 411-086-0210 Dental Services Refer to F791 *************** OAR 411-086-0300 Clinical Records Refer to F842 ***************

Based on interview and record review it was determined the facility failed to asses the resident's respiratory status for 1 of 3 sampled residents (#1) reviewed for change of condition. This placed residents at risk for respiratory complications. Findings include: Resident 1 admitted to the facility in 2015 with diagnoses including chronic obstructive pulmonary disease (COPD) and heart failure. The resident's current respiratory therapy care plan indicated Resident 1's 02 sats was to remain greater than or equal to 89%. Staff were to evaluate respiratory status as indicated for signs and symptoms of impaired respiratory function, including rapid shallow respirations, dyspnea (difficult or labored breathing), orthopnea (discomfort breathing while lying down), coughing, restlessness, irritability, confusion, somnolence, and skin discoloration. A 7/19/22 at 7:47 AM Progress Note indicated Resident 1 complained of shortness of breath and could not reposition. The resident's oxygen decreased to 84%. The oxygen was adjusted and the note indicated the resident was breathing abdominally during sleep. Staff 4 (LPN) attempted to auscultate (listen with a stethoscope) the resident's lungs but was unable to due to body habitus. The medical provider was documented as notified. There was no evidence in the medical record of a respiratory assessment for Resident 1 until 7/19/22 at 6:26 PM. There was no evidence alert charting was initiated for respiratory status. On 8/2/22 at 10:55 AM and 8/4/22 at 12:10 PM Staff 4 confirmed there was no full respiratory assessment, no alert charting documented, and she did not seek assistance to auscultate Resident 1's lungs. On 8/3/22 at 9:16 AM Staff 3 (LPN Resident Care Manager) stated the expectation was for residents to be placed on alert charting for difficulty breathing so nurses could monitor their status and document the status in progress notes. Staff 3 further stated nurses were expected to assess if the resident was using accessory muscles, gasping, listen to lungs and sounds, take the resident's pulse, and take the resident's blood pressure. Staff 3 stated if a nurse was unable to listen to lung sounds the nurse was expected to find another nurse to assist. On 8/3/22 at 9:05 AM Staff 1 (DNS) verified staff did not perform full respiratory assessment and the medical record did not reflect interventions implemented to address the resident's respiratory change of condition. Refer to F842.

1.) Resident 1 has returned to the facility. BIPAP machine has been replaced, setting checked and correct. BIPAP mask replaced. Care plan updated with sitting, vendor contact info. and assessments. TAR updated for daily monitoring. 2.) All resident /s in a similar situation have been assessed, Care plans updated, and TAR updated for assessment, documentation and monitoring of CPAP or BIPAP. 3.) Respiratory education by the DNS is done with all nurses: Lung sounds, Chest movement, color of skin, type of breathing, resident/s response to tx. Education on change of conditions, Acute change of condition and notifications. Timely charting by the DNS has also been completed. 4.) The DNS or designee will audit residents with BIPAP or CPAP weekly for 4 weeks and then monthly to ensure correct documentation and changes of condition have been documented and followed through on. After 4 weeks, this will continue monthly. 5.) Results of the audits will be brought to QA until substantial compliance has been met.

Based on interview and record review it was determined the facility failed to ensure the resident's medical record was complete and accurate for 1 of 3 sampled residents (#1) reviewed for change of condition. This placed residents at risk for inaccurate medical records. Findings include: Resident 1 admitted to the facility in 2015 with diagnoses including chronic obstructive pulmonary disease (COPD) and heart failure. A 7/19/22 at 7:47 AM Progress Note indicated Resident 1 complained of shortness of breath and could not reposition. The resident's 02 sats decreased to 84%. The oxygen was adjusted and the note indicated the resident was breathing abdominally during sleep. Staff 4 (LPN) attempted to auscultate (listen with a stethoscope) the resident's lungs but was unable to due to body habitus. The medical provider was documented as notified. There were no other notes in the medical record related to Resident 1's respiratory status until 7/19/22 at 6:26 PM when the resident was sent out to the hospital for respiratory distress. There was no indication the resident had a respiratory assessment, respiratory status monitoring throughout the day, and there was response from the medical provider available in the record. The Vitals Sheet indicated Resident 1 had the following Oxygen (02) Saturations on 7/19/22: *12:42 AM, 94% on room air *9:50 AM, 91% on oxygen via nasal cannula *11:41 AM, 91% on oxygen via nasal cannula by Staff 7 (CNA) There were no other 02 sats documented in the medical record. On 8/4/22 at 10:38 AM and 10:55 AM Staff 7 (CNA) stated she documented the 02 saturation in Resident 1's medical record at 11:41 AM but she took the oxygen saturation at around 6:20 AM on 7/19/22. Staff 7 further stated she had concerns related to Resident 1's respiratory status at 10:00 AM on 7/19/22 and believed she reported the concern to Staff 4 (LPN). There was no evidence in the medical record of Staff 7's concern related to Resident 1's respiratory status around 10:00 AM. On 8/2/22 at 10:55 AM and 8/4/22 at 12:10 PM Staff 4 (LPN) stated she was aware of staff concerns about the resident's respiratory status and assessed and took Resident 1's 02 sat throughout the day but "probably did not put everything into the computer." On 8/4/22 4:22 PM Staff 1 (DNS) confirmed assessments, vitals, and the medical provider's response regarding Resident 1's respiratory status was not documented in the medical record for the resident's change of condition.

1.) Resident 1 has returned to the facility. BIPAP machine has been replaced, setting checked and correct. BIPAP mask replaced. Care plan updated with sitting, vendor contact info. and assessments. TAR updated for daily monitoring. 2.) All resident /s in a similar situation have been assessed, Care plans updated, and TAR updated for assessment, documentation and monitoring of CPAP or BIPAP. 3.) Respiratory education by the DNS is done with all nurses: Lung sounds, Chest movement, color of skin, type of breathing, resident/s response to tx. Education on change of conditions, Acute change of condition and notifications. Timely charting by the DNS has also been completed. 4.) The DNS or designee will audit residents with BIPAP or CPAP weekly for 4 weeks and then monthly to ensure correct documentation and changes of condition have been documented and followed through on. After 4 weeks, this will continue monthly. 5.) Results of the audits will be brought to QA until substantial compliance has been met.

********************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F695 ********************* OAR 411-086-0370 Clinical Records Refer to F842 *********************

, Based on interview and record review it was determined the facility failed to obtain copies of Advance Directives for 2 of 4 sampled residents (#s 36 and 42) reviewed for Advance Directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 36 admitted to the facility in 4/2022 with diagnosis including dementia and congestive heart failure. A 5/2/22 MDS revealed Resident 36 was cognitively impaired. A 5/20/22 Care Plan revealed "Patient wishes regarding Advanced Directive to be honored." There was no documentation regarding an Advance Directive being present, offered or reviewed. On 6/17/22 at 8:36 AM Staff 7 (Regional RN Consultant) stated it was her expectation for staff to go over Advance Directives within 72 hours of admission. 2. Resident 42 admitted to the facility in 4/2022 with diagnosis including congestive heart failure. A 5/9/22 MDS revealed Resident 42 was cognitively intact. A 5/16/22 Care Plan revealed "Patient wishes regarding Advance Directives to be honored." There was no documentation regarding an Advance Directive being present, offered or reviewed. On 6/17/22 at 8:36 AM Staff 7 (Regional RN Consultant) stated it was her expectation for staff to go over Advance Directives within 72 hours of admission. On 6/21/22 at 11:34 AM Resident 42 stated she/he could not recall if the facility offered to go over an Advance Directive with her/him.

Resident 36 has discharged. Resident 42 Advance directives reviewed with resident All resident reviewed to ensure Advance directives have been discussed and documented in the last 90 days. IDT members will be in-serviced on importance of discussing and offering advance directives on admit and quarterly. Admission manager will include A/D request with documentation when meeting with patient family on admit to referring facility. Advance directives will also be discussed at 72-hour huddles. Administrator or designee will audit 72-hour huddles and care conferences for documentation of Advanced Directive conversations. Audits will be done weekly x4 weeks and then random audits monthly for 3 months. Issues will be brought to QA.

Based on observation and interview it was determined the facility failed to ensure the facility had a medication error rate of less than five percent for 2 of 3 sampled residents (#s 7 and 42) observed for medication administration. This placed residents at risk for ineffective medication regimen. Findings include: 1. On 6/15/22 at 8:03 AM Staff 9 (CMA) was observed to administer Resident 7 Synthroid (hormone to treat low thyroid levels). Staff 9 acknowledged the resident was administered the Synthroid after the resident ate some breakfast and the medication should be given on an empty stomach. On 6/16/22 at 10:45 AM Staff 3 (LPN Resident Care Manager) stated Synthroid was to be administered on an empty stomach 2. On 6/15/22 at 8:10 AM Staff 9 (CMA) was observed to mix together and administer Resident 42 Tylenol (pain medication), Aspirin (non-steroidal anti-inflammatory), actigall (cholesterol medication), baclofen (muscle relaxant), cymbalta (antidepressant), gabapentin (anticonvulsant), atarax (antihistamine), midodrine (increases blood pressure), klonopin (anticonvulsant), valproic acid (anticonvulsant) and carafate (treats ulcers). On 6/16/22 at 2:46 PM and 2:55 PM Staff 7 (Regional RN Consultant) stated carafate should not be mixed with other medications because it decreased the efficacy of the other medications. Staff 7 further stated other medications were not to be given within one hour of carafate administration. The facility had 11 errors in 31 opportunities for an error rate of 35%.

Resident 42 medications were reviewed by pharmacy and medication that should not be mixed with others have been identified. Resident 7 has had no adverse effects to medication administration after eating. MAR was updated to reflect appropriate administration time. Residents with orders for carafate been reviewed and scheduled to allow for separate administration. Residents taking Synthroid have been updated on MAR to reflect appropriate administration times. Nurses and Med Aides in-serviced on crushing meds and concurrent administration. Admits will be audited for use of carafate to ensure separate timed administration. Med administration competency will be done with Nurses and Med Aides on hire, annually, and with any significant med error. DNS or designee will audit 5 med administrations weekly. Audits will continue weekly x4 weeks, then monthly x3 months. Continual issues will be brought to QA.

Based on observation, interview and record review it was determined the facility failed to administer the correct insulin dose and failed to ensure extended release medications were not crushed for 2 of 6 sampled residents (#s 16 and 55) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: 1. Resident 16 was admitted to the facility in 9/2016 with diagnoses including diabetes. Resident 16's Annual MDS dated 12/27/21 indicated the resident had mild cognitive impairment. Resident 16's physician order dated 1/6/22 revealed Lantus solution (long acting insulin providing consistent blood sugar control) 15 units was to be injected at bedtime related to diabetes. A progress note dated 5/4/22 indicated due to the incorrect amount of insulin administered to Resident 16, the physician was notified and the resident was sent to the hospital for overnight monitoring. A facility incident report dated 5/4/22 indicated Resident 16 received her/his roommate's Lantus of 58 units rather than the resident's ordered Lantus of 15 units. The report concluded a medication error occurred and as a result the resident was sent to the hospital. Witness statements in the report included a statement by Staff 23 (Former Agency LPN/staff who made the error) and indicated Staff 23 was interrupted when administering insulin and accidentally gave Resident 16 her/his roommate's 58 unit dose of Lantus. Resident 16's Hospital Discharge Notes dated 5/7/22 indicated Resident 16 was admitted to the hospital due to an insulin overdose. The resident was not in distress. The notes indicated the resident was administered intravenous glucose solution and the residents blood sugars increased to 200-300. Staff 23 was not able to be reached for an interview. On 6/15/22 at 12:16 PM Staff 3 (LPN Resident Care Manager) confirmed Resident 16 received 58 units of insulin in error rather than the 15 units prescribed and as a result the resident went to the hospital for two days. On 6/17/22 at 10:40 AM Staff (Regional RN Consultant), who completed the facility investigation, confirmed the medication error was substantiated by the facility. , 2. Resident 55 was admitted to the facility in 2022 with diagnosed including bowel perforation. A 5/23/22 MDS revealed Resident 55 was cognitively intact. On 6/15/22 at 8:47 AM with Staff 12 (CMA) Resident 55's medications cards were observed to include Metformin Extended Release (decreases blood sugar). The resident's electronic MAR screen revealed a note that all medications were to be crushed. On 6/15/22 at 9:00 AM Resident 15 stated all her/his medications were crushed and it made her/him nauseous and she/he was nauseated for at least a couple of days. The resident also stated her/his potassium (supplement) pill was crushed prior to administration. On 6/15/22 at 9:14 AM Staff 24 (LPN) stated Resident 55's physician provided an order to crush medications as appropriate. Staff indicated she did not know which medications should or should not be crushed. On 6/15/22 at 10:34 AM Staff 4 (LPN Resident Care Manager) stated Resident 55 had orders for staff to crush medications as appropriate and she was aware the staff crushed the resident's medications. Staff 4 stated extended release medications should not be crushed. Staff 4 further stated if a resident had extended release medications which needed to be crushed staff were to request an order for the liquid form of the medication. On 6/15/22 at 10:42 AM Staff 2 (DNS) stated staff should know the difference between instant release and extended release medications and which medications could be crushed. Staff 2 stated potassium was not be crushed and if extended release medications were crushed adverse medication reactions could occur.

Resident 55 has discharged. Resident 16 insulin orders reviewed and correct. Resident/s at risk for similar errors have been identified, orders reviewed and alerts in place. Nurses and Med Aides staff in-serviced immediately on uncrushable medications and a list of medications that can’t be crushed has been made available at each med cart and nurses station. Admits will be audited for medications that can’t be crushed and nurses/CMA will be alerted. Med administration competency will be done with Nurses and Med Aides on hire, annually, and with any significant med error. Insulin administration competency will be done with Nurses on hire, annually and with any significant insulin error. DNS or designee will audit 5 crushed med administrations and 2 insulin administration weekly. Audits will continue weekly x4 weeks, then monthly x3 months. Continual issues will be brought to QA.

Based on observation, interview and record review it was determined the facility failed to properly store and label food for 1 of 1 kitchen reviewed for food storage. This placed residents at risk for foodborne illness. Findings include: On 6/12/22 at 8:58 AM the kitchen refrigerator and dry food storage area was inspected: -Four clear containers covered with plastic were observed on a shelf in the refrigerator: 1. Beef base with an open date of "5/17", no use by date. 2. Applesauce with a use by date of "6/11". 3. Shredded cheddar cheese with a use by date of "6/10". 4. Romaine lettuce with a use by date of "6/11". -Eight unopened items were observed on a shelf in the dry storage area: 1. One expired five pound basic muffin mix dated 4/9/22. 2. One expired mango dessert sauce 15 ounces dated 3/23/22. 3. One expired mango dessert sauce 15 ounces dated 3/28/22. 4. Five expired boxes of angel food cake mix dated 2/20/21. On 6/12/22 at 8:58 AM Staff 14 (Cook) stated the expired items should not have been in the refrigerator or in the dry storage area. On 6/13/22 at 11:22 AM Staff 15 (Dietary Manager) stated it was her expectation that the dates were checked daily and expired foods were thrown out.

Upon notification all staff were immediately gathered, educated, and then proceeded to inventory all items in the coolers for other foods that may be expired. Signage has been put on cooler doors to remind staff to look for expired foods anytime they access foods in the cooler. In the following staff meeting on June 28, in-service was provided as a reminder for attention to detail (particularly food storage and cleanliness in the kitchen). Random audits done by Administrator on refrigerator food expiration dates. Audits will be 3x/week for 1 month and weekly thereafter for 3 months. Continual issues will be brought to QA.

Based on observation, interview and record review it was determined the facility failed to follow manufacturer's recommendations for glucometer (a blood sugar monitoring device) disinfection for 1 of 2 floors (First Floor) observed for infection control. This placed residents at risk for bloodborne pathogens and infections. Findings include: The facility's policy Use of Blood Glucose Meters Machines dated 9/2014 included instructions to: - wash hands; - don gloves; - place blood glucose monitoring device on a clean field; - clean and disinfect the device after each use; - remove gloves; - wash hands; - place the blood glucose monitoring device in storage area after cleaning. On 6/15/22 at 4:00 PM Staff 6 (LPN) was observed leaving a resident's room with a glucometer. He put the glucometer on the top of the treatment cart without a barrier, took his gloves off and put them in the trash. He did not sanitize or wash his hands. He sanitized the glucometer and put it back down on the potentially contaminated treatment cart surface. There was another glucose monitor on the cart which also was not on a barrier. He put both glucometers in a drawer and still did not sanitize his hands. Staff 6 stated he never used a barrier between the treatment care and glucometers. When asked what the next step would be in the disinfection process, he used the same disinfectant wipe used on the second glucometer and wiped a couple of small areas on the cart's surface except where both glucometers were located prior to being sanitized. Staff 6 stated he did not clean the medication cart surface each time a glucometer was set on it without a barrier and sanitized the cart surface once during his shift. On 6/15/22 at 5:31 PM Staff 2 (DNS) confirmed the break in infection control. ,

All Glucometers and treatment carts have been cleaned with disinfectant wipes. Root Cause Analysis has been completed to identify why clean barrier was not used and hand hygiene did not occur. Nurses were in-serviced on importance of hand hygiene after removal of gloves and disinfecting cart surfaces routinely throughout shift and using clean barriers with clean equipment. IP or designee will audit glucometer use 5x/week to ensure clean barriers are used and hand hygiene is occurring. Audits will continue weekly x4 weeks, then monthly. Continual issues will be brought to QA

Based on interview and record review it was determined the facility failed to ensure informed consent was obtained related to immunizations for of 4 of 5 sampled residents (#s 10, 15, 35 and 51) reviewed for immunizations. This placed residents at risk for lack of knowledge for the risk and benefits of vaccinations. Findings include: The facility's Vaccination of Resident Policy revised 10/2019 indicated prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. 1. Resident 10 was admitted to the facility in with diagnoses including diabetes. Resident 10's clinical record revealed the resident was administered the influenza (flu) immunization on 12/18/21 and the most recent consent was dated 11/6/20. On 6/21/22 at 10:29 AM Staff 3 (LPN Resident Care Manager) confirmed consents were not not completed for the 2021 flu vaccination for any residents. , 2. Resident 51 was admitted to the facility in 2020 with diagnoses including heart disease. Review of the resident's record revealed the resident received the influenza vaccine on 12/18/21. There was no documentation of the education provided to the resident related to the risk or benefits of the vaccination. On 6/21/22 at 10:29 AM Staff 3 (LPN Resident Care Manager) confirmed consents were not not completed for the 2021 flu vaccination for any residents , 3. Resident 35 was admitted to the facility on 4/2019 with diagnoses including dementia. Review of Resident 35's medical record revealed no documentation to indicate Resident 35 was offered or received an influenza consent. On 6/21/22 at 1:05 PM Staff 3 (LPN Resident Care Manager) stated the facility did not have a signed consent for Resident 35 and that the facility was in the process of implementing a new system for signed consents. , 4. Resident 15 was admitted to the facility in 2019 with diagnoses including heart disease. 12/26/21 MDS indicated the resident was offered but declined the influenza vaccine. The resident's record did not have documentation to indicate she/he was provided information of the risk and benefits of the influenza vaccine. On 6/22/22 at 10:13 AM Staff (Regional RN Consultant) confirmed Resident was not provided the risk of benefits of the influenza vaccine.

Vaccination information has been reviewed with Resident 10, 15, 35 and 51. Residents with vaccinations in the last 90 days have been interviewed to ensure consent was given and education received. Nursing staff will be educated on importance of vaccination education and obtaining written consents/refusals. IP or designee will audit vaccinations administered in the past week to ensure appropriate documentation is on file. Audits will occur weekly x4 weeks, then monthly x3 months. Continual issues will be brought to QA.

*************** OAR 411-086-0040 Admission of Residents (Advanced Directive) Refer to F578 *************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F759 and F760 *************** OAR 411-086-0250 Dietary Services Refer to F812 *************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 *************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F883 ***************

Based on interview and record review it was determined the facility failed to ensure a resident who was continent was not checked by CNA staff for incontinence for 1 of 3 sampled residents (#1) reviewed for dignity. This caused Resident 1 to have increased anxiety, persistent anger and tearfulness. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses including incomplete quadriplegia (some function remains to the arms and legs). A 4/26/22 Admission Nursing Database indicated Resident 1 was alert, oriented but was agitated. The resident was assessed to be continent of bowel and bladder and independent with transfers, toileting and bed mobility. The resident usually went to bed at 9:00 PM and woke up at 8:00 AM. A note indicated the resident did not want to be disturbed at night because she/he startled easily. A Progress Note dated 4/28/22 at 4:19 AM indicated the resident stated she/he needed to leave the facility. The note indicated the resident signed papers acknowledging she/he left against medical advice, the physician was notified and a message was left with the local state agency to report a concern with the resident's sudden facility departure. The resident later returned. A 4/28/22 Progress Note by Staff 1 (Corporate RN) revealed the resident's friend reported Resident 1 had anxiety and the resident preferred to have "space" and could be overwhelmed with staff when the resident experienced anxiety. The friend also reported the resident could become disoriented at night when staff checked her/his vital signs resulting in increased anxiety. The resident's preference was to not be woken up on night shift for vital signs. The care plan was updated. A Care Plan updated on 4/28/22 revealed the resident had a history of trauma and staff were not to wake the resident for vital signs on the night shift. Staff were to be careful not to invade the resident's personal space. The Care Plan did not include the resident was incontinent and wore incontinent briefs. A 4/29/22 Progress Note written at 5:51 AM by Staff 2 (LPN) revealed a CNA did morning rounds and went into Resident 1's room. The resident started to cry. The nurse attempted to speak to the resident but the resident refused to talk. At 5:00 AM the resident went outside for 45 minutes and then returned to the facility. On 6/6/22 at 4:57 PM Staff 4 (LPN) stated he worked the evening shift. Staff 4 stated as he left his shift he directed Staff 5 (Night Shift CNA) to not enter Resident 1's room unless the resident activated the call light. On 6/5/22 at 10:55 PM Staff 5 stated Staff 4 informed her Resident 1 was admitted to the facility and staff were not to go into her/his room at night unless the resident activated the call light. Staff 5 stated all night she did not hear from the resident and at about 4:00 AM she wanted to check on Resident 1 to see if she/he was incontinent. Staff 5 asked Staff 6 (CNA) to assist her. They knocked on the resident's door before entering the resident's room and before touching the resident's covers she spoke to the resident and stated she needed to check the resident's incontinent brief. The resident covered her/his face with the blanket. Staff 5 tried to pull the blanket down from the top but the resident would not let go of the blanket so Staff 5 lifted the blanket from the bottom and reached under the blanket to feel if the bedding was wet. The resident did not wear an incontinence brief and did not have an incontinence pad under her/his hips. The resident was not wet so they left. The resident did not say anything to them. After they left the room she heard crying from Resident 1's room and Staff 7 (LPN) went into the resident's room but the resident screamed at Staff 7. On 6/6/22 at 4:29 PM Staff 6 stated she was not assigned to Resident 1 but went into Resident 1's room with Staff 5 to check to see if the resident was incontinent. Staff 5 put her hand under the blanket to check if the bedding was wet. The resident said "no" and would not let go of the blanket so they left the resident's room. Staff 2 tried to speak to the resident but the resident screamed more. The resident cried, went outside, sat in her/his van and then called a friend. On 6/8/22 at 10:54 AM Staff 2 stated the CNAs reported Resident 1 was not happy and was crying. He went to the resident room but the resident would not talk to him and "looked very scared". A 4/29/22 Progress Note written at 4:27 PM by Staff 1 revealed the resident was upset with staff when they attempted to provide care when the resident was sleeping. The resident became disoriented and the resident requested staff place signs on the door to not interact with he resident between the hours of 9:00 PM and 8:00 AM. A 5/7/22 email from Resident 1 to Witness 1 (Director of State Department of Human Services) indicated when staff checked her/him in the middle of the night for incontinency with no warning, being woke up out of sleep, brought back "flash points" of the past. The resident indicated she/he "didn't feel safe any more". On 6/8/22 at 4:29 PM Staff 1 stated she spoke with the resident a few hours after the incident and the resident was still very angry.

Resident 1 has discharged. All continent resident/s were interviewed for preferred sleep/personal time and if safe were CP appropriately. All staff were in-serviced on resident/s rights and dignity. Will monitor all 72 hour huddles for 4 weeks and then randomly monthly for 3 months to ensure resident/s rights and dignity are discussed. Any issues will be presented to QA

Based on interview and record review it was determined the facility failed to follow-up with a resident's request to change eye medication administration times for 1 of 3 sampled residents (#1) reviewed for medications. This placed residents at risk for lack of choice in treatment regimen. Findings include: Resident 1 was admitted to the facility in 4/2022 with diagnoses including Sjogren Syndrome (autoimmune disorder characterized by symptoms including dry eyes). The resident's 4/25/22 admission orders revealed the resident was to be administered cyclosporine (increase tear production) one drop each eyes BID and Olopatadine (decreases inflammation) one drop each eye QD. A 4/27/22 Progress Note by Staff 4 (LPN) revealed the resident was upset about her/his eye drops. She/he did not want the cyclosporine in the AM and wanted the Olopatadine. Staff 4 called the physician and eye care physician. A 5/7/22 Progress Note indicated a new order and the Olopatadine one drop to both eyes was to be administered BID. A 5/25/22 e-mail from Resident 1 to Witness 2 (Complainant) revealed the resident wanted one type of eye drop in the am and the other eye drop in the evening and not together, but the facility continue to bring the medications in together. Telephone calls were placed to Resident 1 on 6/6/22 and 6/8/22. A return call was not received. There were no additional notes in the resident's record to indicate the facility addressed the resident's request to have the eye mediations changed until 6/2/22. On 6/7/22 At 1:08 PM Staff 8 (RNCM) acknowledged Resident 1 wanted one type of eye drop administered in the morning and a different type of eye drop administered in the evening but the orders never reflected the the resident's preference. The resident was allowed to refuse medications but the eye medications were not administered per the resident's preference for the resident's entire admission.

Resident 1 has discharged All resident/s with eye medications were interviewed about administration preference. Appropriate changes were made to schedules or requested from providers. All staff in-service on resident right to choices. Will monitor all 72-huddles for 4 weeks and then randomly monthly for 3 months to ensure resident/s rights and dignity are discussed. Any issues will be brought to QA.

Based on interview and record review it was determined the facility failed to ensure a resident's physician order for Tylenol (reduces pain) included frequency prior to implementation for 1 of 4 sampled residents (#1) reviewed for medications and failed to follow physician orders for 1 of 4 sampled residents (#1) reviewed for medications and bowel care. This placed residents at risk for adverse medication side affects and constipation. Findings include: Resident 1 was admitted to the facility 4/26/22 with diagnoses including incomplete quadriplegia (some function remains to the arms and legs). a. Resident 1's 4/27/22 Admission Nursing Database indicated the resident was alert, oriented and her/his last bowel movement was 4/27/22. The assessment indicated the resident usually had daily bowel movements. Resident 1's 4/2022 and 5/2022 Documentation Survey reports (ADLs) indicated the resident had a bowel movement on 4/30/22, 5/5/22, 5/13/22 and 5/18/22. After 5/18/22 the resident had bowel movements at least every three days. The residents 5/2022 MARs and TARs revealed the resident had PRN bowel medications which were available but not administered. Progress Notes revealed the following: -4/29/22 the resident was on alert for no bowel movement for three days and was put on the bowel care list. The resident denied constipation and staff were to monitor the resident. -5/2/22 the resident denied constipation -5/4/22 the resident was on alert for not having a bowel movement for three days and was put on the bowel list. (There was no assessment of the resident or documentation to indicate if the resident was offered bowel medication.) -5/9/22 at 2:57 PM note revealed the resident was on alert for no bowel movement for three days and the resident would be monitored. (There was no assessment of the resident or if staff offered the resident bowel medication.) -5/9/22 at 10:04 PM the note indicated the resident had a bowel movement. -5/10/22 the note indicated the resident was on alert for not having a bowel movement, did not have pain and was placed on the bowel list. (The previous note on 5/9/22 indicated the resident had a bowel movement.) On 6/7/22 at 12:38 PM Staff 8 (RNCM) acknowledged the resident went more than three days without a bowel movement. Staff 8 stated the resident had PRN bowel medications available for constipation but it was not administered. Staff 8 stated she would provide documentation if bowel care was provided but not documented. No additional information was provided. On 6/9/22 at 10:16 AM Staff 9 (DNS) stated staff were to assess the resident upon admission to the facility to determine how often the resident usually had bowel movements and what interventions the resident used to relieve constipation. The facility protocol indicated if a resident did not have a bowel movement for for three days, at the end of the third day the nurse was to assess the resident and provide bowel care as needed unless the resident preferred non-pharmacological interventions. Additional bowel care would be provided on subsequent days as needed. b. Resident 1's 4/28/22 hospital admission orders revealed the resident was to have an optichamber respiratory spacer (device to help administer inhalers). The 4/2022 and 5/2022 MARs indicated the resident refused or did not take the inhaler on 4/28/22 through 5/2/22. A progress note dated 4/30/22 indicated the resident's family questioned why the facility did not have an optichamber for Resident 1. A 5/1/22 note indicated Resident 1 refused her/his inhaler because she/he did not have an optichamber respiratory spacer and staff reported they needed an order. On 6/7/22 at 12:55 PM Staff 8 (RNCM) acknowledged the resident had an order for an optichamber respiratory spacer and the facility did not obtain the spacer until the resident refused the medication and requested the spacer. c. Resident 1's 4/28/22 hospital orders revealed the resident was to be administered Olopatadine (relieves allergy symptoms) eye drops. Resident 1's Progress notes revealed the resident's Olopatadine eye drops were not available on 5/1/22, 5/2/22, 5/3/22, 5/4/22, 5/6/22, 5/10/22, 5/11/22 and 5/12/22. On 6/6/22 at 3:10 PM Witness 3 (Pharmacy Technician) stated the resident was admitted the facility 4/2022 and the pharmacy did not send the Olopatadine to the facility because it was an over the counter medication. The facility should be aware of the medication which they were to provide. On 6/7/22 at 1:19 PM Staff 8 (RNCM) acknowledged the facility staff documented the Olopatadine was not available and the medication was to be provided by the facility because it was an over the counter medication. d. Resident 1's 4/28/22 hospital orders revealed the resident was to be administered Tylenol 500 mg tablets. The orders did not have a frequency of how often the mediation should be taken. The resident's Progress Notes did not indicate the physician was called to clarify the order. The resident's 4/2022 MAR revealed the resident was to be administered Tylenol 1000 mg every eight hours PRN pain. On 6/2/22 at 1:05 PM Staff 4 (LPN) stated the resident readmitted to the facility on 4/28/22 and came with new orders from the hospital including Tylenol. On 6/5/22 at 8:38 PM Staff 9 (DNS) stated all orders were to be checked by two nurses before administration. Staff 9 acknowledged the admission Tylenol orders did not include how often the medication was to be administered. Staff 9 stated he would look for a signed order for the Tylenol. No additional information was provided.

Resident 1 has discharged. All resident/s assessed for Bowel movements and Bowel regime. All resident/s with inhalers orders reviewed for opti- chamber orders and if they had them. All resident/s reviewed for over-the-counter eye gtts to ensure they are being provide. All resident/s pain medication reviewed for accurate orders. Nursing staff in-serviced on Avamere guidelines for Bowel care and assessment Nursing staff in-serviced on importance of obtaining OTC meds timely. Nursing staff in-serviced on ensuring medication orders are complete and importance of clarifying orders that are not. All admit orders are reviewed by RCM and DNS at stand up. All admits will be audit for 4 weeks and then randomly monthly for 3 months. Any issues will be brought to QA.

Based on interview and record review it was determined the facility failed to ensure a resident received PRN Tylenol for 1 of 3 sampled residents (#1) reviewed for pain. This placed residents at risk for unmanaged pain. Findings include: Resident 1 was admitted to the facility with diagnoses including compression fractures. The resident's 5/1/22 BIMs indicated the resident was cognitively intact. An email dated 5/27/22 from Resident 1 to Witness 2 (Complainant) revealed on 5/25/22 at 3:00 PM the resident requested pain medication. At 5:00 PM the staff did not administer the resident pain mediation and she/he went out side, and a CNA opened the door for the resident. The CNA offered to find the nurse to administer pain medication but the resident declined the. The e-mail also indicated the resident did not receive her/his scheduled pain mediation at 8:00 PM. The resident's 5/2022 MAR revealed the resident was to be administered Tylenol PRN pain. The resident received Tylenol on 5/25/22 at 8:30 AM for moderate pain (6/10 pain scale) and was documented to be effective. No additional PRN Tylenol was administered on 5/25/22. The resident's 8:00 PM medications including baclofen (muscle relaxer) was documented by Staff 11 (CMA) as refused. On 5/26/22 the resident received one dose of PRN Tylenol for severe pain (8/10 pain scale) and was documented to be effective. On 6/7/22 at 8:08 AM Staff 10 (CNA) stated on 5/25/22 she informed the nurse the resident requested pain medication. It was at the change of shift and there must have been a miscommunication because the resident did not get her/his pain medication. The resident went outside for a while. The resident did not have visible signs of pain. On 6/6/22 and 6/8/22 a telephone call was placed to Staff 11. A return call was not received. On 6/7/22 at 1:06 PM Staff 8 (RNCM) acknowledged staff reported on 5/25/22 Resident 1 requested pain medication at 3:00 PM and Tylenol was not administered to the resident until the next day.

Resident 1 has discharged. Interviewed resident/s to ensure PRN medications were being given and timely. Residents who cannot be interviewed will be observed for signs of pain. In-serviced nursing staff on importance of PRN pain medication timeliness. Will interview 5 resident/s weekly for PRN pain medication for 4 weeks than monthly for 3 months. Residents who cannot be interviewed will be observed for signs of pain. Issues will be brought to QA.

OAR 411-085-0310 Residents ' Rights: Generally

Refer to F550 and 561 *************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 and 697 ***************

Based on interview and record review it was determined the facility failed to find a resolution to a resident's report of a missing item in a timely manner for 1 of 3 sampled residents (#3) reviewed for grievances. This placed residents at risk for lost personal items. Findings include: Resident 3 was readmitted to the facility in 2021 with diagnoses including depression. Resident 3's 12/19/21 annual assessment indicated the resident was cognitively intact. Resident 3's census (room history) revealed the resident was moved to her/his current room 1/13/22. On 4/5/22 at 11:16 AM Staff 6 stated the resident reported missing items on 3/22/22 and Staff 6 informed Staff 7 (Social Services). On 4/5/22 at 1:35 PM Resident 3 stated when she/he was moved to her/his current room an electronic game was not returned. Resident 3 stated it was reported to Staff 6 (LPN Resident Care Manager). On 4/5/22 at 1:50 PM Staff 7 stated if a resident had a concern or a missing item a grievance form was filled out. A copy of the grievance was provided to the appropriate department which the grievance involved. Staff were to follow up with the concern within 72 hours. The grievance forms were to be kept and filed in a notebook. Staff 7 stated he was aware Resident 3 had some missing items including an electronic game. Staff 7 was made aware of the concern in 2/2022. Staff 7 indicated if an item was not found the administration was to either replace the item or work with the resident on a resolution. Staff 7 stated he did not have a grievance form for Resident 3's missing item. On 4/5/22 at 2:08 PM Staff 1 (Administrator) stated, typically, as soon as the facility was made aware of an issue or complaint, they tried to resolve the concern within five business days. Often a missing item was replaced. Staff 1 acknowledged Resident 3 had a room change, items were placed in storage and not all items were returned to the resident's room. Staff 1 stated he was aware Resident 3's electronic game was missing in late January 2022. Staff did not have the time to look through all the resident's stored boxes to see if they could locate the game. Staff 1 acknowledged Resident 3 still did not have a resolution to her/his missing game.

Resident #3 has been provided with a replacement of the electronic game reported missing. All residents with reports of missing items are at risk for this practice. Grievances for missing items within the last 30 days have been reviewed to ensure item was found or replaced. Education will be provided to clinical and management staff about grievance process and how to submit on behalf of residents. Locations of grievance forms reviewed to ensure ease of access and easy identification. Administrator or designee will audit grievances to ensure timely and appropriate resolution per policy. Audits will occur weekly x4 then monthly. Audit results will be reviewed at QAPI until substantial compliance has been met for 2 quarters.

Based on interview and record review it was determined the facility failed to report an allegation of verbal abuse for 1 of 2 sampled residents (#6) reviewed for abuse. This placed residents at risk for verbal abuse. Findings include: Resident 6 admitted to the facility in 2019 with diagnoses including heart failure. A 12/22/21 Complaint and Grievance form indicated Resident 6 alleged Staff 5 (Housekeeper) laughed at Resident 6 and told Resident 6 she/he was "bullshit". A FRI was not received by the State Agency until 12/28/21, six days after the incident. On 4/12/22 at 9:25 AM Staff 2 (DNS) verified the FRI for the 12/22/21 allegation of verbal abuse was reported six days after the allegation was made.

The allegation of verbal abuse towards Resident #6 was previously reported to the State Agency. Investigation for Resident #6 verbal abuse allegation was updated to reflect final conclusion. All residents with allegations of verbal abuse are at risk for this practice. Allegations made in the last 30 days have been reviewed to ensure investigations are complete and reporting is timely. Education will be provided to clinical and management staff about allegation reporting requirement, process and timeframes. Management will be educated on importance of comprehensive investigations including final conclusions when completed. Administrator or designee will audit allegations to ensure timely reporting occurs and completed investigations are documented with final conclusion summary. Audits will occur weekly x4 then monthly. Audit results will be reviewed at QAPI until substantial compliance has been met for 2 quarters.

Based on interview and record review it was determined the facility failed to initiate an investigation into an allegation of verbal abuse and maintain documentation that the allegation of abuse was thoroughly investigated for 1 of 2 sampled residents (#6) reviewed for abuse. This placed residents at risk for verbal abuse. Findings include: Resident 6 admitted to the facility in 2019 with diagnoses including heart failure. A 12/22/21 Complaint and Grievance form indicated Resident 6 alleged Staff 5 (Housekeeper) laughed at Resident 6 and told Resident 6 she/he was "bullshit". A 12/28/21 Facility Investigation revealed an investigation was initiated for the 12/22/21 allegation of verbal abuse. The investigation findings indicated the investigation was ongoing. A request for the completed investigation was made and the facility was unable to locate the completed investigation. On 4/12/22 at 9:25 AM Staff 2 (DNS) verified the investigation was not initiated until 12/28/21. Staff 3 further stated the investigation was completed by the previous Administrator however the facility was unable to locate the file where the investigation was kept.

Investigation for Resident #6 verbal abuse allegation was updated to reflect final conclusion. All residents with allegations of verbal abuse are at risk for this practice. Allegations made in the last 30 days have been reviewed to ensure investigations are complete and reporting is timely. Education will be provided to clinical and management staff about allegation reporting requirement, process and timeframes. Management will be educated on importance of comprehensive investigations including final conclusions when completed. Administrator or designee will audit allegations to ensure timely reporting occurs and completed investigations are documented with final conclusion summary. Audits will occur weekly x4 then monthly. Audit results will be reviewed at QAPI until substantial compliance has been met for 2 quarters.

Based on interview and record review it was determined the facility failed to develop a comprehensive care plan related to discharge goals for 2 of 3 sampled residents (#s 7 and 15) reviewed for facility discharge. This placed residents at risk for an unsafe discharge. Findings include: 1. Resident 15 was admitted to the facility in 2021 with diagnoses including heart failure and mild cognitive impairment. A 12/14/21 Admission MDS indicated the resident wanted to discharge back to the community. A comprehensive care plan initiated on 12/10/21 did not include the resident's discharge goals, preferences or interventions required for the resident's safe discharge. On 4/13/22 at 12:28 PM Staff 11 (RNCM) acknowledged a care plan was not developed for Resident 15's discharge goals. The resident's medical record indicated the resident was discharged home. 2. Resident 7 was admitted to the facility in 2021 with diagnoses including a hip fracture. A 9/19/21 Admission MDS and CAAs indicated Resident 7 resided in an adult foster home prior to admission to the facility and expected to be discharged back to her/his adult foster home. A comprehensive care plan initiated on 9/15/21 did not include the resident's discharge goals, preferences or interventions required for the resident's safe discharge. On 4/13/22 at 12:28 PM Staff 11 (RNCM) acknowledged a care plan was not developed for Resident 7's discharge goals. The resident's medical record indicated the resident was discharged back to her/his adult foster home she/he previously resided.

Residents #7 and #15 have both discharged from the facility. All Skilled Nursing residents are at risk for this practice. Care plans for these residents have been reviewed to ensure discharge plans are included. Education will be provided to Social Services Director and clinical managers about importance of having discharge locations included in care plans. Administrator or designee will audit 5 SNF care plans to ensure discharge location is included. Audits will occur weekly x4 weeks then monthly. Audit results will be reviewed at QAPI until substantial compliance has been met for 2 quarters.

Based on interview and record review it was determined the facility failed to ensure a latex free Foley (urinary) catheter was inserted on a resident with a latex allergy for 1 of 3 sampled residents (#2) reviewed for Foley catheters. This placed residents at risk for an adverse reaction. Findings include: Resident 2 was readmitted to the facility in 2022 with diagnoses including dementia. The resident's 1/17/22 Order Summary Report indicated she/he had a latex allergy. A Progress Note dated 1/28/22 by Staff 12 (LPN) indicated the resident's Foley catheter leaked and the catheter was changed. A 2/9/22 note indicated Resident 2 was transported to the hospital when the resident's catheter leaked and was able to be flushed. The hospital RN called the facility and reported, when the resident was assessed at the hospital, the resident had a latex catheter in place. Staff 11 was notified of the hospital concern. On 4/8/22 at 9:31 AM Staff 11 acknowledged the catheter inserted by the facility was made from latex and the nurse who placed the catheter did not check the resident's allergies before inserting the catheter. On 4/12/22 Staff 12 stated she did not recall anything about inserting a latex Foley catheter for a resident who had a latex allergy. On 4/8/2022 at 2:28 PM Witness 7 (Spouse) stated when Resident 2 was exposed to latex she/he developed a rash.

Resident #2 now utilizes a silicone catheter. All residents with latex allergies are at risk for this practice. These residents have been reviewed to ensure catheters in use are not latex and appropriate orders are updated with allergy information. Education will be provided to clinical staff about importance of checking allergies prior to inserting a new catheter. Administrator or designee will visualize catheters for residents with latex allergies to ensure they are not latex. Audits of catheter orders for these same residents will ensure allergy information is contained within the order. Audits will occur weekly x4 weeks then monthly. Audit results will be reviewed at QAPI until substantial compliance has been met for 2 quarters.

Based on interview and record review it was determined the facility failed to ensure a resident's pressure ulcer orders were implemented for 1 of 3 sampled residents (#2) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 2 was readmitted to the facility in 2022 with diagnoses including dementia. A 2/1/22 Wound clinic note indicated Resident 2 had a Stage III pressure ulcer (full thickness skin loss) to the buttocks. Treatment recommendations included a dressing infused with an agent to promote blood clotting and a bordered foam dressing was to be applied. The dressing was to be changed daily and PRN. A 2/2022 TAR revealed from 2/1/22 through 2/8/22 powder and cream was applied to the resident's pressure ulcer BID and not the wound clinic recommended dressings. A 2/8/22 Wound clinic note indicated the resident's buttock pressure ulcers improved. A 2/9/22 Progress Note revealed the hospital RN called the facility with concerns related to the resident's buttock wounds. The note indicated staff assured a treatment was in place. A 2/10/22 complaint intake form revealed Witness 8 (Complainant) reported to the state agency that the resident was transferred to the hospital and had a pressure ulcer with no dressing in place. On 4/13/22 Witness 8 stated Resident 2 had a Stage III pressure ulcer to the buttocks and the resident did not have a dressing in place upon arrival to the hospital emergency department. The facility was notified of the concern. On 4/13/22 at 2:23 PM Staff 11 (RNCM) stated on the same day the wound clinic staff assessed the facility residents, they provided treatment recommendations. Staff 11 acknowledged the recommendations from the wound clinic included dressings and staff applied powder and a cream. Staff 11 stated they were trying to dry the wound and the wound clinic agreed to just apply the powder and cream. A request was made to Staff 11 to provide documentation to verify the wound clinic was aware the recommended treatment was not provided. No additional information was provided. On 4/8/22 at 2:28 PM with Staff 9 (LPN) Resident 2's buttocks was observed to not have pressure ulcers.

Resident #2’s buttock pressure ulcers have resolved. All residents with pressure ulcers are at risk for this practice. Treatments for these residents have been reviewed to ensure they reflect current orders and are in place. Education will be provided to clinical staff about importance of completing wound treatments as ordered and replacing dressings that may come off or missing. DNS or designee will audit 5 charts for pressure ulcer treatments and visualize to ensure dressings are in place. Audits will occur weekly x4 weeks then monthly. Audit results will be reviewed at QAPI until substantial compliance has been met for 2 quarters.

Based on observation and interview it was determined the facility failed to ensure all staff were vaccinated for COVID-19 for 1 of 82 staff (#8) and failed to ensure 1 of 2 staff with approved exemptions (#9) followed additional precautions to prevent the spread of COVID -19. This placed residents at risk for infection. Finding include: A COVID-19 Mandatory Vaccination Requirement Policy dated 8/20/21 revealed: -Existing employees must be vaccinated by 10/18/21. -An employee with an approved exemption will be tested once per week, and will be required to wear an N95 mask (filters airborne particles i.e. COVID-19) at all times while in the facility with the exception of when consuming food or beverage. 1. Review of the facility employee vaccination tracking form revealed on 10/18/21 Staff 8 (CMA) received one in a series of two vaccinations. On 4/8/22 at 11:59 AM Staff 10 (Human Resources) acknowledged Staff 8 was not fully vaccinated. Staff 10 also stated the facility did not have COVID-19 positive staff or residents since 1/2022. On 4/12/22 and 4/13/22 telephone calls to Staff 8 were not successful. 2. Review of the facility employee vaccination tracking form revealed Staff 9 (LPN) had an approved exemption. On 4/8/22 at 2:05 PM Staff 9 was observed at the nurse's station talking with two staff. All staff were less than six feet apart. Staff 9 wore a medical grade face mask and not an N95 mask. On 4/8/22 at 2:22 PM Staff 3 (Regional RN) acknowledged Staff 9 should wear an N95 mask. On 4/8/22 at 2:33 PM Staff 9 stated at the start of her shift, when she arrived to the front desk to be screened, the N95 mask box was empty and she did not obtain one until Staff 3 intervened. On 4/8/22 at 11:59 PM Staff 10 (Human Resources) stated the facility did not have COVID-19 positive staff or residents since 1/2022.

Staff #8 has now received the 2nd COVID vaccination to complete the series. Staff #9 has been counseled about need to wear N95 when in building per policy. Staff vaccination records have been reviewed to ensure all staff receiving vaccinations have the initial series completed (as eligible) or a valid exemption on file. Staff with exemptions on file have been reminded of need to wear an N95 when in building per policy. DNS or designee will review staff vaccination records weekly to ensure staff have the initial series completed (as eligible) or a valid exemption on file. Visual audits of unvaccinated staff will be made weekly to ensure N95s are in place per policy. Audits will occur weekly x4 weeks then monthly. Audit results will be reviewed at QAPI until substantial compliance has been met for 2 quarters.

*************** OAR 411-085-0310 Residents' Rights: Generally Refer to F585 *************** OAR 411-085-0360 Abuse Refer to F609 and 610 *************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F660 *************** 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 *************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F888 ***************

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment accommodated the individual needs and preferences for 2 of 2 floors reviewed. This placed residents at risk for lack of ADL care. Findings include: On 11/5/21 at 11:16 AM the facility identified 27 residents who required slings for mechanical lift transfers. a. A list provided by the facility on 11/4/21 indicated 27 residents required the use of slings for mechanical lifts. On 11/1/21 at 12:19 PM Resident 20 stated she/he did not always get showers because the facility did not have shower slings available. On 11/2/21 at 2:31 PM Staff 26 (Regional RN) counted six slings and confirmed these were the only slings clean and available for resident use for the entire facility. Staff 26 further stated she was unsure of the amount of slings the facility had. b. 11/1/21 3:09 PM Staff 7 (CNA) stated she was not able to give Resident 53 a shower on 10/30/21 because there was not a sling available. Staff 7 stated she gave Resident 53 a bed bath instead but the resident preferred a shower. On 11/2/21 at 2:08 PM Resident 53 stated she/he preferred showers but had to take a bed bath if there was no sling available. Resident 53 stated she/he took a bed bath the previous Saturday [10/30/21] due to because staff informed her/him the sling was not available to take a shower. On 11/2/21 at 2:31 PM Staff 26 (Regional RN) counted six slings and confirmed these were the only slings clean and available for resident use for the entire facility. Staff 26 further stated she was unsure of the amount of slings the facility had. c. On 11/2/21 at 1:37 PM Resident 53 stated she/he ran out of facial tissue the day before. On 11/2/21 at 1:38 PM and 1:39 PM observations were made of the closets in the 100 hall. There was no facial tissue located in the closets. Staff 7 (CNA) stated there was no facial tissue available to give to the residents. On 11/2/21 at 1:47 PM Staff 4 (LPN) stated there was currently no staff assigned to the central supply position to reorder supplies. On 11/2/21 at 2:30 PM an observation was made with Staff 26 (Regional RN) and there was no facial tissue found in central supply. Staff 26 acknowledged there was no facial tissue available in central supply. d. On 11/2/21 at 12:56 PM Staff 21 (CNA) stated they often ran out of facial tissue. Staff 21 further stated the facility often ran out of facial tissue and she purchased some from the store and gave them to Resident 54 because she/he had a raw nose from using paper towels. On 11/2/21 at 1:31 PM an observation was made of the 200 hall closets with Staff 22 (Personal Care Assistant) and there was no facial tissue observed in the closets. On 11/2/21 at 1:38 PM Resident 54 stated she/he went up to a month without facial tissue. On 11/2/21 at 2:30 PM an observation was made with Staff 26 (Regional RN) and there was no facial tissue found in central supply. Staff 26 acknowledged there was no facial tissue available in central supply.

Residents 20 and 53 have each had a shower in the past 7 days. Residents 53 and 54 have each been provided with tissue. Current residents requiring hoyers are at risk of not receiving showers due to not having slings. Current residents are at risk of not having tissues. These residents have been audited to ensure showers have been offered and received and personal tissues are at bedside. Additional shower slings have been obtained to ensure residents requiring hoyers each have a sling, with several more clean and ready if needed. Clinical & laundry staff have been educated about sling use, storage and laundering. Facility stock of tissue has been replenished. Clinical staff have been educated about how to request more if inventory gets low or speaking to a manager for local purchase if they run out. Administrator or designee will audit for available clean slings and facility supply of tissue 2x/week to ensure there is ample supply for staff and resident use. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on interview and record review, it was determined the facility failed to effectively respond to resident council concerns expressed at 3 of 3 resident council meetings reviewed. This placed residents at risk for unadressed concerns related to resident care and quality of life. Findings include: The 6/2004 Resident Council Policy and Resident Grievance Policy indicated resident council meetings would be held twice monthly and all grievances noted during the council meeting would be given to department managers who would respond in writing within 5 days. Resident Council Meeting Minutes from 9/6/21, 9/27/21 and 10/26/21 indicated: -9/2021: Call light times on both floors took longer than "normal" and "normal wasn't great." A resident reported they were often left sitting on the toilet for "awhile." Day and swing shift took and hour and a half to answer call lights and NOC shift rarely answered, "at all." -10/2021: Resident s felt "exasperated" with no changes to staffing shortages and long call light wait times. Three residents reported they waited up to two hours for their call light to be answered. The minutes did not identify solutions, explanations nor did appropriate staff respond to the group's concerns timely. On 11/8/21 at 9:42 AM Staff 38 (Activities Director) stated she wrote resident council meeting notes based on interviews with residents. Staff 38 further stated residents were frustrated because the concerns they brought forward month after month were not addressed. Staff 38 stated the resident council concerns from 9/6/21, 9/27/21 and 10/26/21 were forwarded to administrative staff with no response to the resident council's recommendations or expressed concerns. On 11/8/21 at 11:31 AM Staff 26 (Regional RN) acknowledged the facility had not responded to the residents' grievances per the facility policy and acknowledged only one resident council meeting was held in 10/2021.

Resident Council meeting from 10/26/21 has been reviewed to ensure response was received from appropriate departments, to address concerns from the group. Resident Council follow-up was held 11/17/21 to review department responses with the group. Another Resident Council meeting occurred on 11/24/21 with follow up meeting in mid-December. Education has been provided to Activities staff and department managers about Resident Council meetings twice monthly. Department managers have been educated about addressing issues with specific interventions and the turnaround time expectations for response. Administrator or designee will audit Resident Council minutes and responses 2x/month. After 2 months, audits will continue once monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from neglect. The facility failed to identify, monitor and assess residents at risk for aspiration. The facility failed to ensure residents who were not cognitively intact were supervised at a medical appointment to prevent accidents. The facility to ensure there was adequate staffing in place to meet acuity levels, which lead to the inability to provide bathing assistance and the inability to provide timely incontinence care for two of two floors. The facility failed to provide appropriate resident equipment to prevent falls. The facility failed to ensure medications were administered as ordered. The facility failed to ensure pressure ulcers were assessed and monitored. The facility failed to ensure sufficient resident equipment was available for resident transfers and showers. The cumulative effect of these failures in providing care and services contributed to an environment of neglect for 51 residents (#s 2, 7, 8, 9, 10, 11, 12, 15, 16, 17, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 46, 53, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, and 72). Findings include: ASPIRATION a. Resident 20 readmitted to the facility in 2/2020 with diagnoses including multiple sclerosis. The 10/1/21 Care Plan indicated Resident 20 required 1:1 assistance with eating. The 10/9/21 Aspiration Precaution sign indicated Resident 20 was to receive 1:1 assistance, encourage intake and check to check for "pocketing." On 10/28/21 at 5:55 PM Staff 41 (CNA) was observed to leave Resident 20's room. The resident had her/his meal at the bedside within reach and was observed chewing food. The surveyor asked Resident 20 if she/he was chewing food and she/he stated "yes." On 10/28/21 at 6:03 PM Staff 41 acknowledged Resident 20 was left in the room unattended with the meal and acknowledged the resident should not have been left alone. b. Resident 25 admitted to the facility in 2015 with diagnoses including stroke. Resident 25 was diagnosed with Alzheimer's disease and dementia in 2019. The 7/20/17 Care Plan indicated Resident 25 was on aspiration precautions and required to sit up for meals, distant supervision and "feed" assist PRN. The 8/31/21 and 9/26/21 Aspiration Precaution signs located in an Aspiration Risk Book and/or in the resident room indicated Resident 25 was to receive close supervision with meals and to have supervision with meals in the dining room. Resident 25's medical record indicated the resident required distant supervision in the dining room. Resident 25 had a history of aspiration and aspirated at the facility in 3/2021. On 10/26/21 at 5:47 PM Resident 25 was observed eating independently in the hallway and drinking thin liquids with no staff present. c. Resident 26 admitted to the facility in 9/2020 with diagnoses including Parkinson's disease and dysphagia (difficulty swallowing). The 10/27/21 Kardex (staff care plan) indicated Resident 26 required 1:1 staff participation to eat and after the meal "search mouth for food residue", and keep upright. The 1/20/21 Aspiration Precaution Sign indicated Resident 26 required 1:1 assistance with meals and to "limit distractions." On 10/28/21 at 5:15 PM Resident 26 sat across from the nurses station with a mug of fluid on the bedside table in front of her/him and within reach. At 5:47 PM a staff member walked up to Resident 26, moved the mug of fluid so it was directly in front of her/him and then walked away. At 5:48 PM Resident 26 began to take sips out of the mug; no staff supervision or assistance was provided. At 5:54 PM the dinner tray was placed in front of Resident 26, the food was set-up and the bedside table was lowered. The staff member then walked away which left Resident 26 alone and unsupervised with her/his meal tray. Resident 26 attempted to clean her/his hands and start the meal without staff assistance or supervision. At 5:58 PM a staff member sat next to Resident 26 and began to assist her/him with the meal. At 6:28 PM Resident 26 sat with two cups of fluid on the bedside table in front of her/him with no assistance or supervision from staff. On 10/28/21 at 6:46 PM Staff 39 (CNA) stated she placed the food tray in front of Resident 26 and left without providing eating assistance or supervision. On 10/28/21 at 6:43 PM Staff 14 (CNA) stated Resident 26's assistance with meals "fluctuated" daily and acknowledged she was not aware Resident 26 required 1:1 supervision or assistance. Staff 14 acknowledged Resident 26 sat across the nurses station with two cups of fluid in front of her/him without supervision. On 10/28/21 at 6:50 PM Staff 26 (Regional RN) stated 1:1 assistance and supervision meant there should be a staff member with the resident when the resident had food or fluids. Staff 26 verified any resident who required 1:1 assistance or supervision with meals should never be left alone with fluids. d. Resident 27 admitted to the facility in 2019 with diagnoses including multiple sclerosis, stroke and epilepsy. The 4/13/19 Care Plan indicated Resident 27 required 1:1 close supervision for meals in the dining room for swallow precautions. The 4/19/21 Aspiration Precaution Sign indicated Resident 27 was to receive 1:1 assistance as needed and assist with small bites. On 10/28/21 at 5:35 PM Resident 27 was observed sitting outside of her/his room. The resident was given her/his food tray and utensils. Resident 27 was observed to eat independently. At 5:42 PM the resident was observed to be cough and drool while eating independently in the hall. No staff were present. At 5:44 PM staff were observed to move the residents tray out reach for a brief moment and placed the tray back within the resident's reach and walked away. At 5:48 PM staff were observed telling Resident 2 that they would be right back and walked away. e. Resident 28 admitted to the facility in 10/2021 with diagnoses including stroke and dysphagia (difficulty swallowing). The 10/27/21 Care Plan indicated Resident 28 was to receive supervision with eating and PRN assistance. The 10/19/21 Aspiration Precautions Sign indicated Resident 28 required 1:1 supervision with meals and to check for "pocketing." On 10/28/2021 at 5:17 PM a visitor was observed at the front door stating she wanted staff to give Resident 28 food as they were doing a window visit downstairs. Staff 1 took the food from the visitor. On 10/28/21 at 6:05 PM Resident 28 was observed to have nachos on a table next to her/him within reach in the dining room. Staff 48 (RN) entered the dining room and removed the nachos and stated the resident was on aspiration precautions and was not supposed to have nachos. On 10/28/21 at 7:04 PM Staff 1 stated she provided the nachos to Resident 28. On 10/28/21 at 9:28 PM Staff 1 (Administrator), Staff 25 (Regional RN) and Staff 26 (Regional RN) were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during meals. Refer to F689, example 1. ELOPEMENT Resident 15 admitted to the facility on 3/4/21 with diagnoses including paranoid schizophrenia and anxiety. The 3/4/21 Admission Nursing Database indicated Resident 15 had short term memory loss with moderate impairment. The resident was alert to self and somewhat to her/his surroundings with mild confusion and delayed response time. The resident was anxious and received antipsychotic, antianxiety, antidepressant, and mood stabilizer medications. The 3/5/21 BIMS indicated Resident 15 had a severe cognitive impairment. A 3/8/21 Progress Note indicated Resident 15 was sent the physician clinic unaccompanied, did not wait for the appointment and left the clinic. The resident unsafely `entered a busy intersection in an urban environment. Cars swerved to avoid hitting the resident. The clinic staff escorted the resident around the block until she/he "eventually agreed" to return to the clinic. On 3/11/21 at 2:32 PM Witness 19 (Complainant) stated Resident 15 was dropped off for a medical appointment at her/his physician clinic unaccompanied on 3/8/21 at 3:23 PM. On 10/28/21 at 2:43 PM Witness 31 (Former LPN) stated Resident 15 exhibited decreased cognition and exit-seeking behaviors since admission and had previously left the facility and crossed the street. Witness 31 stated the facility did not have enough staff to go with residents to appointments. Refer to F689, example 2. PRESSURE Resident 10 was admitted to the facility in 8/27/20 with diagnoses including heart failure. The 8/27/20 Admission Nursing Database revealed Resident 10 was admitted to the facility with blanchable redness to her/his bilateral heels [indicating no pressure ulcers]. The 9/11/20 Facility Investigation revealed Resident 10's right heel had a blood blister or "maroon area" which measured 3.3 cm x 2.5 cm. The left heel had a blood blister which "popped" and was now a reddened area which measured 1.7 cm x 3.2 cm. Treatments were implemented for the bilateral pressure ulcers. The 9/2020 TAR revealed a 9/11/20 order to monitor the deep tissue injuries (DTI - a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear), apply skin prep every shift, ensure the heels were floated, and to monitor for signs of infection or worsening of wounds. The 9/12/20 Weekly Skin Check revealed Resident 10's right heel had a red area which measured 5 cm x 2 cm and a red area which measured 3 cm x 1 cm to the left heel. A formal wound assessment of the bilateral wounds was not completed. The 9/15/20 Weekly Skin Check revealed Resident 10's right heel had a red area which measured 5 cm x 3 cm and the left heel had a red area which measured 3 cm x 1 cm. A formal assessment of the bilateral wounds was not completed. The 9/17/20 Nutrition at Risk assessment revealed the wounds to Resident 10's bilateral heels were pressure ulcers. The 9/22/20 Weekly Skin Check revealed the blister to the right heel had "popped", measured 3.2 cm x 3.9 cm.. The left heel had a blister which measured 2.2 cm x 1.3 cm. A formal assessment of the bilateral pressure ulcers was not completed. The 9/29/20 Weekly Skin Audit indicated the right heel pressure ulcer measured 2.8 cm x 3.6 cm and the left heel pressure ulcer measured 2.1 cm x 1.6 cm. The left heel was dark red in color and "very slightly" raised. The 9/29/20 Wound and Skin Evaluation indicated Resident 10 had a facility acquired deep tissue injury to the right heel. The 10/6/20 Weekly Skin Audit revealed Resident 10's skin was intact. The 10/6/20 Wound and Skin Evaluation revealed the right heel DTI was first observed on "unknown date" and measured 2.3 cm x 3.4 cm. A full skin assessment of the right heel was completed. A full skin assessment was not completed for the left heel. The 10/13/20 Weekly Skin Audit revealed no measurements or assessments of the bilateral heel pressure ulcers. The 10/20/20 Weekly Skin Audit revealed Resident 10 had a pressure ulcer to the right and left heels, the left heel contained eschar (a collection of dry, dead tissue within the wound; a Stage III pressure ulcer). The Audit further revealed the nurse was unable to stage the wound and referred to the RN "skin/wound" sheet for staging of the pressure ulcers [No RN skin wound sheet was completed]. On 11/1/21 at 10:30 AM Staff 25 (Regional RN) and Staff 26 (Regional RN) acknowledged Resident 10 admitted to the facility with red, blanchable heels and on 9/11/20 the facility identified bilateral pressure ulcers to both heels. Staff 26 further acknowledged formal assessments and monitoring of the facility acquired bilateral heel wounds was not initiated until 9/19/20 and the left heel wound worsened to a Stage III pressure ulcer. Refer to F686. FALL The 11/17/20 Annual MDS indicated Resident 13 had severe cognitive impairment and required extensive, two or more persons for bed mobility. The 12/17/20 Fall Investigation completed by Staff 31 (LPN) indicated a former Witness 29 (Former CNA) was in Resident 13's room providing care when the resident rolled out of bed onto the floor due to the mattress bending over the edge of the bed. There was no time indicated when the resident fell. When asked if the resident hit her/his head the resident responded "yes" and stated her/his "legs were broken" and "knees hurting." The resident was assessed as having 5/10 pain and the investigation indicated pain medication was offered but the resident refused. Later in the investigation pain was assessed as 7/10 and the resident reported left shoulder, arm, and torso pain. An x-ray was ordered, and the results determined Resident 13 sustained three left ribs fractures. The investigation summary concluded the mattress was too big and soft for the bed frame and folded over when weight was applied. Maintenance replaced the mattress and applied non-skid strips to the bottom to keep the mattress from sliding and the care plan was updated for the resident to receive two-person cares with bed mobility. Multiple attempts were made to contact Witness 29 but there was no response. On 10/28/21 at 2:48 PM Staff 31 (LPN) stated she recalled Resident 13's mattress not being the correct size and stated after the fall Witness 29 reported the fall occurred due to Resident 13's mattress not being the correct size and slid around the bed frame. Staff 31 stated Witness 29 reported he had brought up the mattress being the wrong size twice to management before and the mattress was never changed. On 10/27/21 at 1:08 PM Witness 30 (Former RNCM) stated she was not aware Resident 13's mattress was too big for the bed. Witness 30 stated during her investigation she had found a couple of CNAs that knew the mattress hung over the side of the bed. Witness 30 stated she did not write-down the interviews with the CNAs and could not recall who she interviewed. On 11/1/21 at 12:58 PM Staff 6 (CNA) stated the facility previously had multiple mattresses that slid "very bad" over the bed frames and administrative staff were aware and did not replace them. On 11/1/21 at 9:49 AM Staff 25 (Regional RN) confirmed Resident 13 had a fall with rib fractures due to the mattress being the incorrect size for the bed. Refer to F689, example 3a. PAIN Resident 7 admitted to the facility in 2018 with diagnoses including kidney failure and cancer. The 7/26/21 BIMS indicated Resident 7 was cognitively intact. The 9/22/21 Physician Order indicated Resident 7 was to receive oxycodone (narcotic pain medication) at bedtime and every 6 hours PRN. The 10/2021 narcotic logs and MARs indicated the following: -Resident 7 received a dose of oxycodone on 10/19/21 at 4:00 AM. -Resident 7 did not receive another dose of oxycodone until 10/20/21 at 2:19 AM and had 10/10 pain. The 10/20/21 at 1:14 AM progress note indicated Resident 7 was crying, reported being sick to her/his stomach due to pain and the resident thought she/he was having withdrawal from the medication. The nurse called the pharmacy and the pharmacy indicated a prescription was not received. The provider indicated she would call the pharmacy with a new prescription for oxycodone. On 10/25/21 at 11:18 AM Resident 7 stated there were instances when she/he did not receive oxycodone timely due to staff failure to order oxycodone. The resident stated she/he recently did not receive oxycodone for one day and had "a lot of pain, was laying in bed crying and shaking all day long and had withdrawals." Resident 7 stated staff offered her/him Tylenol which did not help the pain. On 10/25/21 at 3:24 PM Staff 3 (LPN) stated Resident 7 ran out of oxycodone due to the physician needing to sign new orders. Staff 3 stated she noticed Resident 7 was running low on oxycodone on 10/19/21 and notified the physician and the oncoming shift. Staff 3 further stated when she returned to work on 10/20/21 Resident 7 did not have oxycodone available and she called the physician to get an order. Staff 3 informed the physician the resident was crying, shaking and reported she/he was "hurting all over." Staff 3 stated she received the order for the oxycodone and was able to administer it on 10/20/21. On 10/26/21 at 9:28 AM Staff 4 (LPN) stated on 10/19/21 staff informed him that Resident 7 needed a new order for oxycodone. Staff 4 stated the physician was contacted via email of the need for the new order and the physician did not reply. Staff 4 further stated an order for oxycodone was not received on 10/19/21 and the night shift nurse was able to get an order in the early morning on 10/20/21. Staff 4 further stated the physician visited every Wednesday and acknowledged medications were not always reordered timely. On 11/1/21 at 11:45 AM Staff 25 (Regional RN) acknowledged Resident 7 ran out of oxycodone due to staff not reordering it timely. Staff 25 acknowledged Resident 7 received oxycodone on 10/19/21 at 4:00 AM and did not receive an additional dose until 10/20/21 at 2:19 AM and acknowledged the resident had unrelieved pain due to not receiving oxycodone on time. SIGNIFICANT MEDICATION ERRORS 1. Resident 22 admitted to the facility in 1/2020 with diagnoses including diabetes. The 9/14/21 Skin and Wound Evaluation indicated Resident 22 had a facility acquired open lesion to the lower right abdomen. The wound appeared "two weeks prior", measured 1.8 cm x 0.6 cm and had no signs of infection. Treatment was in place. The 9/22/21 Progress Notes revealed the abdominal wound was raised, red, warm to touch, painful with moderate yellow drainage. [Indicative of infection.] The 9/22/21 Physician Order revealed an new antibiotic order for doxycycline hyclate twice daily for abdominal cellulitis (skin infection). The 9/2021 MARs revealed the order for the doxycycline hyclate was not transcribed onto the MAR and was not administered. The 9/24/21 Progress Noted revealed Resident 22 had a temperature of 100.4F [normal is between 97F to 99F] and a pulse of 120 [normal is 60 to 100 beats per minute]. Resident 22 complained of pain at the abdominal wound site. Resident 22's lower abdomen was red and hot to the touch. Resident 22 was transferred to the hospital. The 9/27/21 Hospital Re-Admission orders revealed Resident 22 was admitted to the hospital for sepsis (full body infection) due to the infection of skin and soft tissues of the left pannus (stomach apron). Resident 22 was discharged with a PICC (peripherally inserted central catheter) line for two weeks of IV (intravenous) antibiotics. Resident 22 was to follow up with the infectious disease clinic in one week. On 11/1/21 at 10:47 AM Staff 25 (Regional RN), Staff 26 (Regional RN) and Staff 2 (Interim DNS) acknowledged the 9/22/21 antibiotic order was not transcribed or administered to Resident 22 which resulted in the transfer and admission to the hospital for IV antibiotics to treat the sepsis. Refer to F760. 2. Resident 23 admitted to the facility on 2/22/20 with diagnoses including heart failure. The 2/22/20 at 12:36 PM progress note indicated Resident 23 admitted to the facility. The 2/22/20 Physician Order indicated Resident 23 was to receive a enoxaparin injection (anticoagulant medication) BID. The 2/22/20 at 9:24 PM progress note indicated enoxaparin was not available. The 2/2020 MAR indicated Resident 23 did not receive her/his first dose of enoxaparin until 2/23/20 at 8:00 PM. On 11/2/21 at 9:16 AM Staff 26 (Regional RN) stated Resident 23 admitted to the facility on 2/22/20 with an order for enoxaparin BID and did not receive the first dose until 2/23/20 at 8:00 PM. Refer to F760. STAFFING On 11/5/21 at 11:16 AM the facility identified 12 residents who required two person transfers in addition to 27 residents who required mechanical lift transfers. Staff and resident interviews indicated the following: -On 10/25/21 at 2:19 PM Resident 33 stated call lights could take anywhere from 15 minutes to three hours to be answered and shift change was "the worst." Resident 33 stated she/he had previously waited so long for assistance she/he self-transferred three times. -On 10/25/21 at 3:09 PM Staff 19 (CNA) stated staffing was an issue, especially when she worked with Personal Care Assistants (PCAs) who could not chart or perform vitals. -On 10/25/21 at 2:45 PM Resident 20 stated call lights were not answered timely, especially during meals and shift change. Resident 20 stated she/he often waited up to 90 minutes for assistance. Resident 20 further stated she/he received intermittent assistance with eating and staff would have to leave her/him during meals to assist other residents. -On 10/25/21 at 2:53 PM Staff 45 (LPN) stated the facility was "constantly" understaffed, and she currently had 31 residents to herself, which was the whole first floor and it took longer to provide care. -On 10/25/21 at 3:09 PM Staff 19 (CNA) stated it was difficult to complete showers as there were six scheduled for her side of the hall and only two CNAs working on that side. Staff 19 stated staff had spoken to administrative staff about showers and staffing but nothing had changed. -On 10/26/21 at 10:35 AM Staff 41 (CNA) stated some days the facility was short staffed to the point where there was one CNA for 15 to 16 residents. Staff 41 stated due to staffing shortages, residents were not getting showers. Staff 41 stated call lights could take up to 45 minutes to be answered. Staff 41 stated staffing issues started in July 2021. -On 10/26/21 at 11:25 AM Staff 5 (CNA) stated resident acuity was higher despite the census being lower and on evening shift there was not enough staff to complete showers. -On 10/26/21 at 2:18 PM Staff 9 (CNA) the facility was understaffed and most of the staff was agency and the long term staff had to spend time training them. Staff 9 stated she basically had a whole hall to herself and there were times residents did not receive showers due to staffing shortages. -On 10/26/21 at 3:31 PM Staff 42 (Nurse Aide) stated at times she was responsible for 12 residents, which made it hard to complete cares, especially showers. -On 10/26/21 at 3:38 PM Staff 7 (CNA) stated the facility had staffing shortages and showers were missed almost daily due not enough staff. Staff 7 stated resident call lights could take up to 20 minutes to answer or more staff were completing a resident shower. -On 10/27/21 at 12:05 PM Staff 46 (CNA) stated it was difficult to work being short staffed as the facility had high resident acuity. Staff 46 stated it was a challenge to fit showers in if there were more than two scheduled, especially when most residents required more assistance. Staff 46 further stated there were "trends" for call lights not being answered due to staffing. -On 10/27/21 at 1:28 PM Staff 13 (LPN) stated there were not enough staff and when a new admission came into the facility it made it difficult to complete regular duties including treatments. Staff 13 further stated treatments did not get done when there were not enough nursing staff. Staff 13 further stated downstairs on 10/31/21 there was one Personal Care Assistant (PCA) and one Nurse Aide (NA) for part of the evening and night shift for over 30 residents . -On 10/27/21 at 2:34 PM Staff 30 (CNA) stated the facility did not have enough staff and she felt "overwhelmed" with the State's higher resident to staff ratio mandates. Staff 30 stated showers were the hardest tasks to get done. Staff 30 stated there were a lot of residents who required 1:1 assistance with eating and it was difficult to assist the residents as there was not enough staff. -On 10/28/21 at 9:44 AM Staff 14 (CNA) stated the facility was short staffed and there were so many new staff, especially on evening shift, getting showers done for residents was difficult. Staff 14 stated there were times residents did not receive showers or eating assistance due to not enough staff. -On 10/28/21 at 2:54 PM Staff 31 (LPN) stated staffing was an issue, especially with residents on end of life care as she spent a lot of time doing treatments on night shift as the treatments were unable to be completed on evening shift. Staff 31 stated on night shift the facility was short staffed so she had to answer resident call lights and help with cares and it was difficult to complete tasks. -On 11/1/21 at 4:08 PM Resident 52 stated call lights took "a long time" to answer due to staffing as staff were always "running around." Resident 52 stated call light wait times were 20 minutes to over an hour, especially on evening shift. Resident 52 stated the evening of 10/31/21, she/he had to sit in a wet brief for over an hour and staff stated it was due to the facility being short staffed. Resident 52 stated concerns were communicated to administrative staff but they did not "do anything." Lastly, Resident 52 stated meals were served late and were cold 90% of the time and staff were unable to reheat the food due to being short staffed. -On 11/4/21 at 10:59 AM Staff 43 (CNA) stated the facility had staffing issues, she was exhausted, it was difficult to complete cares, and the facility mandated staff to work extra hours. Refer to F725 and M183. INCONTINENCE Resident 17 admitted to the facility in 2017 with diagnoses including congestive heart failure and major depressive disorder. a. On 10/22/21 at 9:21 AM Witness 27 (Mental Health Therapist) stated Resident 17 reported a week prior Staff 36 (CNA) left the resident sitting in her/his own excrement for over an hour after telling the resident she would be "right back" when the resident's call light was on. Witness 27 stated Resident 17 was tearful and reported and exhibited increased depression due to the lack of timely incontinence care. The 9/6/21 Annual MDS indicated the resident was cognitively intact and required extensive one-person staff assistance with toileting. On 10/26/21 at 1:32 PM Staff 36 (CNA) stated on 10/14/21 she changed Resident 17 three- or four-times during day shift. Staff 36 stated she told Resident 17 she was in the middle of changing another resident and would help the resident after. Staff 36 stated the next morning Staff 37 (LPN) informed her the resident complained about the wait time and Staff 37 observed the call light on for about an hour. On 10/29/21 at 3:10 PM staff 37 (LPN) stated on day shift 10/14/21 she noticed Resident 17's call light was on and was on longer than 20 minutes but was unsure the exact time. Staff 37 stated CNAs were "really busy" trying to get everyone done and Staff 36 did not intentionally leave the resident in a soiled brief. On 11/1/21 at 12:09 PM Resident 17 stated she/he was left in a soiled brief two times in October 2021 by Staff 36. Resident 17 stated approximately 10/14/21 Staff 36 kept telling the resident there were three residents who required assistance before her/him, so by the time the resident's brief was changed it was one and a half hours later. Resident 17 stated Staff 36 did not intentionally not change her/his brief, but staffing was "pretty bad" and a times call lights take over an hour to be answered. On 11/8/21 at 12:07 PM Staff 25 (Regional RN) stated the expectation was for call lights to be answered within 15 to 20 minutes. Refer to F677. b. A 4/25/21 Grievance Form indicated Resident 17 reported long wait times on night shift related to how the assignments were made and short staffing at times. The investigation indicated education and extensive directives for the evening to provide the residents cares. The investigation indicated an [unnamed] nurse reported Resident 17 used her/his call light "a lot" that shift. The 4/26/21 follow-up indicated the resident was happy with the outcome and cares. On 4/28/21 at 7:34 AM Witness 20 (Hospital Social Worker) stated Resident 17 reported the facility was short staffed, which resulted in long call light response times and staff telling the resident they were "too busy" to help. Resident 17 further stated staff did not see her/his call light initiated as the resident resides on the ground floor and staff took care of residents on the second floor as well as the first floor. On 10/28/21 at 2:08 PM Staff 24 (CNA) stated Resident 17 had reported to her she/he had waited an hour for her/his brief to be changed but there were a lot of residents and "rounds" were every two hours. Staff 24 stated she used to be a "float" person who worked upstairs and downstairs. Staff 24 stated when she worked upstairs she was up there for two hours and then downstairs for two hours. She further stated if she was working upstairs people downstairs should have been answering her residents' call lights and vice versa. On 11/1/21 at 12:09 PM Resident 17 stated staffing was "pretty bad" and a times call lights took over an hour to be answered and the resident had been left in a soiled brief multiple times. On 11/01/2021 at 3:18 PM Staff 6 (CNA) stated in Spring of 2021 on night shift, she observed Resident 17's call light on for over an hour because a CNA that was not supposed to work with the resident was assigned to Resident 17, so no one answered the light as the other CNAs were busy with other residents. On 11/8/21 at 12:07 PM Staff 25 (Regional RN) stated the expectation was for call lights to be answered within 15 to 20 minutes. ACCOMMODATION OF NEEDS On 11/5/21 at 11:16 AM the facility identified 27 residents who required slings for mechanical lift transfers. a. A list provided by the facility on 11/4/21 indicated 27 residents required the use of slings for mechanical lifts. On 11/1/21 at 12:19 PM Resident 20 stated she/he did not always get showers because the facility did not have shower slings available. On 11/2/21 at 2:31 PM Staff 26 (Regional RN) counted six slings and confirmed these were the only slings clean and available for resident use for the entire facility. Staff 26 further stated she was unsure of the amount of slings the facility had. b. 11/1/21 3:09 PM Staff 7 (CNA) stated she was not able to give Resident 53 a shower on 10/30/21 because there was not a sling available. Staff 7 stated she gave Resident 53 a bed bath instead but the resident preferred a shower. On 11/2/21 at 2:08 PM Resident 53 stated she/he preferred showers but had to take a bed bath if there was no sling available. Resident 53 stated she/he took a bed bath the previous Saturday [10/30/21] due to because staff informed her/him the sling was not available to take a shower. On 11/2/21 at 2:31 PM Staff 26 (Regional RN) counted six slings and confirmed these were the only slings clean and available for resident use for the entire facility. Staff 26 further stated she was unsure of the amount of slings the facility had. Refer F558. RESIDENT COUNCIL The 6/2004 Resident Council Policy and Resident Grievance Policy indicated resident council meetings would be held twice monthly and all grievances noted during the council meeting would be given to department managers who would respond in writing within 5 days. Resident Council Meeting Minutes from 9/6/21, 9/27/21 and 10/26/21 indicated: -9/2021: Call light times on both floors took longer than "normal" and "normal wasn't great." A resident reported they were often left sitting on the toilet for "awhile." Day and swing shift took and hour and a half to answer call lights and night shift rarely answered, "at all." -10/2021: Resident s felt "exasperated" with no changes to staffing shortages and long call light wait times. Three residents reported they waited up to two hours for their call light to be answered. The minutes did not identify solutions, explanations nor did appropriate staff respond to the group's concerns timely. On 11/8/21 at 9:42 AM Staff 38 (Activities Director) stated she wrote resident council meeting notes based on interviews with residents. Staff 38 further stated residents were frustrated because the concerns they brought forward month after month were not addressed. Staff 38 stated the resident council concerns from 9/6/21, 9/27/21 and 10/26/21 were forwarded to administrative staff with no response to the resident council's recommendations or expressed concerns. On 11/8/21 at 11:31 AM Staff 26 (Regional RN) acknowledged the facility had not responded to the residents' grievances per the facility policy and acknowledged only one resident council meeting was held in 10/2021. Refer F565. BATHING 1. Resident 12 admitted to the facility on 9/1/20 with diagnoses including a stroke and hemiplegia (paralysis of half the body). Resident 12's 9/6/21 Annual MDS indicated the resident was cognitively intact. The 9/1/20 Care Plan indicated the resident was dependent on staff for bathing. The Bathing/Shower Task Sheet indicated on 10/30/21 Resident 12 did not receive a shower or bed bath. The reason was marked "RR" [Resident Refused] by Staff 13 (LPN). On 11/3/21 at 12:50 PM Staff 13 (LPN) stated Staff 20 (Personal Care Assistant) completed the shower documentation under her credentials. On 11/3/21 at 1:26 PM Staff 20 (Personal Care Assistant) stated she did not recall completing a shower for Resident 12. Staff 20 stated if a shower was unable to be completed, she was supposed to inform a nurse and re-approach the resident. Staff 20 did not recall informing a nurse or re-approaching Resident 12. Staff 20 stated she was "definitely" not able to get everything done because there were not enough staff. 2. Resident 11 admitted to the facility in 2014 with diagnoses including schizophrenia and heart failure. Resident 11's 9/11/21 Annual MDS indicated the resident required one staff person physical assist with bathing. The care plan, last revised 4/8/20, indicated Resident 11 was totally dependent on one staff member for bathing on Mondays, Wednesday, and Friday evenings and preferred bed baths at 2:00 PM. The Staff Shower Schedule indicated Resident 11 received bathing on Mondays, Wednesdays, and Saturdays. The 10/23/21 Bathing Task Sheet was blank for 10/22/21 (Friday) and indicated Resident 11 did not receive a shower on 10/23/21 (Saturday). The reason was marked as "RR" [Resident Refused]. On 10/25/21 at 3:09 PM Staff 19 (CNA) stated Resident 11 did not receive her/his bed bath on 10/23/21 due to staffing shortages. Staff 19 stated if staff were unable to provide a bath for a resident they would let the nurse know. Staff 19 stated she marked "RR" in the electronic health record as there was not an option if a bed bath was not provided due to staffing issues. On 11/4/21 at 9:26 AM Staff 26 (Regional RN) Staff 26 acknowledged the concerns related to residents not being provided showers were due to staffing. Refer to F677, 725 and F842 PHYSICIAN ORDERS 1. Resident 23 admitted to the facility on 2/22/20 with diagnoses including heart failure. The 2/22/20 physician order indicated Resident 23 was to receive tramadol (narcotic pain medication) 25 mg every 8 hours PRN for pain. The 2/2021 MAR indicated Resident 23 received tramadol 25 mg on 2/22/21 at 11:14 PM. The 2/23/20 Medication Error Report indicated Witness 29 (Former Staff/LPN) administered tramadol 100 mg on the evening shift of 2/22/20 instead of the ordered 25 mg. The report further indicated the resident had no adverse side effects. On 10/29/21 at 3:09 PM Witness 29 stated he did not recall administering the wrong dose of tramadol to Resident 23. On 11/2/21 at 9:16 AM Staff 25 (Regional RN) acknowledged Resident 23 received tramadol 100 mg instead of the ordered 25 mg as indicated on the medication error report on 2/23/20. Refer to F697 and F684. 2. Resident 9 admitted to the facility on 9/21/20 with diagnoses including femur fracture. The 9/21/20 physician order indicated Resident 9 was to receive Norco (narcotic pain medication) every four hours PRN. The 9/21/20 hospital records indicated Resident 9 had physician orders for Tylenol, morphine (narcotic pain medication) and Norco. The 9/2020 MAR indicated Norco was not added to the MAR until 9/22/20 at 4:30 PM and Resident 9 did not receive her/his first dose of Norco until 9/22/20 at 4:40 PM. On 11/1/21 at 1:00 PM Staff 25 (Regional RN) stated Resident 9 admitted on 9/21/20 with an order for Norco and the order was not implemented until 9/22/20. Refer F684. 3. Resident 17 admitted to the facility in 2017 with diagnoses including congestive heart failure, diabetes, and major depressive disorder. The 9/6/21 Annual MDS indicated the resident was cognitively intact and required extensive one person assistance for toileting. A 4/25/21 Grievance Form completed by Resident 17 indicated the resident had requested treatment for her/his hemorrhoids for over a week but was told she/he did not have an order. The grievance investigation indicated the resident had an order for Preparation H (hemorrhoid medication) since 9/27/20 and the medication was not used until 4/25/21. The investigation indicated Staff 4 (LPN) was aware of the requests made by Resident 17 and did not follow up as he believed the concern had already been addressed. The grievance was signed by the former administrator on 5/7/21. The 4/2021 MAR indicated Resident 17 had an order for Preparation H since 9/27/20 and the medication was not provided until 4/25/21. A 9/27/20 Physician Order indicated Resident 17 was to receive Preparation H every six hours as needed for burning/itching. On 10/26/21 at 9:16 AM Staff 4 (LPN) stated Resident 17 requested Preparation H but he was informed the doctor had been faxed and the facility was waiting on an order. Staff 4 stated if the resident already had an order then staff should have provided the Preparation H immediately. On 11/1/21 at 12:09 PM Resident 17 stated when she/he requested Preparation H staff told her/him there was no order for it. Resident 17 stated she/he had difficulty sleeping due to the itching and pain and it took over a week for staff to find the order. Resident 17 further stated she/he had a previous order for Preparation H, but staff did not look closely until a nurse found the order a week later. On 11/1/21 at 9:46 AM Staff 25 (Regional RN) stated Resident 17 had an order for hemorrhoid medication and staff were expected to provide the medication as ordered. Refer to F684, example 3a. 4. Resident 2 was admitted to the facility on 5/17/19 with diagnoses including paranoid schizophrenia, depression, personality disorder and post traumatic stress disorder (PTSD). A physician order dated 10/1/20 indicated Resident 2 was to receive Topamax (neurological medication) daily for PTSD. The 1/2020 MAR indicated Resident 2 did not receive Topamax on 1/1/20 and 1/2/20. Progress notes dated 1/1/20 and 1/2/20 indicated the medication was on order from the pharmacy. There was no indication the physician was notified of the missed doses. On 11/1/21 at 9:47 AM Staff 25 (Regional RN) confirmed Resident 2 did not receive the Topamax as ordered. Refer to F684.

All residents currently in the facility with aspiration precautions will be reviewed to ensure care plan and aspiration precautions reflect the same information. Residents that are not to have fluids at bedside have been checked to ensure fluids currently not at bedside. All nursing staff will be in serviced on the policy of aspiration precautions, how to read and understand the pink precautions signs and definitions of supervisions as outlined in the policy. All nursing staff in the building currently will receive the in-service prior to leaving tonight and dayshift will be in serviced prior to starting their shift in the morning. All other nursing staff will be in serviced no later than 2359 of 10/29/21 unless staff is unreachable ie: on leave, vacation or PTO. Any staff that are not reachable will receive in service prior to starting their next shift. By end of the day on 10/29/21 the dining room will be open to residents requiring assistance for eating and residents that require assistance that stay in their bed will receive the 1 to 1 assistance as outlined in the care plan and aspiration sheet. Any current residents on aspiration precautions that have not been seen by speech therapy in the past 12 months or that have had a change in cognition, will be reevaluated by speech therapy. This will be completed by 11/5/21. DNS or designee will complete weekly audits of all residents on aspiration precautions to ensure that staff are following aspiration precautions and that the sign in the room is matching the care plan. These audits will be completed weekly for 3 months and will be reviewed at QAPI until substantial compliance has been met for 2 quarters. Res. # 15 is no longer at this facility. Current residents need for an appointment attendant will be assessed by a nurse based on cognition, elopement risk and safety concerns. Residents designated as needing an Appointment Attendant will be documented in the chart. Residents with appointments in the next 2 weeks have been reviewed to ensure those needing an Appointment Attendant are identified and scheduled the next 24 hours. All staff (unless unreachable due to LOA, vacation or FMLA) will be in-serviced on importance of always using Appointment Attendants for those residents identified. In-servicing will be done prior to beginning of their next shift, starting today 11/2/21 with DAY and EVE shift staff, and continue until all staff have received the training. This will be completed by DNS/Admin or designee before 1159 at 11/3/21. All new admissions will be assessed by a nurse based on cognition, elopement risk and safety concerns. Residents designated as needing an Appointment Attendant will be documented in the chart. Admin/DNS will audit 4 res. charts weekly to assure residents needing appointment attendant have been identified in the chart and upcoming appointment for the week have attendants as identified. Any areas found not in place will be immediately rectified. These audits will continue for 3 months with results brought QAPI for 2 quarters or until substantial compliance is met. Resident 10 has discharged from the facility. Current residents with limited mobility are at risk for pressure injury development. These residents have been assessed for unidentified pressure injuries, with updates to care plans and treatments as appropriate. Education was provided to clinical staff about pressure injury prevention, appropriate notifications, and comprehensive assessments. Weekly wound meetings were initiated with DNS & RCMs to review active wound healing progress. DNS or designee will audit 24-hour reports 5 days/week for new or worsening skin impairments. DNS or designee will visualize 5 residents weekly to ensure pressure injury interventions are in place. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved. Resident 13 has discharged from the facility. Current residents are at risk for mattress not fitting bed correctly. Audit was completed for current residents to ensure all mattresses are sized correctly to the frame. Education provided to clinical staff about submitting requests for equipment repair or replacement or notifying the Maintenance Director directly if equipment concern is urgent. Education provided to clinical staff about importance of following resident care plans. Administrator or designee will inspect 5 resident beds weekly for proper fit of mattress. Additionally, DNS or designee will audit 5 resident transfers weekly to ensure care plan is being followed. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved. Resident 7 was verified as having an adequate supply of oxycodone. All residents receiving schedule 2 medications are at risk for this deficient practice. Nurses have been educated about facility process for reordering schedule 2 medications and importance of submitting requests timely. Nurses have also received education about how to access cubex medications when supply is needed immediately. DNS or designee will audit 5 resident medications weekly to ensure schedule 2 medications have adequate supply available. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to complete baseline care plans related to safety for 1 of 3 residents (#15) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 15 admitted to the facility on 3/4/21 with diagnoses including paranoid schizophrenia, anxiety, and stroke. The 3/4/21 Admission Nursing Database indicated Resident 15 had short term memory loss with moderate impairment. The resident was alert to self and somewhat to her/his surroundings with mild confusion and a delayed response time. The resident was anxious and received antipsychotic, antianxiety, antidepressant and mood stabilizer medications. The 3/5/21 BIMS indicated Resident 15 had a severe cognitive impairment. The baseline care plan was initiated 3/7/21 and did not address Resident 15's behaviors, cognition, or if the resident was an elopement risk. A 3/8/21 Progress Note indicated Resident 15 was sent to a physician clinic unaccompanied, did not wait for the appointment and left the clinic. The resident unsafely entered a busy intersection in an urban environment. Cars had to swerve to avoid hitting the resident. The clinic staff escorted the resident around the block until she/he "eventually agreed" to return to the clinic. The clinic staff indicated the resident was anxious, agitated and exhibited self-injurious behavior when approached by clinic staff. The 3/9/21 Code Pink Assessment [elopement risk] indicated Resident 15 was an elopement risk, had a diagnosis of schizophrenia and would hit her/himself when "triggered" and triggers included: "new places, new faces." On 3/11/21 at 2:32 PM Witness 19 (Complainant) stated Resident 15 was dropped off for a medical appointment at her/his physician clinic unaccompanied on 3/8/21 at 3:23 PM. At 3:30 PM Resident 15 was observed outside in her/his wheelchair self-propelling towards traffic into a busy street. Cars swerved to avoid hitting the resident. Clinic staff attempted to talk with the resident, but the resident was unable to provide her/his name or information and was agitated and anxious. On 3/15/21 an anti-elopement device was placed on the resident after the resident attempted multiple times to leave the facility. Resident 15's care plan for elopement was not initiated until 3/16/21 (12 days after admission). On 10/28/21 at 2:43 PM Witness 31 (Former LPN) stated Resident 15 exhibited decreased cognition and exit-seeking behaviors upon admission, had previously eloped from the facility and was found across the street. The resident had exit seeking behaviors both before and after the 3/8/21 incident. On 11/1/21 at 12:56 PM Staff 25 (Regional RN) confirmed Resident 15 was an elopement risk and the expectation was for staff to assess the resident for safety and potential elopement. On 11/8/21 at 12:07 PM Staff 25 (Regional RN) stated the expectation was a cognitive care plan was to be in place upon admission and she stated the expectation was for a [behavior] care plan to be initiated immediately after the [3/8/21] incident was reported. Refer to F689, example 2.

Resident 15 has discharged from the facility. Current residents with high risk for wandering are at risk. These residents have been audited to ensure an elopement care plan has been initiated. Nurses have been educated about the need for an elopement assessment on new admits, and initiating baseline care plan if assessed as being high risk. DNS or designee will audit 5 new admits weekly for elopement assessment risk and baseline care plan if applicable. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

1.

Based on interview and record review it was determined the facility failed to provide timely incontinence care and bathing for 3 of 7 sampled residents (#s 11, 12 and 17) reviewed for bathing and incontinence care. This placed residents at risk for skin break down, uncleanliness and psychosocial harm. Findings include: 1. Resident 17 admitted to the facility in 2017 with diagnoses including congestive heart failure and major depressive disorder. a. On 10/22/21 at 9:21 AM Witness 27 (Mental Health Therapist) stated Resident 17 reported the week prior, Staff 36 (CNA) left the resident sitting in her/his own excrement for over an hour after telling the resident she would be "right back" when the resident's call light was on. Witness 27 stated Resident 17 was tearful and reported and exhibited increased depression due to the lack of timely incontinence care. The 9/6/21 Annual MDS indicated the resident was cognitively intact and required extensive one-person staff assistance with toileting. Resident Council notes were reviewed from 8/2021 through 10/2021 and indicated: -8/2021: Call light wait times took 30 minutes to two hours to answer and residents felt staffing was "incredibly inadequate." -9/2021: Call light times on both floors took longer than "normal" and "normal wasn't great." A resident reported they were often left sitting on the toilet for "awhile." Day and swing shift took and hour and a half to answer call lights and night shift rarely answered, "at all." -10/2021: Residents felt "exasperated" with no changes to staffing shortages and long call light wait times. Three residents reported they waited up to two hours for their call light to be answered. On 10/26/21 at 1:32 PM Staff 36 (CNA) stated on 10/14/21 she assisted another resident and informed Resident 17 she would help her/him afterward. Staff 36 stated the next morning Staff 37 (LPN) informed her the resident complained about the wait time and Staff 37 indicated the call light was on for approximately an hour. On 10/29/21 at 3:10 PM Staff 37 (LPN) stated on day shift on 10/14/21 she noticed Resident 17's call light was on longer than 20 minutes but was unsure the exact time. On 11/1/21 at 12:09 PM Resident 17 stated she/he was left in a soiled brief two times in October 2021 by Staff 36. Resident 17 stated her/his brief was changed approximately an hour and a half later. On 11/8/21 at 12:07 PM Staff 25 (Regional RN) stated the expectation was for call lights to be answered within 15 to 20 minutes. 2. Resident 12 admitted to the facility on 9/1/20 with diagnoses including a stroke and hemiplegia (paralysis of half the body). Resident 12's 9/6/21 Annual MDS indicated the resident was cognitively intact. The 9/1/20 Care Plan indicated the resident was dependent on staff for bathing. The Bathing/Shower Task Sheet indicated on 10/30/21 Resident 12 did not receive a shower or bed bath. The reason was marked "RR" [Resident Refused] by Staff 13 (LPN). On 11/3/21 at 12:50 PM Staff 13 (LPN) stated Staff 20 (Personal Care Assistant) completed the shower documentation under her credentials. On 11/3/21 at 1:26 PM Staff 20 (Personal Care Assistant) stated she did not recall completing a shower for Resident 12. Staff 20 stated if a shower was unable to be completed, she was supposed to inform a nurse and reapproach the resident. Staff 20 did not recall informing a nurse or reapproaching Resident 12. Staff 20 stated she was "definitely" not able to get everything done because there were not enough staff. Refer to F725 and F842 3. Resident 11 admitted to the facility in 2014 with diagnoses including schizophrenia and heart failure. Resident 11's 9/11/21 Annual MDS indicated the resident required one staff person physical assist with bathing. The care plan, last revised 4/8/20, indicated Resident 11 was totally dependent on one staff member for bathing on Mondays, Wednesday, and Friday evenings and preferred bed baths at 2:00 PM. The Staff Shower Schedule indicated Resident 11 received bathing on Mondays, Wednesdays, and Saturdays. The 10/23/21 Bathing Task Sheet was blank for 10/22/21 (Friday) and indicated Resident 11 did not receive a shower on 10/23/21 (Saturday). The reason was marked as "RR" [Resident Refused]. On 10/25/21 at 3:09 PM Staff 19 (CNA) stated Resident 11 did not receive her/his bed bath on 10/23/21 due to staffing shortages. Staff 19 stated if staff were unable to provide a bath for a resident they would let the nurse know. Staff 19 stated she marked "RR" in the electronic health record as there was not an option if a bed bath was not provided due to staffing issues. There was no evidence in the progress notes as to why the 10/23/21 shower was not provided for Resident 11. On 11/4/21 at 9:26 AM Staff 26 (Regional RN) stated if staff were not able to provide bathing to a resident staff were expected to mark "no" in the electronic health record and give the most appropriate reason. Then staff were to notify the nurse and put the reason in a progress note. Staff 26 acknowledged the concerns related to residents not being provided showers were due to staffing. Refer to F725.

Resident 11 has expired. Resident 17 has been assessed for recent incontinence care concerns and continues to be monitored for signs of depression. Resident 12 has had a shower in the past 7 days. Current incontinent residents are at risk for delay of incontinence care. Incontinent residents were assessed for worsening signs of depression. Current residents are at risk for not receiving bath/shower as scheduled. Audit was done for previous 7 days to ensure all residents received bathing. Residents not receiving a bath or shower were interviewed to ensure the opportunity was provided. If not, they were offered a bathing at that time. Education was provided to clinical staff about expectations for timely incontinence care and bathing as scheduled. Bathing schedule was reevaluated for optimal distribution across days and shifts. Shower audit has been scheduled weekly to identify residents who have not yet received a shower, for reapproach. DNS or designee will interview 5 residents weekly about timely incontinent care and receiving showers as scheduled. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 6 sampled residents (#s 2, 9, 17, and 23) reviewed for medication and physician orders. This placed residents at risk for adverse drug reactions, increased pain, and psychosocial harm. Findings include: 1. Resident 23 admitted to the facility on 2/22/20 with diagnoses including heart failure. The 2/22/20 physician order indicated Resident 23 was to receive tramadol (narcotic pain medication) 25 mg every 8 hours PRN for pain. The 2/2021 MAR indicated Resident 23 received tramadol 25 mg on 2/22/21 at 11:14 PM. The 2/23/20 Medication Error Report indicated Witness 29 (Former Staff/LPN) administered tramadol 100 mg on the evening shift of 2/22/20 instead of the ordered 25 mg. The report further indicated the resident had no adverse side effects. On 10/29/21 at 3:09 PM Witness 29 stated he did not recall administering the wrong dose of tramadol to Resident 23. On 11/2/21 at 9:16 AM Staff 25 (Regional RN) acknowledged Resident 23 received tramadol 100 mg instead of the ordered 25 mg as indicated on the medication error report on 2/23/20. 2. Resident 9 admitted to the facility on 9/21/20 with diagnoses including femur fracture. The 9/21/20 physician order indicated Resident 9 was to receive Norco (narcotic pain medication) every four hours PRN. The 9/21/20 hospital records indicated Resident 9 had physician orders for Tylenol, morphine (narcotic pain medication) and Norco. The 9/2020 MAR indicated Norco was not added to the MAR until 9/22/20 at 4:30 PM and Resident 9 did not receive her/his first dose of Norco until 9/22/20 at 4:40 PM. On 11/1/21 at 1:00 PM Staff 25 (Regional RN) stated Resident 9 admitted on 9/21/20 with an order for Norco and the order was not implemented until 9/22/20. , 3. Resident 17 admitted to the facility in 2017 with diagnoses including congestive heart failure, diabetes, and major depressive disorder. The 9/6/21 Annual MDS indicated the resident was cognitively intact and required extensive one person assistance for toileting. a. A 4/25/21 Grievance Form completed by Resident 17 indicated the resident had requested treatment for her/his hemorrhoids for over a week but was told she/he did not have an order. The grievance investigation indicated the resident had an order for Preparation H (hemorrhoid medication) since 9/27/20 and the medication was not used until 4/25/21. The investigation indicated Staff 4 (LPN) was aware of the requests made by Resident 17 and did not follow up as he believed the concern had already been addressed. The grievance was signed by the former administrator on 5/7/21. The 4/2021 MAR indicated Resident 17 had an order for Preparation H since 9/27/20 and the medication was not provided until 4/25/21. A 9/27/20 Physician Order indicated Resident 17 was to receive Preparation H every six hours as needed for burning/itching. On 10/26/21 at 9:16 AM Staff 4 (LPN) stated Resident 17 requested Preparation H but he was informed the doctor had been faxed and the facility was waiting on an order. Staff 4 stated if the resident already had an order then staff should have provided the Preparation H immediately. On 11/1/21 at 12:09 PM Resident 17 stated when she/he requested Preparation H staff told her/him there was no order for it. Resident 17 stated she/he had difficulty sleeping due to the itching and pain and it took over a week for staff to find the order. Resident 17 further stated she/he had a previous order for Preparation H, but staff did not look closely until a nurse found the order a week later. On 11/1/21 at 9:46 AM Staff 25 (Regional RN) stated Resident 17 had an order for hemorrhoid medication and staff were expected to provide the medication as ordered. b. A 10/14/21 Physician Order instructed staff to provide a small diet soda every morning for upset stomach. The 10/14/21 order was revised on 10/17/21 by Staff 17 (RNCM), which instructed staff to provide a small diet soda every morning and "supply to be provided by the resident." Resident 17's 10/20/21 Care Plan completed by Staff 13 (Dietary Manager) indicated the resident was to receive a small can of diet soda at breakfast. On 10/22/21 at 9:21 AM Witness 31 (Mental Health Therapist) stated during a 10/20/21 visit with Resident 17, the resident sounded tearful and "really depressed", which was different from the resident's appointment two weeks prior. The resident reported part of her/his concerns was with staff not providing the resident with a diet soda. Resident 17 told Witness 31 the facility would no longer provided the resident with the soda and the resident was told she/he would have to pay for her/his own soda and could not afford it. On 10/27/21 at 1:39 PM Staff 13 (LPN) stated Resident 17 requested to have a diet soda with her/his medications as it helped prevent the resident from feeling "sick to [her/his] stomach." Staff 13 stated the kitchen staff did not want to provide the soda one day despite Resident 17 having an order. Staff 13 stated she noticed the order changed to the resident having to provide her/his own soda and was unsure why the facility would not provide the diet sodas for the resident. On 11/1/21 at 12:09 PM Resident 17 stated her/his physician ordered the diet soda as it prevented nausea when taking medications and the resident's order was then changed to indicate the resident would provide the soda, but no one at the facility discussed the reason why the order was changed. On 11/1/21 at 9:45 AM Staff 25 (Regional RN) stated there was no reason Resident 17 would need to provide her/his own diet soda. Staff 25 stated the facility was expected to provide the soda per the physician's order., 4. Resident 2 was admitted to the facility on 5/17/19 with diagnoses including paranoid schizophrenia, depression, personality disorder and post traumatic stress disorder (PTSD). A physician order dated 10/1/20 indicated Resident 2 was to receive Topamax (neurological medication) daily for PTSD. The 1/2020 MAR indicated Resident 2 did not receive Topamax on 1/1/20 and 1/2/20. Progress notes dated 1/1/20 and 1/2/20 indicated the medication was on order from the pharmacy. There was no indication the physician was notified of the missed doses. On 11/1/21 at 9:47 AM Staff 25 (Regional RN) confirmed Resident 2 did not receive the Topamax as ordered.

Resident #23 and 9 have discharged from the facility. Resident 17 has completed recent hemorrhoid treatment, continues with an order for use as needed and now receives a small diet soda with breakfast. Resident 2 was verified as having an adequate supply of Topamax. Current residents are at risk for staff not carrying out MD orders. Current orders were audited to ensure notifications and appropriate actions were taken if staff were unable to complete or administer. Education was provided to nurses about Rights of medication administration, time expectations for order transcription, how to access as needed medication orders, how to reorder medications and importance of notifying MD if medication is not available for administration. DNS or designee will audit 24-hour reports 5 days/week for orders not administered or administered incorrectly and appropriate response. After 4 weeks, audits will continue at least 2 days/week. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to assess and monitor a pressure ulcers for 1 of 3 sampled residents (#10) reviewed for pressure ulcers. This resulted in a worsening pressure ulcers. Findings include: Resident 10 was admitted to the facility in 8/27/20 with diagnoses including heart failure. The 8/27/20 Admission Nursing Database revealed Resident 10 was admitted to the facility with blanchable redness to her/his bilateral heels [indicating no pressure ulcers]. The 9/11/20 Facility Investigation revealed Resident 10's right heel had a blood blister or "maroon area" which measured 3.3 cm x 2.5 cm. The left heel had a blood blister which "popped" and was now a reddened area which measured 1.7 cm x 3.2 cm. Treatments were implemented for the bilateral pressure ulcers. The 9/2020 TAR revealed a 9/11/20 order to monitor the deep tissue injuries (DTI - a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear), apply skin prep every shift, ensure the heels were floated, and to monitor for signs of infection or worsening of wounds. The 9/12/20 Weekly Skin Check revealed Resident 10's right heel had a red area which measured 5 cm x 2 cm and a red area which measured 3 cm x 1 cm to the left heel. A formal wound assessment of the bilateral wounds was not completed. The 9/15/20 Weekly Skin Check revealed Resident 10's right heel had a red area which measured 5 cm x 3 cm and the left heel had a red area which measured 3 cm x 1 cm. A formal assessment of the bilateral wounds was not completed. The 9/17/20 Nutrition at Risk assessment revealed the wounds to Resident 10's bilateral heels were pressure ulcers. The 9/22/20 Weekly Skin Check revealed the blister to the right heel had "popped", measured 3.2 cm x 3.9 cm.. The left heel had a blister which measured 2.2 cm x 1.3 cm. A formal assessment of the bilateral pressure ulcers was not completed. The 9/29/20 Weekly Skin Audit indicated the right heel pressure ulcer measured 2.8 cm x 3.6 cm and the left heel pressure ulcer measured 2.1 cm x 1.6 cm. The left heel was dark red in color and "very slightly" raised. The 9/29/20 Wound and Skin Evaluation indicated Resident 10 had a facility acquired deep tissue injury to the right heel. The 10/6/20 Weekly Skin Audit revealed Resident 10's skin was intact. The 10/6/20 Wound and Skin Evaluation revealed the right heel DTI was first observed on "unknown date" and measured 2.3 cm x 3.4 cm. A full skin assessment of the right heel was completed. A full skin assessment was not completed for the left heel. The 10/13/20 Weekly Skin Audit revealed no measurements or assessments of the bilateral heel pressure ulcers. The 10/20/20 Weekly Skin Audit revealed Resident 10 had a pressure ulcer to the right and left heels, the left heel contained eschar (a collection of dry, dead tissue within the wound; a Stage III pressure ulcer). The Audit further revealed the nurse was unable to stage the wound and referred to the RN "skin/wound" sheet for staging of the pressure ulcers [No RN skin wound sheet was completed]. On 11/1/21 at 10:30 AM Staff 25 (Regional RN) and Staff 26 (Regional RN) acknowledged Resident 10 admitted to the facility with red, blanchable heels and on 9/11/20 the facility identified bilateral pressure ulcers to both heels. Staff 26 further acknowledged formal assessments and monitoring of the facility acquired bilateral heel wounds was not initiated until 9/19/20 and the left heel wound worsened to a Stage III pressure ulcer.

Resident 10 has discharged from the facility. Current residents with limited mobility are at risk for pressure injury development. These residents have been assessed for unidentified pressure injuries, with updates to care plans and treatments as appropriate. Education was provided to clinical staff about pressure injury prevention, appropriate notifications and comprehensive assessments. Weekly wound meetings were initiated with DNS & RCMs to review active wound healing progress. DNS or designee will audit 24-hour reports 5 days/week for new or worsening skin impairments. DNS or designee will visualize 5 residents weekly to ensure pressure injury interventions are in place. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to assess and provide treatments and equipment for pressure ulcers for 1 of 3 sampled residents (#62) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 62 was readmitted to the facility in 10/2021 with diagnoses including quadriplegia. a. The 12/21/21 Skin and Wound Evaluation indicated Resident 62 had an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) on the coccyx and a Stage 4 pressure ulcer (full-thickness skin and tissue loss) on the right ischial tuberosity (curved bone on the bottom of the pelvis). The 12/3/21 physician order indicated Resident 62 was to receive wound care to pressure injuries on right ischium and left buttock daily and PRN. The 12/2021 TAR indicated Resident 62 did not receive wound care on 12/24/21 or on 12/26/21. On 1/13/22 at 12:20 PM Staff 2 (Regional RN) acknowledged Resident 62 had physician orders for daily wound care and the resident did not receive wound care on 12/24/21 and 12/26/21 as ordered. b. On 1/13/22 at 10:30 AM the Skin and Wound Evaluations were reviewed for 12/21/21, 12/28/21, 1/4/22 and 1/11/22 for the pressure ulcers located on the coccyx and right ischial tuberosity. There were no measurements indicating the depth of the wounds. On 1/13/22 at 10:40 AM Staff 13 (LPN Resident Care Manager) stated both the coccyx wound and the ischial tuberosity wound had a depth of 2.5 cm to 3 cm. Staff 13 acknowledged the Skin and Wound Evaluations dated 12/21/21, 12/28/21, 1/4/22 and 1/11/22 were not comprehensive and did not include the information regarding the pressure ulcer depth. c. The 1/6/22 physician progress note indicated the following: Resident 62 had limited time up in her/his wheelchair due to pressure ulcers with poor healing. The resident would benefit from a new or revised wheelchair pressure relieving cushion that would fit in her/his electric wheelchair and reduce pressure on the right ischial tuberosity. The resident would greatly benefit from pressure relief while up in chair to improve quality of life and reduce pain. Please send the progress note to [durable medical equipment company] for the evaluation of a modified cushion. On 1/13/22 at 9:41 AM Staff 14 (CNA) stated Resident 62 enjoyed being up in her/his wheelchair, had pressure ulcers and had the same wheelchair cushion "for a while." On 1/13/22 at 9:55 AM Resident 62 stated she/he had the same wheelchair cushion for the past two years, the cushion put pressure on her/his wounds and the doctor wanted the resident to get a new cushion. On 1/13/22 at 12:20 PM Staff 2 (Regional RN) acknowledged the referral for the wheelchair cushion was made by the physician on 1/6/22 and the progress note was not sent to the durable medical equipment company until 1/12/22 (6 days later). Staff 2 acknowledged the referral was not completed timely.

Resident 62 weekly wound assessment has been updated to reflect current measured depth and wound description. His wheelchair cushion has been evaluated, with no changes recommended at this time. Current residents with pressure injuries are at risk for this practice. Pressure injury assessments have been reviewed to ensure they include accurate measurements and descriptions. Education was provided to nursing staff about comprehensive pressure injury assessments. Weekly wound meetings are held with DNS & RCMs to review active wound healing progress. DNS or designee will audit 5 residents/week for comprehensive wound assessments including measured depth and wound bed description. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

1.

Based on observation, interview, and record review it was determined the facility failed to provide supervision for swallowing safety for 5 of 22 residents (#s 20, 25, 26, 27 and 28) identified at risk for aspiration and who were to be supervised while eating. All identified residents were observed to be left unattended with meals and/or fluids during continuous observations. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: The 8/2017 Dysphagia Diets and Aspiration Precautions policy statement indicated residents with observed indicators of dysphagia or required altered textures and/or thick liquids would have general aspiration precautions taken. a. Resident 20 readmitted to the facility in 2/2020 with diagnoses including multiple sclerosis. The 10/26/21 Physician Order indicated Resident 20 was to receive a regular diet with an easy chew texture and thin consistency. The 10/1/21 Care Plan indicated Resident 20 required 1:1 assistance with eating. The 10/9/21 Aspiration Precaution sign indicated Resident 20 was to receive 1:1 assistance, encourage intake and check to check for "pocketing." On 10/28/21 at 5:55 PM Staff 41 (CNA) was observed to leave Resident 20's room. The resident had her/his meal at the bedside within reach and was observed chewing food. The surveyor asked Resident 20 if she/he was chewing food and she/he stated "yes." On 10/28/21 at 6:03 PM Staff 41 acknowledged Resident 20 was left in the room unattended with the meal and acknowledged the resident should not have been left alone. b. Resident 25 admitted to the facility in 2015 with diagnoses including stroke. Resident 25 was diagnosed with Alzheimer's disease and dementia in 2019. The 10/20/21 Physician Order indicated Resident 25 was to receive a regular diet with pureed texture and thin consistency. The 7/20/17 Care Plan indicated Resident 25 was on aspiration precautions and required to sit up for meals, distant supervision and "feed" assist PRN. The 8/31/21 and 9/26/21 Aspiration Precaution signs located in an Aspiration Risk Book and/or in the resident room indicated Resident 25 was to receive close supervision with meals and to have supervision with meals in the dining room. Resident 25's medical record indicated the resident required distant supervision in the dining room. Resident 25 had a history of aspiration and aspirated at the facility in 3/2021. On 10/26/21 at 5:47 PM Resident 25 was observed eating independently in the hallway and drinking thin liquids with no staff present. c. Resident 26 admitted to the facility in 9/2020 with diagnoses including Parkinson's disease and dysphagia (difficulty swallowing). The 10/11/21 Physician Order indicated Resident 26 was to receive a regular diet with soft and bite sized texture, thin consistency and swallow precautions. The 10/27/21 Kardex (staff care plan) indicated Resident 26 required 1:1 staff participation to eat and after the meal "search mouth for food residue", and keep upright. The 1/20/21 Aspiration Precaution Sign indicated Resident 26 required 1:1 assistance with meals and to "limit distractions." On 10/28/21 at 5:15 PM Resident 26 sat across from the nurses station with a mug of fluid on the bedside table in front of her/him and within reach. At 5:47 PM a staff member walked up to Resident 26, moved the mug of fluid so it was directly in front of her/him and then walked away. At 5:48 PM Resident 26 began to take sips out of the mug; no staff supervision or assistance was provided. At 5:54 PM the dinner tray was placed in front of Resident 26, the food was set-up and the bedside table was lowered. The staff member then walked away which left Resident 26 alone and unsupervised with her/his meal tray. Resident 26 attempted to clean her/his hands and start the meal without staff assistance or supervision. At 5:58 PM a staff member sat next to Resident 26 and began to assist her/him with the meal. At 6:28 PM Resident 26 sat with two cups of fluid on the bedside table in front of her/him with no assistance or supervision from staff. On 10/28/21 at 6:46 PM Staff 39 (CNA) stated she placed the food tray in front of Resident 26 and left without providing eating assistance or supervision. On 10/28/21 at 6:43 PM Staff 14 (CNA) stated Resident 26's assistance with meals "fluctuated" daily and acknowledged she was not aware Resident 26 required 1:1 supervision or assistance. Staff 14 acknowledged Resident 26 sat across the nurses station with two cups of fluid in front of her/him without supervision. On 10/28/21 at 6:50 PM Staff 26 (Regional RN) stated 1:1 assistance and supervision meant there should be a staff member with the resident when the resident had food or fluids. Staff 26 verified any resident who required 1:1 assistance or supervision with meals should never be left alone with fluids. d. Resident 27 admitted to the facility in 2019 with diagnoses including multiple sclerosis, stroke and epilepsy. The 10/20/21 Physician Order indicated Resident 27 was to receive a regular diet pureed texture and mildly thick consistency. The 4/13/19 Care Plan indicated Resident 27 required 1:1 close supervision for meals in the dining room for swallow precautions. The 4/19/21 Aspiration Precaution Sign indicated Resident 27 was to receive 1:1 assistance as needed and assist with small bites. On 10/28/21 at 5:35 PM Resident 27 was observed sitting outside of her/his room. The resident was given her/his food tray and utensils. Resident 27 was observed to eat independently. At 5:42 PM the resident was observed to be cough and drool while eating independently in the hall. No staff were present. At 5:44 PM staff were observed to move the residents tray out reach for a brief moment and placed the tray back within the resident's reach and walked away. At 5:48 PM staff were observed telling Resident 2 that they would be right back and walked away. e. Resident 28 admitted to the facility in 10/2021 with diagnoses including stroke and dysphagia (difficulty swallowing). The 10/20/21 Physician Order indicated Resident 28 was to receive a regular diet with soft and bite sized texture and thin consistency. The 10/27/21 Care Plan indicated Resident 28 was to receive supervision with eating and PRN assistance. The 10/19/21 Aspiration Precautions Sign indicated Resident 28 required 1:1 supervision with meals and to check for "pocketing." On 10/28/2021 at 5:17 PM a visitor was observed at the front door stating she wanted staff to give Resident 28 food as they were doing a window visit downstairs. Staff 1 took the food from the visitor. On 10/28/21 at 6:05 PM Resident 28 was observed to have nachos on a table next to her/him within reach in the dining room. Staff 48 (RN) entered the dining room and removed the nachos and stated the resident was on aspiration precautions and was not supposed to have nachos. On 10/28/21 at 7:04 PM Staff 1 stated she provided the nachos to Resident 28. On 10/28/21 at 9:28 PM Staff 1 (Administrator), Staff 25 (Regional RN) and Staff 26 (Regional RN) were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during meals. An immediate plan of correction (POC) was requested. On 10/28/21 at 10:41 PM the facility submitted a final POC was approved. The IJ Immediacy Removal Plan included: -All residents currently in the facility with aspiration precautions would be reviewed to ensure care plan and aspiration precautions reflect the same information. Residents that are not to have fluids at bedside have been checked to ensure fluids currently not at bedside. -All nursing staff will be in-serviced on the policy of aspiration precautions, how to read and understand the "pink" precautions signs and definitions of supervisions as outlined in the policy. All nursing staff in the building currently would receive the in-service prior to leaving [10/28/21] and day shift would be in-serviced prior to staring their shift [10/29/21]. All other nursing staff would be in-serviced no later than 11:59 PM on 10/29/21 unless staff were unreachable, ie: on leave, vacation or paid time off (PTO). Any staff who were not reachable would receive the in-service prior to starting their next shift. -By end of day on 10/29/21 the dining room would be open to residents requiring assistance for eating and residents that required assistance that stayed in bed would receive the 1:1 assistance as outlined in the care plan and aspiration sheet. -Any current residents on aspiration precautions that had not been assessed by speech therapy in the past 12 months or who had a change in cognition would be reevaluated by speech therapy. This would be completed by 11/5/21. -The DNS or designee would complete weekly audits of all residents on aspiration precautions to ensure staff were following aspiration precautions and that the sign in the room matched the care plan. The audits would be completed weekly for three months and would be reviewed at QAPI until substantial compliance had been met for two quarters. On 11/2/21 at 10:06 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 25 (Regional RN) and Staff 26 (Regional RN) were notified the immediacy was removed based on observations, staff interviews, and record review that the IJ immediacy removal plan was fully implemented. , 2. Based on interview and record review it was determined the facility failed to ensure a resident received supervision to prevent avoidable accidents for 1 of 3 residents (#15) reviewed for accidents. The facility failed to fully assess Resident 15, who was at risk for elopement, including the need for supervision to eliminate the risk of an accident. This failure resulted in an immediate jeopardy situation. This placed residents at risk for injury and death. Findings include: Resident 15 admitted to the facility on 3/4/21 with diagnoses including paranoid schizophrenia, anxiety, and a stroke. The 3/4/21 Admission Nursing Database indicated Resident 15 had short term memory loss with moderate impairment. The resident was alert to self and somewhat to her/his surroundings with mild confusion and delayed response time. The resident was anxious and received antipsychotic, antianxiety, antidepressant, and mood stabilizer medications. The 3/5/21 BIMS indicated the resident had a severe cognitive impairment. A 3/8/21 Progress Note indicated Resident 15 was sent to a physician clinic unaccompanied, did not wait for the appointment and left the clinic. The resident unsafely entered a busy intersection in an urban environment. Cars swerved to avoid hitting the resident. The clinic staff escorted the resident around the block until she/he "eventually agreed" to return to the clinic. The clinic staff indicated the resident was anxious and agitated and exhibited self-injurious behavior when approached by clinic staff. A 3/8/21 Physician Progress Note indicated clinic staff observed Resident 15 acting confused in the parking lot and the resident "almost" rolled her/himself out into the street multiple times. Clinic staff walked around the building with the resident as the resident yelled "leave me alone. I don't trust you guys." The resident did not allow staff to help or assess her/him. The 3/9/21 Code Pink [Elopment Risk] Assessment indicated Resident 15 was an elopement risk, had a diagnosis of schizophrenia and would hit her/himself when "triggered" and triggers included: "new places, new faces." On 3/11/21 at 2:32 PM Witness 19 (Complainant) stated Resident 15 was dropped off for a medical appointment at her/his physician clinic unaccompanied on 3/8/21 at 3:23 PM. At 3:30 PM Resident 15 was observed outside in her/his wheelchair self-propelling towards traffic into a busy street. Cars swerved to avoid hitting the resident. Clinic staff attempted to talk with the resident, but the resident was unable to provide her/his name or information and was agitated and anxious. Witness 19 called the facility and was told Resident 15 was "not their resident." Witness 19 was able to contact staff from Resident 15's former adult foster home to calm Resident 15 down. On 3/15/21 an anti-elopement device was placed after the resident attempted multiple times to leave the facility. On 10/28/21 at 2:43 PM Witness 31 (Former LPN) stated Resident 15 exhibited decreased cognition and exit-seeking behaviors since admission and had previously left the facility and crossed the street. Witness 31 stated the facility did not send staff to appointments with residents and on 3/8/21 she and another nurse were concerned that Resident 15 was sent to an appointment unaccompanied. On 11/2/21 at 11:36 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 25 (Regional RN) and Staff 26 (Regional RN) were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised to prevent accidents related to elopement. An immediate plan of correction (POC) was requested. On 11/2/21 at 3:06 PM the facility submitted a final POC was approved. The IJ Immediacy Removal Plan included: -Current residents need for an appointment attendant would be assessed by a nurse based on cognition, elopement risk and safety concerns. -Residents designated as needing an appointment attendant would be documented in the chart. Residents with appointments in the next two weeks were reviewed to ensure those needing appointment attendants were identified and scheduled within the next 24 hours. -All staff would be in-serviced on the importance of always using appointment attendants for the residents identified. In-servicing would be completed by 11:59 PM on 11/3/21. -All new admissions would be assessed by a nurse based on cognition, elopement risk, and safety concerns. -The Administrator or DNS would audit four resident charts weekly to ensure residents needing an appointment attendant had been identified in the chart. Audits would continue for three months with results brought to QAPI for two quarters or until substantial compliance was met. On 11/4/21 at 9:43 AM Staff 26 (Regional RN) was notified the immediacy was removed based on observations, staff interviews, and record review that the IJ immediacy removal plan was fully implemented. 3. Based on interview and record review it was determined the facility failed to ensure residents were provided appropriate equipment and staff followed the care plan for transfers to prevent accidents for 2 of 4 residents (#s 13 and 24) reviewed for falls and accidents. This failure resulted in Resident 13 sustaining a fall fractures and placed residents at risk for falls and injury. Findings include: 3a. Resident 13 admitted to the facility in 2012 with diagnoses including dementia and a stroke. The 11/17/20 Annual MDS indicated Resident 13 had severe cognitive impairment and required extensive, two or more persons for bed mobility. The 12/17/20 Fall Investigation completed by Staff 31 (LPN) indicated a former Witness 29 (Former CNA) was in Resident 13's room providing care when the resident rolled out of bed onto the floor due to the mattress bending over the edge of the bed. There was no time indicated when the resident fell. When asked if the resident hit her/his head the resident responded "yes" and stated her/his "legs were broken" and "knees hurting." The resident was assessed as having 5/10 pain and the investigation indicated pain medication was offered but the resident refused. Later in the investigation pain was assessed as 7/10 and the resident reported left shoulder, arm, and torso pain. An x-ray was ordered, and the results determined Resident 13 sustained three left ribs fractures. The investigation summary concluded the mattress was too big and soft for the bed frame and folded over when weight was applied. Maintenance replaced the mattress and applied non-skid strips to the bottom to keep the mattress from sliding and the care plan was updated for the resident to receive two-person cares with bed mobility. Multiple attempts were made to contact Witness 29 but there was no response. On 10/28/21 at 2:48 PM Staff 31 (LPN) stated she recalled Resident 13's mattress not being the correct size and stated after the fall Witness 29 reported the fall occurred due to Resident 13's mattress not being the correct size and slid around the bed frame. Staff 31 stated Witness 29 reported he had brought up the mattress being the wrong size twice to management before and the mattress was never changed. On 10/27/21 at 1:08 PM Witness 30 (Former RNCM) stated she was not aware Resident 13's mattress was too big for the bed. Witness 30 stated during her investigation she had found a couple of CNAs that knew the mattress hung over the side of the bed. Witness 30 stated she did not write-down the interviews with the CNAs and could not recall who she interviewed. On 11/1/21 at 12:58 PM Staff 6 (CNA) stated the facility previously had multiple mattresses that slid "very bad" over the bed frames and administrative staff were aware and did not replace them. On 11/1/21 at 9:49 AM Staff 25 (Regional RN) confirmed Resident 13 had a fall with rib fractures due to the mattress being the incorrect size for the bed. 3b. Resident 24 admitted to the facility in 2016 with diagnoses including chronic pain. The 9/3/20 Care Plan indicated Resident 24 required two person assistance for transfers to the shower chair. On 11/1/21 at 3:57 PM Staff 10 (Nurse Aide) was observed to enter Resident 24's room independently with a shower chair and closed the door. On 11/1/21 at 4:01 PM Staff 10 was observed to assist Resident 24 to the shower room across the hall. Staff 10 stated Resident 24's care plan indicated she/he preferred only male staff. Staff 10 acknowledged the care plan indicated Resident 24 was to receive two person assistance to the shower chair and Staff 10 transferred the resident to the shower chair independently. On 11/1/21 at 4:36 PM Staff 26 (Regional RN) stated Resident 24's care plan indicated she/he was to receive two person assistance for transfers to the shower chair and stated the expectation was for two staff to assist her/him with transfers.

All residents currently in the facility with aspiration precautions were reviewed to ensure care plan and aspiration precautions reflected the same information. Residents that were not to have fluids at bedside were checked to ensure fluids were not at bedside. All nursing staff were in serviced on the policy of aspiration precautions, how to read and understand the pink precautions signs and definitions of supervisions as outlined in the policy. All nursing staff in the building at that time received the in-service prior to leaving that night and dayshift was in serviced prior to starting their shift in the morning. All other nursing staff were in serviced no later than 2359 of 10/29/21 unless staff was unreachable ie: on leave, vacation or PTO. Any staff that were not reachable received in service prior to starting their next shift. By end of the day on 10/29/21 the dining room was open to residents requiring assistance for eating and residents that required assistance while staying in bed received 1 to 1 assistance as outlined in the care plan and aspiration sheet. Any residents on aspiration precautions that had not been seen by speech therapy in the past 12 months or that had a change in cognition, were reevaluated by speech therapy. This was completed by 11/5/21. DNS or designee will complete weekly audits of all residents on aspiration precautions to ensure that staff are following aspiration precautions and that the sign in the room is matching the care plan. These audits will be completed weekly for 3 months and will be reviewed at QAPI until substantial compliance has been met for 2 quarters. Res. # 15 is no longer at this facility. Resident need for an appointment attendant was assessed by a nurse based on cognition, elopement risk and safety concerns 11/2/21. Residents designated as needing an Appointment Attendant was documented in the chart. Residents with appointments in the following 2 weeks were reviewed to ensure those needing an Appointment Attendant were identified and scheduled the next 24 hours. Staff (unless unreachable due to LOA, vacation or FMLA) were in-serviced on importance of using Appointment Attendants for those residents identified. In-servicing was done prior to beginning of their next shift starting 11/2/21 with DAY and EVE shift staff, and continue until all staff have received the training. This was completed by DNS/Admin or designee before 1159 at 11/3/21. New admissions will be assessed by a nurse based on cognition, elopement risk and safety concerns. Residents designated as needing an Appointment Attendant will be documented in the chart. DNS or designee will audit 4 resident charts weekly to assure residents needing appointment attendant have been identified in the chart and upcoming appointment for the week have attendants as identified. Any areas found not in place will be immediately corrected. These audits will continue for 3 months with results brought QAPI for 2 quarters or until substantial compliance is met. Resident 13 has discharged from the facility. Current residents are at risk for mattress not fitting bed correctly. Audit was completed for current residents to ensure all mattresses are sized correctly to the frame. Education provided to clinical staff about submitting requests for equipment repair or replacement or notifying the Maintenance Director directly if equipment concern is urgent. Education provided to clinical staff about importance of following resident care plans. Administrator or designee will inspect 5 resident beds weekly for proper fit of mattress. Additionally, DNS or designee will audit 5 resident transfers weekly to ensure care plan is being followed. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on observation, interview and record review it was determined the facility failed to provide supervision for swallowing safety for 1 of 20 residents (#25) identified at risk for aspiration (food or fluids enter the airway which could cause serious health problems including pneumonia) and who were to be supervised while eating. The identified resident was observed to be left unattended with meals and fluids during continuous observations. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: The 10/2021 Dysphagia Diets and Aspiration Precautions policy statement indicated residents with observed indicators of dysphagia or required altered textures and/or thick liquids would have general aspiration precautions taken. Resident 25 admitted to the facility in 2015 with diagnoses including stroke and hemiplegia (right sided paralysis). Resident 25 was severely cognitively impaired. A 10/20/21 Progress Note indicated Resident 25 had swallowing problems and was on aspiration protocols. The 10/31/21 Aspiration Precautions sign located in the aspiration precautions book indicated Resident 25 received a pureed diet and thin consistency liquids. The 12/1/21 Physician Order indicated Resident 25 was to receive a regular diet with pureed texture, thin consistency liquids and distant supervision. The 12/23/21 Care Plan indicated Resident 25 was on aspiration precautions and required distant supervision for meals. If choking occurred staff were to ensure safety, evaluate the resident and notify the doctor. Resident 25's medical record indicated the resident had a history of aspiration and aspirated at the facility in 3/2021. On 1/12/22 the following observations were made: -At 12:02 PM Resident 25 was observed to eat her/his lunch in the doorframe of her/his room. Staff 3 (CNA) was observed in the hallway. -At 12:08 PM Staff 3 donned PPE while looking at Resident 25 then left the hallway and entered another resident's room. No other staff were in the hallway. -From 12:08 PM to 12:16 PM Resident 25 ate multiple bites of her/his lunch independently with no staff present in the hallway or at the nurse's station. On 1/12/22 at 12:17 PM Staff 2 (Regional RN) confirmed there was no staff in the hallway and Resident 25 required distant supervision for meals. Staff 2 further stated Staff 11 (CNA) was scheduled to monitor residents in the hallway during this meal but Staff 11 assisted another resident with their meal instead. On 1/12/22 at 12:25 PM Staff 3 stated he was told to assist a different resident during this meal and thought another staff would be in the hallway to pick up resident meal trays. Staff 3 further stated lunchtime monitoring schedules were made but the schedules did not matter because staff did not follow them. On 1/12/22 from 12:24 PM to 12:27 PM Resident 25 was observed in the hallway with her/his drink. No staff were present in the hall. On 1/12/22 at 12:27 PM Staff 4 (LPN) approached Resident 25 and asked if she/he was done with her/his drink. Staff 4 stated Resident 25 required distant supervision with food but not drinks. Staff 4 then left the area but returned within a minute and stated she checked and Resident 25 actually required distant supervision for both food and drink. On 1/12/22 at 2:50 PM Staff 5 (SLP) stated distant supervision meant the resident needed staff close enough to see the resident and the resident should not be left alone for any length of time with food or drink. Staff 5 confirmed Resident 25 aspirated in March, 2021. On 1/12/22 at 3:30 PM Staff 1 (Administrator), Staff 2 (Regional RN) and Staff 6 (Regional RN) were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during meals. An immediate plan of correction was requested. On 1/12/22 at 4:44 PM the facility submitted final POC was approved. The IJ Immediacy Removal Plan included: -All residents currently in the facility with aspiration precautions would be reviewed to ensure care plan and aspiration precautions reflected the same information. Residents that were not to have fluids at bedside were checked to ensure fluids were currently not at bedside. All residents with aspiration precautions would be supervised in the dining room, as long as they were appropriate and agreeable to communal dining. Anyone who was not appropriate or agreeable to communal dining would be supervised as outlined on their precaution sign. -All nursing staff would be inserviced on the policy of aspiration precautions, how to read and understand the precautions signs and definitions of supervisions as outlined in the policy. All nursing staff in the building currently would receive the inservice prior to leaving tonight [1/12/22]. All other nursing staff would be inserviced no later than 11:59 PM on 1/13/22 unless staff was unreachable (on leave, vacation or using paid time off). Any staff that were not reachable would receive inservice prior to starting their next shift. -DNS or designee would audit all residents on aspiration precautions weekly at various meal times to ensure staff were following supervision levels as outlined on their aspiration precautions. These audits would be completed weekly for three months and would be reviewed at QAPI until substantial compliance was met for two quarters. On 1/14/22 at 3:24 PM Staff 1, Staff 2, Staff 6 and Staff 12 (Infection Preventionist) were notified the immediacy was removed based on observations, staff interviews, and record review and the IJ immediacy removal plan was fully implemented. , ,

All residents currently in the facility with aspiration precautions have been reviewed to ensure care plan and aspiration precautions reflect the same information. Residents that are not to have fluids at bedside have been checked to ensure fluids currently not at bedside. All residents with aspiration precautions will be supervised in the dining room, as long as they are appropriate and agreeable to communal dining. Anyone who is not appropriate or agreeable to communal dining will be supervised as outlined on their precaution sign. All nursing staff have been inserviced on the policy of aspiration precautions, how to read and understand the precautions signs and definitions of supervisions as outlined in the policy. All nursing staff in the building at time of the citation received the inservice prior to leaving their shift. All other nursing staff were inserviced by 2359 of 1/13/22 unless staff were unreachable ie: on leave, vacation or PTO. Any staff that were not reachable received inservice prior to starting their next shift. DNS or designee will audit all residents on aspiration precautions weekly at various meal times to ensure that staff are following supervision levels as outlined on their aspiration precautions. These audits will be completed weekly for 3 months and will be reviewed at QAPI until substantial compliance has been met for 2 quarters.

Based on interview and record review it was determined the facility failed to follow physician orders for the use of a continuous positive airway pressure therapy (CPAP) machine for 1 of 3 sampled residents (#5) reviewed for respiratory care. This placed residents at risk for anoxia and death. Findings include: Resident 5 was admitted to the facility in 2018 with diagnoses including obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep). The 1/25/19 care plan indicated Resident 5 was to use a CPAP at night and while sleeping in bed throughout the day. a. The 1/24/19 Physician Order indicated Resident 5 was to wear a CPAP every night for obstructive sleep apnea and to replace CPAP supplies at regular intervals. The 1/2020 TAR indicated Resident 5 used the CPAP at bedtime with three refusals noted between 1/1/20 and 1/19/20. The 12/1/19 through 1/18/20 TARs indicated Resident 5 used a CPAP 31 of 43 days reviewed. The 1/19/20 Progress Note indicated the resident's CPAP machine was missing the "part that goes under the nose" and the resident's family was notified the CPAP was not in place "last night" and would not be in place "tonight." There was no indication in Resident 5's clinical record to indicate the CPAP part was ordered or replaced. The 2/2020 TAR indicated Resident 5 did not use her/his CPAP machine until 2/8/21 (19 days after it was noted the part was noted as missing). The 2/4/20 progress note indicated Resident 5 did not use her/his CPAP and then the mask "became missing." A fax was sent to the physician to place the CPAP on hold and a hold was placed for 30 days. There was no indicated a physician order to hold the CPAP for 30 days was obtained. On 11/1/21 at 1:03 PM Staff 25 (Regional RN) acknowledged Resident 5's CPAP broke on 1/19/20 and there was no indication the CPAP part was replaced. On 11/2/21 at 1:59 PM Staff 17 (RNCM) reviewed progress notes and stated Resident 5's CPAP was broken on 1/19/20 and she attempted to get a replacement part from the resident's family member on 2/4/20. Staff 17 stated the family did not bring in the mask and told her the facility was responsible for the mask [The facility has a liability to replace resident equipment]. Staff 17 further stated she was unsure why the CPAP was restarted on 2/8/20. b. The 12/31/19 progress note indicated Resident 5 was to receive an overnight sleep study on 1/28/20 and the facility nursing staff must be present per the physician order. The 1/3/20 progress note indicated the sleep study center was contacted and indicated they were unable to administer medications including insulin and were unable to provide ADL care during the study. The note further indicated Resident 5 needed to have staff available to provide her/him care during the sleep study and the sleep center was not able to be the attendant for the resident. The 1/7/20 progress note indicated Resident 5's family member was notified of the upcoming overnight sleep study and discussed the resident needed to have someone go to the appointment with her/him to provide care. The 1/24/20 progress note indicated the sleep study appointment was canceled due to not having anyone available to provide resident care. The 2/4/20 progress note indicated Resident 5's family canceled the sleep study appointment because the family could not provide the care the resident needed during the appointment. The note further indicated the family could hire a caregiver. The sleep center was contacted and inquired about a "take home study" and the sleep center would follow up with the facility. On 11/1/21 at 12:55 PM Witness 28 (Sleep Center Staff) stated Resident 5 had an order for a sleep study on 1/28/20 and required someone to accompany her/him to provide care. Witness 28 stated the appointment was canceled due to staff not being able to provide care for Resident 5 during the sleep study. Witness 28 stated the sleep study was never rescheduled. On 11/1/21 at 1:03 PM Staff 25 (Regional RN) acknowledged Resident 5 had a physician order for a sleep study and she/he did not receive the sleep study. On 11/2/21 at 1:59 PM Staff 17 (RNCM) reviewed progress notes and indicated on 1/24/20 the facility received a call from the Sleep Study Center indicating Resident 5's family member canceled the sleep study because there was nobody available to stay with Resident 5 during the sleep study. Staff 17 further stated she attempted to check and see if the resident's family member or friends could go to the sleep study or the family could hire a caregiver to go. Staff 17 stated facility staff could not go to the sleep study with the resident because there would be no way to pay them since they were out of the building.

Resident 5 has discharged from the facility. Current residents using CPAP, BiPAP or with orders for sleep studies are at risk for deficient practice. These residents have been assessed to ensure current equipment is functioning and sleep study orders have been scheduled as appropriate. Clinical staff have been educated about importance of CPAP/BiPAP use and follow-up with providers and vendors if unable to use. Clinical staff have been educated about need to arrange for attendant if sleep studies are ordered or making alternate arrangements with ordering provider. DNS or designee will audit 24-hour reports 5 days/week for concerns and follow-up regarding CPAP use, BiPAP use or sleep study appointments. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to ensure residents received pain medications timely for 1 of 6 sampled residents (#7) reviewed for physician orders. This in resulted Resident 7 experiencing unrelieved pain and placed residents at increased risk for pain and psychosocial harm. Findings include: Resident 7 admitted to the facility in 2018 with diagnoses including kidney failure and cancer. The 7/26/21 BIMS indicated Resident 7 was cognitively intact. The 9/22/21 Physician Order indicated Resident 7 was to receive oxycodone (narcotic pain medication) at bedtime and every 6 hours PRN. The 10/2021 narcotic logs and MARs indicated the following: -Resident 7 received a dose of oxycodone on 10/19/21 at 4:00 AM. -Resident 7 did not receive another dose of oxycodone until 10/20/21 at 2:19 AM and had 10/10 pain. The 10/20/21 at 1:14 AM progress note indicated Resident 7 was crying, reported being sick to her/his stomach due to pain and the resident thought she/he was having withdrawal from the medication. The nurse called the pharmacy and the pharmacy indicated a prescription was not received. The provider indicated she would call the pharmacy with a new prescription for oxycodone. On 10/25/21 at 11:18 AM Resident 7 stated there were instances when she/he did not receive oxycodone timely due to staff failure to order oxycodone. The resident stated she/he recently did not receive oxycodone for one day and had "a lot of pain, was laying in bed crying and shaking all day long and had withdrawals." Resident 7 stated staff offered her/him Tylenol which did not help the pain. On 10/25/21 at 3:24 PM Staff 3 (LPN) stated Resident 7 ran out of oxycodone due to the physician needing to sign new orders. Staff 3 stated she noticed Resident 7 was running low on oxycodone on 10/19/21 and notified the physician and the oncoming shift. Staff 3 further stated when she returned to work on 10/20/21 Resident 7 did not have oxycodone available and she called the physician to get an order. Staff 3 informed the physician the resident was crying, shaking and reported she/he was "hurting all over." Staff 3 stated she received the order for the oxycodone and was able to administer it on 10/20/21. On 10/26/21 at 9:28 AM Staff 4 (LPN) stated on 10/19/21 staff informed him that Resident 7 needed a new order for oxycodone. Staff 4 stated the physician was contacted via email of the need for the new order and the physician did not reply. Staff 4 further stated an order for oxycodone was not received on 10/19/21 and the night shift nurse was able to get an order in the early morning on 10/20/21. Staff 4 further stated the physician visited every Wednesday and acknowledged medications were not always reordered timely. On 11/1/21 at 11:45 AM Staff 25 (Regional RN) acknowledged Resident 7 ran out of oxycodone due to staff not reordering it timely. Staff 25 acknowledged Resident 7 received oxycodone on 10/19/21 at 4:00 AM and did not receive an additional dose until 10/20/21 at 2:19 AM and acknowledged the resident had unrelieved pain due to not receiving oxycodone on time.

Resident 7 was verified as having an adequate supply of oxycodone. All residents receiving schedule 2 medications are at risk for this alleged deficient practice. Nurses have been educated about facility process for reordering schedule 2 medications and importance of submitting requests timely. Nurses have also received education about how to access cubex medications when supply is needed immediately. DNS or designee will audit 5 resident medications weekly to ensure schedule 2 medications have adequate supply available. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on observation, interview, and record review it was determined the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable level of well-being for 2 of 2 floors reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 11/5/21 at 11:16 AM the facility identified 12 residents who required two person transfers in addition to 27 residents who required mechanical lift transfers. RESIDENT COUNCIL Resident Council notes were reviewed from 8/2021 through 10/2021. The notes indicated: -8/2021: Call light wait times on both floors were 30 minutes to two hours long and residents felt staffing was "incredibly inadequate." -9/2021: Call light times on both floors took longer than "normal" and "normal wasn't great." One resident reported they were often left sitting on the toilet for "awhile." Day and evening shift took and hour and a half to answer call lights and night shift rarely answered, "at all." -10/2021: Residents felt "exasperated" with no changes to staffing shortages and long call light wait times. Three residents reported they waited up to two hours for their call light to be answered. Eight residents reported staff were "burned out" and it was "obvious." , INTERVIEWS Staff and resident interviews indicated the following: -On 10/25/21 at 2:19 PM Resident 33 stated call lights could take anywhere from 15 minutes to three hours to be answered and shift change was "the worst." Resident 33 stated she/he had previously waited so long for assistance she/he self-transferred three times. -On 10/25/21 at 3:09 PM Staff 19 (CNA) stated staffing was an issue, especially when she worked with Personal Care Assistants (PCAs) who could not chart or perform vitals. -On 10/25/21 at 2:45 PM Resident 20 stated call lights were not answered timely, especially during meals and shift change. Resident 20 stated she/he often waited up to 90 minutes for assistance. Resident 20 further stated she/he received intermittent assistance with eating and staff would have to leave her/him during meals to assist other residents. -On 10/25/21 at 2:53 PM Staff 45 (LPN) stated the facility was "constantly" understaffed, and she currently had 31 residents to herself, which was the whole first floor and it took longer to provide care. -On 10/25/21 at 3:09 PM Staff 19 (CNA) stated it was difficult to complete showers as there were six scheduled for her side of the hall and only two CNAs working on that side. Staff 19 stated staff had spoken to administrative staff about showers and staffing but nothing had changed. -On 10/26/21 at 10:35 AM Staff 41 (CNA) stated some days the facility was short staffed to the point where there was one CNA for 15 to 16 residents. Staff 41 stated due to staffing shortages, residents were not getting showers. Staff 41 stated call lights could take up to 45 minutes to be answered. Staff 41 stated staffing issues started in July 2021. -On 10/26/21 at 11:25 AM Staff 5 (CNA) stated resident acuity was higher despite the census being lower and on evening shift there was not enough staff to complete showers. -On 10/26/21 at 2:18 PM Staff 9 (CNA) the facility was understaffed and most of the staff was agency and the long term staff had to spend time training them. Staff 9 stated she basically had a whole hall to herself and there were times residents did not receive showers due to staffing shortages. -On 10/26/21 at 3:31 PM Staff 42 (Nurse Aide) stated at times she was responsible for 12 residents, which made it hard to complete cares, especially showers. -On 10/26/21 at 3:38 PM Staff 7 (CNA) stated the facility had staffing shortages and showers were missed almost daily due not enough staff. Staff 7 stated resident call lights could take up to 20 minutes to answer or more staff were completing a resident shower. -On 10/27/21 at 12:05 PM Staff 46 (CNA) stated it was difficult to work being short staffed as the facility had high resident acuity. Staff 46 stated it was a challenge to fit showers in if there were more than two scheduled, especially when most residents required more assistance. Staff 46 further stated there were "trends" for call lights not being answered due to staffing. -On 10/27/21 at 1:28 PM Staff 13 (LPN) stated there were not enough staff and when a new admission came into the facility it made it difficult to complete regular duties including treatments. Staff 13 further stated treatments did not get done when there were not enough nursing staff. Staff 13 further stated downstairs on 10/31/21 there was one Personal Care Assistant (PCA) and one Nurse Aide (NA) for part of the evening and night shift for over 30 residents . -On 10/27/21 at 2:34 PM Staff 30 (CNA) stated the facility did not have enough staff and she felt "overwhelmed" with the State's higher resident to staff ratio mandates. Staff 30 stated showers were the hardest tasks to get done. Staff 30 stated there were a lot of residents who required 1:1 assistance with eating and it was difficult to assist the residents as there was not enough staff. -On 10/28/21 at 9:44 AM Staff 14 (CNA) stated the facility was short staffed and there were so many new staff, especially on evening shift, getting showers done for residents was difficult. Staff 14 stated there were times residents did not receive showers or eating assistance due to not enough staff. -On 10/28/21 at 2:54 PM Staff 31 (LPN) stated staffing was an issue, especially with residents on end of life care as she spent a lot of time doing treatments on night shift as the treatments were unable to be completed on evening shift. Staff 31 stated on night shift the facility was short staffed so she had to answer resident call lights and help with cares and it was difficult to complete tasks. -On 11/1/21 at 4:08 PM Resident 52 stated call lights took "a long time" to answer due to staffing as staff were always "running around." Resident 52 stated call light wait times were 20 minutes to over an hour, especially on evening shift. Resident 52 stated the evening of 10/31/21, she/he had to sit in a wet brief for over an hour and staff stated it was due to the facility being short staffed. Resident 52 stated concerns were communicated to administrative staff but they did not "do anything." Lastly, Resident 52 stated meals were served late and were cold 90% of the time and staff were unable to reheat the food due to being short staffed. -On 11/4/21 at 10:59 AM Staff 43 (CNA) stated the facility had staffing issues, she was exhausted, it was difficult to complete cares, and the facility mandated staff to work extra hours. OBSERVATIONS The following random observations were made by the State Survey Team: -On 10/25/21 at 2:33 PM Resident 11's call light was initiated and was answered at 3:09 PM (36 minutes later) by Staff 19 (CNA). Staff 19 stated Resident 11 inquired about her/his bed bath and Staff 19 attempted to coordinate with another staff member. Staff 19 confirmed the 36 minute call light time. -On 10/26/21 at 1:26 PM staff were observed to rush around, the phone rang and was not answered. There were no staff at the nursing station. -On 10/26/21 at 1:28 PM the phone rang multiple times and there were no staff observed to answer. RESIDENT 15 Resident 15 admitted to the facility on 3/4/21 with diagnoses including paranoid schizophrenia and anxiety. The 3/4/21 Admission Nursing Database indicated Resident 15 had short term memory loss with moderate impairment. The resident was alert to self and somewhat to her/his surroundings with mild confusion and delayed response time. The resident was anxious and received antipsychotic, antianxiety, antidepressant, and mood stabilizer medications. The 3/5/21 BIMS indicated Resident 15 had a severe cognitive impairment. A 3/8/21 Progress Note indicated Resident 15 was sent the physician clinic unaccompanied, did not wait for the appointment and left the clinic. The resident unsafely `entered a busy intersection in an urban environment. Cars swerved to avoid hitting the resident. The clinic staff escorted the resident around the block until she/he "eventually agreed" to return to the clinic. On 3/11/21 at 2:32 PM Witness 19 (Complainant) stated Resident 15 was dropped off for a medical appointment at her/his physician clinic unaccompanied on 3/8/21 at 3:23 PM. On 10/28/21 at 2:43 PM Witness 31 (Former LPN) stated Resident 15 exhibited decreased cognition and exit-seeking behaviors since admission and had previously left the facility and crossed the street. Witness 31 stated the facility did not have enough staff to go with residents to appointments. Refer to F689, example 2. RESIDENT 17 Resident 17 admitted to the facility in 2017 with diagnoses including congestive heart failure and major depressive disorder. a. On 10/22/21 at 9:21 AM Witness 27 (Mental Health Therapist) stated Resident 17 reported a week prior Staff 36 (CNA) left the resident sitting in her/his own excrement for over an hour after telling the resident she would be "right back" when the resident's call light was on. Witness 27 stated Resident 17 was tearful and reported and exhibited increased depression due to the lack of timely incontinence care. The 9/6/21 Annual MDS indicated the resident was cognitively intact and required extensive one-person staff assistance with toileting. On 10/26/21 at 1:32 PM Staff 36 (CNA) stated on 10/14/21 she changed Resident 17 three- or four-times during day shift. Staff 36 stated she told Resident 17 she was in the middle of changing another resident and would help the resident after. Staff 36 stated the next morning Staff 37 (LPN) informed her the resident complained about the wait time and Staff 37 observed the call light on for about an hour. On 10/29/21 at 3:10 PM staff 37 (LPN) stated on day shift 10/14/21 she noticed Resident 17's call light was on and was on longer than 20 minutes but was unsure the exact time. Staff 37 stated CNAs were "really busy" trying to get everyone done and Staff 36 did not intentionally leave the resident in a soiled brief. On 11/1/21 at 12:09 PM Resident 17 stated she/he was left in a soiled brief two times in October 2021 by Staff 36. Resident 17 stated approximately 10/14/21 Staff 36 kept telling the resident there were three residents who required assistance before her/him, so by the time the resident's brief was changed it was one and a half hours later. Resident 17 stated Staff 36 did not intentionally not change her/his brief, but staffing was "pretty bad" and a times call lights take over an hour to be answered. On 11/8/21 at 12:07 PM Staff 25 (Regional RN) stated the expectation was for call lights to be answered within 15 to 20 minutes. Refer to F677 b. A 4/25/21 Grievance Form indicated Resident 17 reported long wait times on night shift related to how the assignments were made and short staffing at times. The investigation indicated education and extensive directives for the evening to provide the residents cares. The investigation indicated an [unnamed] nurse reported Resident 17 used her/his call light "a lot" that shift. The 4/26/21 follow-up indicated the resident was happy with the outcome and cares. On 4/28/21 at 7:34 AM Witness 20 (Hospital Social Worker) stated Resident 17 reported the facility was short staffed, which resulted in long call light response times and staff telling the resident they were "too busy" to help. Resident 17 further stated staff did not see her/his call light initiated as the resident resides on the ground floor and staff took care of residents on the second floor as well as the first floor. On 10/28/21 at 2:08 PM Staff 24 (CNA) stated Resident 17 had reported to her she/he had waited an hour for her/his brief to be changed but there were a lot of residents and "rounds" were every two hours. Staff 24 stated she used to be a "float" person who worked upstairs and downstairs. Staff 24 stated when she worked upstairs she was up there for two hours and then downstairs for two hours. She further stated if she was working upstairs people downstairs should have been answering her residents' call lights and vice versa. On 11/1/21 at 12:09 PM Resident 17 stated staffing was "pretty bad" and a times call lights took over an hour to be answered and the resident had been left in a soiled brief multiple times. On 11/01/2021 at 3:18 PM Staff 6 (CNA) stated in Spring of 2021 on night shift, she observed Resident 17's call light on for over an hour because a CNA that was not supposed to work with the resident was assigned to Resident 17, so no one answered the light as the other CNAs were busy with other residents. On 11/8/21 at 12:07 PM Staff 25 (Regional RN) stated the expectation was for call lights to be answered within 15 to 20 minutes. RESIDENT 11 Resident 11 admitted to the facility in 2014 with diagnoses including schizophrenia and heart failure. Resident 11's 9/11/21 Annual MDS indicated the resident required one person physical assist with bathing. The Staff Shower Schedule indicated Resident 11 received bathing on Mondays, Wednesdays, and Saturdays. The 10/23/21 Bathing Task Sheet indicated Resident 11 did not receive a shower on 10/23/21 (Saturday). On 10/25/21 at 3:09 PM Staff 19 (CNA) stated Resident 11 did not receive her/his bed bath on 10/23/21 due to staffing shortages. On 11/4/2021 at 9:26 AM Staff 26 (Regional RN) acknowledged the concerns related to residents not being provided showers due to staffing. Refer to F565, F677, F684, and F689. RESIDENT 12 Resident 12 admitted to the facility on 9/1/20 with diagnoses including a stroke and hemiplegia (paralysis of half the body). Resident 12's 9/6/21 Annual MDS indicated the resident was cognitively intact. The 9/1/20 Care Plan indicated the resident was dependent on staff for bathing. The Bathing/Shower Task Sheet indicated on 10/30/21 Resident 12 did not receive a shower or bed bath. The reason was marked "RR" [Resident Refused] by Staff 13 (LPN). On 11/3/21 at 12:50 PM Staff 13 (LPN) stated Staff 20 (Personal Care Assistant) completed the shower documentation under her credentials. On 11/3/21 at 1:26 PM Staff 20 (Personal Care Assistant) stated she did not recall completing a shower for Resident 12. Staff 20 stated if a shower was unable to be completed, she was supposed to inform a nurse and reapproach the resident. Staff 20 did not recall informing a nurse or reapproaching Resident 12. Staff 20 stated she was "definitely" not able to get everything done because there were not enough staff. Refer to F677 and F842.

Res. # 15 is no longer at this facility. Resident need for an appointment attendant was assessed by a nurse based on cognition, elopement risk and safety concerns 11/2/21. Residents designated as needing an Appointment Attendant was documented in the chart. Residents with appointments in the following 2 weeks were reviewed to ensure those needing an Appointment Attendant were identified and scheduled the next 24 hours. Staff (unless unreachable due to LOA, vacation or FMLA) were in-serviced on importance of using Appointment Attendants for those residents identified. In-servicing was done prior to beginning of their next shift starting 11/2/21 with DAY and EVE shift staff, and continue until all staff have received the training. This was completed by DNS/Admin or designee before 1159 at 11/3/21. New admissions will be assessed by a nurse based on cognition, elopement risk and safety concerns. Residents designated as needing an Appointment Attendant will be documented in the chart. DNS or designee will audit 4 resident charts weekly to assure residents needing appointment attendant have been identified in the chart and upcoming appointment for the week have attendants as identified. Any areas found not in place will be immediately corrected. These audits will continue for 3 months with results brought QAPI for 2 quarters or until substantial compliance is met. Resident 11 has expired. Resident 17 has been assessed for recent incontinence care concerns and continues to be monitored for signs of depression. Resident 12 has had a shower in the past 7 days. Current incontinent residents are at risk for delay of incontinence care. Incontinent residents were assessed for worsening signs of depression. Current residents are at risk for not receiving bath/shower as scheduled. Audit was done for previous 7 days to ensure all residents received bathing. Residents not receiving a bath or shower were interviewed to ensure the opportunity was provided. If not, they were offered a bathing at that time. Education was provided to clinical staff about expectations for timely incontinence care and bathing as scheduled. Bathing schedule was reevaluated for optimal distribution across days and shifts. Shower audit has been scheduled weekly to identify residents who have not yet received a shower, for reapproach. Education has been provided to Staffing Coordinator about staffing ratios for CNAs, NAs and PCAs. Staffing meeting has been scheduled weekly between the Administrator, DNS and Staffing Coordinator to review coverage and potential gaps. DNS or designee will interview 5 residents weekly about timely incontinent care and receiving showers as scheduled. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 6 sampled residents (#s 22 and 23) reviewed for medications and physician orders. This resulted in Resident 22 being hospitalized and placed residents at risk for adverse drug reactions. Findings include: 1. Resident 22 admitted to the facility in 1/2020 with diagnoses including diabetes. The 9/14/21 Skin and Wound Evaluation indicated Resident 22 had a facility acquired open lesion to the lower right abdomen. The wound appeared "two weeks prior", measured 1.8 cm x 0.6 cm and had no signs of infection. Treatment was in place. The 9/22/21 Progress Notes revealed the abdominal wound was raised, red, warm to touch, painful with moderate yellow drainage. [Indicative of infection.] The 9/22/21 Physician Order revealed an new antibiotic order for doxycycline hyclate twice daily for abdominal cellulitis (skin infection). The 9/2021 MARs revealed the order for the doxycycline hyclate was not transcribed onto the MAR and was not administered. The 9/24/21 Progress Noted revealed Resident 22 had a temperature of 100.4F [normal is between 97F to 99F] and a pulse of 120 [normal is 60 to 100 beats per minute]. Resident 22 complained of pain at the abdominal wound site. Resident 22's lower abdomen was red and hot to the touch. Resident 22 was transferred to the hospital. The 9/27/21 Hospital Re-Admission orders revealed Resident 22 was admitted to the hospital for sepsis (full body infection) due to the infection of skin and soft tissues of the left pannus (stomach apron). Resident 22 was discharged with a PICC (peripherally inserted central catheter) line for two weeks of IV (intravenous) antibiotics. Resident 22 was to follow up with the infectious disease clinic in one week. On 11/1/21 at 10:47 AM Staff 25 (Regional RN), Staff 26 (Regional RN) and Staff 2 (Interim DNS) acknowledged the 9/22/21 antibiotic order was not transcribed or administered to Resident 22 which resulted in the transfer and admission to the hospital for IV antibiotics to treat the sepsis. , 2. Resident 23 admitted to the facility on 2/22/20 with diagnoses including heart failure. The 2/22/20 at 12:36 PM progress note indicated Resident 23 admitted to the facility. The 2/22/20 Physician Order indicated Resident 23 was to receive a enoxaparin injection (anticoagulant medication) BID. The 2/22/20 at 9:24 PM progress note indicated enoxaparin was not available. The 2/2020 MAR indicated Resident 23 did not receive her/his first dose of enoxaparin until 2/23/20 at 8:00 PM. On 11/2/21 at 9:16 AM Staff 26 (Regional RN) stated Resident 23 admitted to the facility on 2/22/20 with an order for enoxaparin BID and did not receive the first dose until 2/23/20 at 8:00 PM.

Resident 22 has completed treatment for infection and wound continues to be followed by her provider. Resident 23 has discharged from the facility. Current residents are at risk for staff not carrying out MD orders. Current orders were audited to ensure notifications and appropriate actions were taken if staff were unable to complete or administer. Education was provided to nurses about time expectations for order transcription, how to access as needed medication orders, how to reorder medications and importance of notifying MD if medication is not available for administration. DNS or designee will audit 24-hour reports 5 days/week for orders not administered or administered incorrectly and appropriate response. After 4 weeks, audits will continue at least 2 days/week. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on observation and interview the facility failed to ensure medications were stored safely for 1 of 4 treatment carts randomly observed for medication storage. This placed residents at risk for unauthorized access to medications. Findings include: On 10/28/21 at 5:26 PM the second floor south treatment cart was observed in the hallway by room 203 unlocked and unattended. The treatment cart contained various topical and injectable medications. On 10/28/21 at 5:29 PM Staff 40 (LPN) verified the treatment cart was left unlocked and unattended.

All nursing carts were audited to ensure they were locked when unattended. Education provided to all clinical staff about the need to lock all nursing carts when not in use. DNS or designee will audit treatment carts daily to ensure they are locked when not in use. After 4 weeks, audits will continue at least 2 days/week. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on observation and interview it was determined the facility failed to serve palatable food at a safe and appetizing temperature for 2 of 2 floors reviewed for food temperatures. This placed residents at risk for receiving unpalatable food at an unsafe and unappetizing temperature. Findings include: The 9/6/21 Resident Council Meetings Notes indicated the food was served cold and was not always flavorful. The 10/26/21 Resident Council Meeting notes indicated the second floor food was served cold and staff reported they did not have time to reheat the food. Residents further indicated they did not get the food they ordered. On 11/4/21 at 7:20 AM an observation of food service from the kitchen to all hall trays was initiated. At 8:44 AM the final resident tray was passed and the test tray was delivered and sampled by the survey team and Staff 26 (Regional RN). The tray consisted of oatmeal, banana (brown spotted), quiche, potatoes, 2% milk and juice. The milk and juice were observed sitting out on a pan without ice. The temperature of the milk was 50.5F [safe temperature of milk was to be under 41F], the quiche was slightly warm and undercooked and the potatoes were cold and not palatable. On 10/28/21 at 6:18 PM Resident 43 stated the food tasted like "dog food." On 11/01/21 at 4:08 PM Resident 52 stated the food was cold 90% of the time and not reheated because staff did not have time to reheat the food. Resident 52 further stated she/he never received a hot drink at dinner when requested because staff stated they were too busy. Resident 52 stated the meals carts sat in halls and it took a long time to get food. On 11/2/21 at 12:20 PM Staff 21 (CNA) stated she had heard multiple food complaints from the residents and the food was always cold. Staff 21 stated the past week biscuits and gravy were served but the biscuit was completely hard. On 11/4/21 at 8:50 AM Staff 26 (Regional RN) verified the milk was too warm, the quiche tasted "doughy", undercooked and only slightly warm and the potatoes were cold and unpalatable.

Corrective action(s). (How are you going to correct the alleged deficient practice?) To ensure the facility serves palatable food at safe and appetizing temperatures the facility has purchased a portable steam table for each floor, will keep all cold beverages iced during tray service and monitor tray service temperatures. 2. Identify Other Potential Residents (How will other residents be affected/identified?) All residents have the potential to be affected by the alleged deficient practice 3. Systemic Changes (What training will be completed, or systemic changes implemented? This is your plan of correction) The Foodservice team will be in-serviced on Food Safety Time Temperatures, the policy for Food Temperatures, and were provided a resource: Critical Temperatures for Safe Food Handling; the Dining Experience Meal Manager Program was introduced to the Administrator and implemented. Certified Dietary Manager will review resident council minutes and follow up with resident specific complaints and/or the council if process changes are required. Certified Nursing Assistants will be scheduled to assist in each dining venue including In-Room. 4. Monitoring (How will citations be monitored?) Daily, the Meal Service Observation form will be completed during meal service with the prior days results reviewed the next day in morning meeting; the Registered Dietitian will complete and rotate monthly the Nutrition Services Quality Assurance Audit for Tray Service and Resident Meal Satisfaction, results will be discussed with the Administrator and Certified Dietary Manager. Trends brought to QAPI. 5. Responsibility (Who is responsible?) The Certified Dietary Manager and Registered Dietitian

Based on observation, interview and record review it was determined the facility failed to honor a resident's food intolerance for 1 of 1 randomly sampled residents (#29) reviewed for food preferences. This placed residents at risk for being served food they could not tolerate. Findings include: Resident 29 admitted to the facility in 2019 with diagnoses including dementia and adult failure to thrive. On 11/2/21 at 12:21 PM Resident 29 was observed to have green beans on her/his food tray. Resident 29 received 1:1 assistance from Staff 21 (CNA). The 2/6/19 Food Preferences assessment revealed Resident 29 had food intolerances to green beans and spinach. On 11/2/21 at 12:20 PM Staff 21 stated Resident 29 was served green beans on her/his lunch tray although Resident 29's food tray card indicated not to serve green beans. Staff 21 stated this occurred "all the time."

1. Corrective action(s). (How are you going to correct the alleged deficient practice?) To ensure the facility honors residents food preferences the facility serve foods according to the resident tray card. 2. Identify Other Potential Residents (How will other residents be affected/identified?) All residents have the potential to be affected by the alleged deficient practice 3. Systemic Changes (What training will be completed, or systemic changes implemented? This is your plan of correction) The interdisciplinary team will be in-serviced on How to Read a Tray Card; staff assisting in dining locations or delivering room trays will review the tray card prior to assisting the residents dining in-room; and the Dining Experience Meal Manager Program was introduced to the Administrator and implemented. Certified Dietary Manager to update resident food preferences, per resident request or as identified and yearly in conjunction with the RAI process. 4. Monitoring (How will citations be monitored?) Daily, the Meal Service Observation form will be completed during meal service with the prior days results reviewed the next day in morning meeting; the Registered Dietitian will complete, every other month, the Nutrition Services Quality Assurance Audit for Tray Service and Resident Meal Satisfaction, results will be discussed with the Administrator and Certified Dietary Manager. Trends brought to QAPI. 5. Responsibility (Who is responsible?) The Certified Dietary Manager and Registered Dietitian

Based on observation, interview and record review it was determined the facility failed to store and distribute food and fluids in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. This placed residents at risk for foodborne and chemical contamination related illness. Findings include: 1. On 8/12/20 it was reported blue sanitizer came out of a coffee urn instead of coffee. On 10/25/21 at 9:31 AM Staff 28 (Dietary Aide) stated approximately a year prior there was an incident when blue sanitizer used to clean coffee urns was served to residents instead of coffee. Staff 28 was unaware if residents consumed the sanitizer. On 10/25/21 at 12:56 PM Witness 28 (Former Dietary Aide) stated she was preparing coffee and one coffee urn was not placed in the dishwashing area indicating it was dirty, so she placed the coffee urn on the drink cart. She stated at that time a staff member discovered the urn contained the blue sanitizer, but no residents drank the sanitizer. Witness 28 stated she reported the incident to Staff 18 (Dietary Manager). Witness 28 stated there was another incident after when a new dietary aide was unaware of the process for dirty coffee urns and placed multiple ones with blue sanitizer in them on the drink cart and residents did consume the liquid. On 10/25/21 at 1:06 PM Staff 18 (Dietary Manager) stated she was only aware of one incident during 11/2020 when a former staff put out multiple coffee urns with blue sanitizer and Staff 18 was notified by staff that the coffee was "blue with bubbles." Staff 18 did not recall any residents consuming the sanitizer and staff removed all coffee from residents and placed residents on alert charting. Staff 18 could not recall the specific residents involved. Staff 18 stated dietary staff were in-serviced regarding the incident. On 10/26/21 at 1:21 PM Staff 27 (Dietary Aide) stated she worked as a dietary aide for eight years and was not aware of any issues with blue sanitizer being served instead of coffee or any in-services related to the incident. Staff 27 showed the surveyor the type of cleaner the facility used to clean the coffee urns and the label stated "Urnex: Urn & Brewer Cleaner" and she stated the sanitizer was blue. On 10/27/21 at 2:31 PM Staff 30 (CNA) stated she went to pour coffee out of the urn on a cart and realized the coffee had bubbles and was blue. Staff 30 stated she believed the incident occurred 3/2021 and that was the second time blue sanitizer was in the coffee urn instead of coffee. Staff 30 stated no residents ingested the blue sanitizer. On 11/1/2021 at 9:47 AM Staff 25 (Regional RN) stated she did not believe residents ingested the urn sanitizer and residents who may have received coffee during the incident were placed on alert charting. Staff 25 was asked to provide the surveyor with in-services related to the incidents and residents placed on alert. On 11/1/21 at 12:06 PM Staff 25 stated there were no in-services related to the blue urn sanitizer and was unable to provide the residents placed on alert charting. 2. On 10/25/21 at 9:21 AM a half of an onion dated 10/19, an undated opened bag of shredded turkey, an opened container of heavy cream with an expiration date of 10/15/21, and an open container of buttermilk with an expiration date of 10/17/21 were observed in one facility kitchen fridge. On 10/25/21 at 9:27 AM Staff 29 (Cook) confirmed the open bag of turkey was undated, the half onion was dated "10/19", and the buttermilk and heavy cream were expired. Staff 29 stated the process was for kitchen staff to go through facility fridges daily and toss out any expired foods. On 10/25/21 at 1:17 PM Staff 18 (Dietary Manager) acknowledged the identified undated or expired food items.

1. Corrective action(s). (How are you going to correct the alleged deficient practice?) To prevent the risk for foodborne illness the facility will store and distribute food according to foodservice safety standards by discarding expired food; following manufacturers guidelines for cleaning coffee equipment and label/dating food. 2. Identify Other Potential Residents (How will other residents be affected/identified?) All residents have the potential to be affected by the alleged deficient practices. 3. Systemic Changes (What training will be completed, or systemic changes implemented? This is your plan of correction) Foodservice staff received in-service training on how to clean coffee equipment and the policy for Cleaning Instructions. In addition, foodservice staff will post on the coffee equipment when actively using urn cleaner and sign off when the solution was rinsed thoroughly removed. Foodservice staff will receive in-service training on How to Label and Date Foods. The Certified Dietary Manager will conduct routine monitoring to ensure food items are appropriately labeled and dated. 4. Monitoring (How will citations be monitored?) Administrator or Designee to complete weekly SPOT-It audit; Certified Dietary Manager validates coffee urn cleaning process monthly; and the Registered Dietitian will conduct monthly Nutrition Services Quality Assurance Food Safety and Sanitation Audit. Trends brought to QAPI. 5. Responsibility (Who is responsible?) Administrator, Certified Dietary Manager, and Registered Dietitian

Based on interview and record review it was determined the facility failed to ensure accurate medical records for 4 of 10 sampled residents (#s 10, 12, 17 and 33) reviewed for respiratory care, bathing, and skin conditions. This placed residents at risk for inaccurate documentation. Findings include: 1. Resident 12 admitted to the facility on 9/1/20 with diagnoses including a stroke and hemiplegia (paralysis of half the body). Resident 12's 9/6/20 Annual MDS indicated the resident was cognitively intact. The 9/1/20 Care Plan indicated the resident was dependent on staff to assist with bathing. The Bathing/Shower Task Sheet indicated on 10/30/21 Resident 12 did not receive a shower or bed bath. The reason was marked "RR" [Resident Refused] by Staff 13 (LPN). On 11/3/21 at 12:50 PM Staff 13 (LPN) stated she was unsure if Resident 12 received a shower as she did not complete the shower task sheet. Staff 13 further stated Staff 20 (PCA, Personal Care Assistant) was assigned a section of residents to provide care, but did not have access to the electronic health record, therefore she allowed Staff 20 to document under her credentials. On 11/3/21 at 1:26 PM Staff 20 (PCA) stated she did not recall completing a shower for Resident 12. Staff 20 further stated she used Staff 13's login information to document tasks as she did not have access to the electronic health record. , 2. Resident 10 admitted to the facility in 4/2020 with diagnoses including heart failure. The 9/11/20 Facility Investigation revealed Resident 10 had pressure ulcers to her/his bilateral heels. The 10/13/20 and 10/20/20 Weekly Skin Audits indicated Resident 10 had bilateral heel pressure ulcers. The 10/16/20 Weekly Skin Audit indicated Resident 10 had intact skin. On 11/2/21 at 10:30 AM Staff 26 (Regional RN) acknowledged the 10/16/21 Weekly Skin Audit inaccurately identified Resident 10 to have intact skin., 3. Resident 17 readmitted to the facility in 9/2020 with chronic chronic respiratory failure. The 9/1/21 Physician Order indicated Resident 17 was to have the Continuous Positive Airway Pressure Therapy (CPAP) on while sleeping and to fill with 4-8 cm of distilled water. On 11/1/21 at 11:40 AM Resident 17 stated she/he wore the CPAP and was able to put it on independently. The 10/2021 TAR indicated the CPAP monitoring was not implemented until 10/27/21. On 11/1/21 at 1:02 PM Staff 25 (Regional RN) stated a resident who required a CPAP should have monitoring completed on the TAR. Staff 25 acknowledged Resident 17 had orders for a CPAP and the monitoring was not implemented on the TARs until 10/27/21. 4. Resident 33 readmitted to the facility in 2017 with diagnoses including obstructive sleep apnea. The 9/22/21 Physician Order indicated Resident 33 was to have a CPAP with 8-11 cm of water. On 10/25/21 at 2:27 PM Resident 33 was observed to wear a CPAP while in bed. The resident stated she/he was able to use it independently. The 10/2021 TARs indicated there was no CPAP monitoring in place. On 11/1/21 at 1:02 PM Staff 25 (Regional RN) stated a resident who required a CPAP should have monitoring completed on the TAR. Staff 25 acknowledged Resident 33 had orders for a CPAP and monitoring was not initiated on the TAR.

Resident 10 has discharged from the facility. Resident 12 has had a shower in the past 7 days. Resident 17 and 33 treatment records were updated to reflect use of CPAP. Current residents are at risk for the alleged deficient practice. Audit was done for previous 7 days to ensure all residents received bathing with an accurate skin assessment. Residents using CPAP/BiPAP were reviewed to ensure treatment records reflected current CPAP/BiPAP use. Education was provided to clinical staff about expectations for accurate charting of cares they provide. Education was provided to nurses about accurate completion of weekly skin assessments and scheduling CPAP/BiPAP cares on the treatment record. DNS or designee will audit 5 charts weekly for accuracy of charting on showers and weekly skin assessments. New admits with orders for CPAP/BiPAP use will be audited weekly for cares appearing on the treatment record. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to ensure the Medical Director or designee attended the QAA committee meetings at least quarterly for 3 of 3 QAA meetings reviewed for QAA. This placed residents at risk for lack of Medical Director or designee oversight related to medical care and facility operational activities. Findings Include: Review of the QAA meetings between 6/28/21 through 11/1/21 revealed the Medical Director or designee did not attend the 6/28/21, 7/30/21 and the 9/15/21 QAA meetings. No other QAA meetings were held in this time period. On 11/1/21 at 1:41 PM Staff 1 (Administrator) verified the Medical Director or designee did not attend the 6/21/21, 7/30/21 and the 9/15/21 QAA meetings. Staff 1 stated the Medical Director or designee was required to attend the QAA meetings at least quarterly and acknowledged the Medical Director or designee had not.

QAPI meeting was held on 11/17/21 with Medical Director in attendance. Education provided to IDT team about QAPI attendance of Medical Director at least quarterly. Next QAPI meeting scheduled for 12/15/21 with Medical Director attendance planned. Administrator will be in attendance at future QAPI meetings and will ensure attendance is documented. Previous attendance sheets will be audited in QAPI meetings for 6 months or until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 5 out of 6 months reviewed for minimum CNA staffing. This placed residents at risk for delayed care. Findings include: Due to Oregon's current statewide hospital capacity crisis, the Oregon Department of Human Services, Safety, Oversight and Quality Unit temporarily revised the Oregon Administrative Rules (OARs) related to certified nursing assistant staffing, effective immediately. The Department temporarily amended the minimum certified nursing assistant ratios as follows: Current OARs for Certified Nursing Assistants (411-086-0100(C)): o DAY SHIFT: 1 certified nursing assistant per 7 residents. o EVENING SHIFT: 1 certified nursing assistant per 9.5 residents. o NIGHT SHIFT: 1 certified nursing assistant per 17 residents. Effective August 24th, 2021, Temporary OARs for Certified Nursing Assistants (411-086-0100(C)): o DAY SHIFT: 1 certified nursing assistant per 8.5 residents. o EVENING SHIFT: 1 certified nursing assistant per 12 residents. o NIGHT SHIFT: 1 certified nursing assistant per 18 residents. The Department also temporarily expanded definitions of who can be counted towards the minimum certified nursing assistant ratios. Effective immediately, nursing facilities may temporarily utilize the services of nursing assistants, personal care assistants, physical therapists and occupational therapists to account for up to 25% of the required minimum staff required on each shift. The revised staffing ratios and use of staff other than certified nursing assistants to meet the minimum CNA staffing ratio is a temporary measure and will only be allowed during this statewide emergency. A review of the facility's Direct Care Staff Daily Reports for the months of 3/2020, 4/2021, 7/2021, 8/2021 and 9/27/21 through 10/30/21 revealed the following dates when the required state minimum CNA staffing ratios were not met for one or more shifts: -3/6/20 -3/23/20 -4/1/21 -4/2/21 -4/3/21 -4/4/21 -4/7/21 -4/10/21 -4/11/21 -4/13/21 -4/16/21 -4/19/21 -4/22/21 -4/24/21 -4/30/21 -7/18/21 -7/19/21 -7/20/21 -7/21/21 -7/24/21 -7/26/21 -7/27/21 -8/1/21 -8/4/21 -8/5/21 -8/6/21 -8/12/21 -8/16/21 -8/18/21 -8/19/21 -8/20/21 -8/21/21 -8/22/21 -8/23/21 -10/30/21 On 11/4/21 at 8:11 AM Staff 1 (Administrator) acknowledged the lack of required CNAs on duty on the identified dates.

Education has been provided to Staffing Coordinator about staffing ratios for CNAs, NAs and PCAs. Staffing meeting has been scheduled weekly between the Administrator, DNS and Staffing Coordinator to review coverage and potential gaps. Administrator or designee will audit daily staffing sheets 5x/week to verify staffing ratios were met. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for the dates 12/16/21 through 1/14/22 reviewed for minimum CNA staffing. This placed residents at risk for delayed care. Findings include: A review of the facility's Direct Care Staff Daily Reports for the dates of 12/16/21 through 1/14/22 revealed the following dates when the required state minimum CNA staffing ratios were not met for one or more shifts: 1/5/22 1/6/22 1/9/22 1/11/22 On 1/14/22 at 11:44 AM Staff 2 (Regional RN) acknowledged the lack of required CNAs on duty on the identified dates. ,

Education has been provided to Staffing Coordinator about current staffing ratios in place for CNAs, NAs and PCAs. Staffing meeting continues to be held weekly between the Administrator, DNS and Staffing Coordinator to review coverage and potential gaps. Administrator or designee will audit daily staffing sheets 5x/week to verify staffing ratios were met. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.

********************* OAR 411-086-0360 Resident Furnishings, Equipment Refer to F558 ********************* OAR 411-085-0310 Residents' Rights: Generally Refer to F565 ********************* 411-085-0360 Abuse Refer to F600 ********************* OAR 411-086-0040 Admission of Residents Refer to F655 ********************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684, F695, F697 and F760 ********************* OAR 411-086-0370 Clinical Records Refer to F842 ********************* OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686 and F689 ********************* OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ********************* OAR 411-086-0260 Pharmaceutical Services Refer to F761 ********************* OAR 411-086-0250 Dietary Services Refer to F804, F806 and F812 ********************* OAR 411-085-0220 Quality Assurance Refer to F868 *********************

********************* OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686 and F689 ********************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F658 *********************

Based on interview and record review it was determined the facility failed to ensure Staff 13 (LPN Resident Care Manager) adhered to professional standards related to documentation for 1 of 3 sampled residents (#62) reviewed for pressure ulcers. This placed residents at risk for inaccurate records and lack of competent nursing care. Findings include: 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: (4) Conduct related to communication: (c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or agency records. This includes but is not limited to: (A) Documenting nursing practice implementation that did not occur; Resident 62 was readmitted to the facility in 10/2021 with diagnoses including quadriplegia. The 12/21/21 Skin and Wound Evaluations indicated Resident 62 had an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) on the coccyx and a Stage 4 pressure ulcer (full-thickness skin and tissue loss) on the right ischial tuberosity (curved bone on the bottom of the pelvis). On 1/13/22 at 10:30 AM the Skin and Wound Evaluations were reviewed for 12/21/21, 12/28/21, 1/4/22 and 1/11/22 for the pressure ulcers located on the coccyx and right ischial tuberosity. There were no measurements to indicate the depth of the wounds. On 1/13/22 at 10:40 AM Staff 13 stated both the coccyx wound and the ischial tuberosity wound had a depth of 2.5 cm to 3 cm. Staff 13 acknowledged the Skin and Wound Evaluations dated 12/21/21, 12/28/21, 1/4/22 and 1/11/22 were not comprehensive and did not include the information regarding the pressure ulcer depth. On 1/13/22 at 12:04 PM Staff 13 stated she added some information to the Skin and Wound Evaluations dated 12/21/21, 12/28/21, 1/4/22 and 1/11/22 based on "years of experience with [Resident 62's] wound and my notes." Staff 13 was unable to locate the notes. On 1/13/22 at 1:54 PM Staff 13 stated she changed three of the Skin and Wound Evaluations dated 12/21/21, 12/28/21, 1/4/22 and 1/11/22 based on her undated notes. Staff 13 stated she located the notes. The notes were reviewed with Staff 13 and included resident names and some numbers. The notes had no dates and no indication of what the numbers referenced. Staff 13 acknowledged she changed the wound evaluations based on these notes. On 1/13/22 at 2:30 PM Staff 2 (Regional RN) acknowledged Staff 13 should not have changed the Skin and Wound Evaluations dated 12/21/21 through 1/11/22 based on the undated notes which were not comprehensive.

Staff 13 has been educated about importance of comprehensive documentation at time of assessment and need to ensure any written documentation is transcribed into the chart prior to signing and locking. Nursing staff have been educated about importance of comprehensive and timely documentation in resident charts. DNS or designee will audit wound assessments each week to ensure they are comprehensive and complete prior to the week’s end. After 4 weeks, audits will continue monthly. Results of audits will be submitted to QAPI until substantial compliance is achieved.