Gresham Post Acute Care And Rehabilitation

Resident 2 admitted to the facility in 6/2025 with diagnoses of bipolar disorder, ADHD (Attention Deficit Hyperactive Disorder), and depression. -á Review of Resident 2GÇÖs physician orders revealed a new psychotropic medication for bupropion (an antidepressant) 75 mg was added on 12/9/25 and included an indication a consent was required before administering the medication. The 12/2025 MAR revealed bupropion 75mg was administered to Resident 2 starting 12/11/25. Review of Resident 2GÇÖs medical record found no consent was obtained prior to administering the medication. On 12/18/25 at 1:15 PM Staff 20 (Resident Care Manager/LPN) confirmed nurses were expected to obtain consent for psychotropic medications prior to administering psychotropic medication. Staff 20 acknowledged a consent was not obtained prior to Resident 2 starting bupropion 75mg. -á

Missing consent obtained on 1/8/26 for Bupropion  for resident 2. Resident 2 consented All residents residing in the facility have the potential to be impacted by this deficiency. A ll licensed nurses, including resident care managers will be  in - serviced  on the policies and procedures associated with implementation of psychotropic medications, including that consent for administration must be obtained prior to initiation of medication. An initial  audit has been conducted for all residents  residing  in the facility with current orders for psychotropic medication therapy.  It has been ensured that consent and associated care plans for psychotropic medication use are in place for those residents. To prevent further recurrence, DNS or designee wi ll  conduct an audit of all newly ordered psychotropic medications  for consent and associated care planning, weekly x4 weeks and then monthly thereafter until substantial compliance is achieved. Date of compliance: 1/22/2026

2. Resident 5 was admitted to facility in 3/2025 with diagnoses including muscle weakness and somatoform disorder (a mental illness that causes bodily symptoms, including pain).-á -á Observations on 12/15/25 at 3:54 PM revealed two overbed lights in Resident 5GÇÖs room were missing their cords. Resident 5 was sitting up in bed -á and stated she/he had to use the call light for staff assistance to turn the light on and off because the only working light was controlled by a switch located at the entrance of her/his room.-á -á The Quarterly MDS dated 12/2/25 revealed Resident 5 required extensive assistance with all ADLs. -á On 12/17/25 at 11:50 AM, Staff 36 (CNA) stated if something was broken in a residentGÇÖs room, she would inform maintenance by inputting the issue into the computer. She stated maintenance would notice it right away and fix it. -á On 12/17/25 at 11:53 AM, Staff 39 (Lead CNA) stated if the lights needed to be fixed in a residentGÇÖs room, the issues were reported to maintenance by inputting the concerns into a computer system.-á -á On 12/17/25 at 3:14 PM, Staff 15 (Maintenance Director) confirmed there were no cords for two of Resident 5GÇÖs overbed lights. He stated residents shouldnGÇÖt have to call staff to turn off and on their overbed lights.-á -á On 12/19/25 at 10:45 AM, Staff 1 (Administrator) acknowledged the broken cords in Resident 5's room and stated all overhead lights should be available for residents to use.-á , 1. The facility's 9/2022 Answering the Call Light Policy directed staff to ensure the call light was accessible to the resident when in bed.-á Resident 30 was admitted to the facility in 11/2022 with diagnoses including quadriplegia (paralysis affecting all four limbs and the torso) and dependence on a ventilator (when a person cannot breathe adequately on their own and relies on a machine for life).-á Resident 30's 10/1/25 Annual MDS revealed the resident was cognitively intact, experienced upper and lower extremity impairment on both sides and was dependent upon staff assistance to complete all ADLs.-á Resident 30's 10/3/25 Care Plan indicated the resident utilized a soft touch call light (an assistance device, often a lightweight button or pad, designed for individuals with poor dexterity or limited movement) with her/his left hand to make her/his needs known.-á On 12/15/25 at 10:04 AM, Resident 30 was observed in her/his room in bed. The resident's call light was positioned on the left side of the bed near the resident's head. The resident demonstrated she/he was unable to independently access the call light as it was positioned too high on her/his bed. The resident stated her/his call light was placed out of reach on a daily basis, and as a result, she/he had to yell out to get staff's attention.-á On 12/16/25 at 1:20 PM, Resident 30 was observed in her/his room in bed. The resident's call light was positioned near the resident's left shoulder. The resident demonstrated she/he was unable to independently access the call light as it was positioned too high on her/his bed. The resident stated an unidentified staff person just assisted her/him in bed, left her/his room and did not ensure she/he could reach her/his call light before they left.-á On 12/16/25 at 5:03 PM, Resident 30 was observed in her/his room in bed. The resident attempted to reach her/his call light but was unable to do so. The state surveyor activated the resident's call light at the request of the resident, and it was answered at 5:05 PM by Staff 42 (CNA). Staff 42 assisted the resident and exited the room without ensuring the resident was able to reach her/his call light. Staff 42 stated the positioning of Resident 30's call light was dependent upon the resident's ""strength for the day."" Staff 42 stated staff ""usually"" did a call light test with the resident to ensure the resident could reach her/his call light before they left the room.-á On 12/17/25 at 6:19 AM, Resident 30 was observed in her/his room in bed. The resident's call light was placed by her/his left hip, and the resident independently activated her/his call light. At 6:27 AM Staff 43 (CNA) answered the resident's call. Staff 43 raised the head of the bed to assist the resident with a drink of water and then lowered it after the resident was finished. Staff 43 did not confirm with the resident if she/he could reach her/his call light and exited the room. The resident demonstrated at this time she/he could no longer reach her/his call light.-á On 12/17/25 6:34 AM, Staff 43 stated Resident 30's call light was to be placed on her/his left side and staff were supposed to ensure the resident was able to reach it before leaving her/his room.-á On 12/17/25 at 1:28 PM, Resident 30 was observed in her/his room in bed. Staff 22 (RN) and Staff 25 (CNA) observed Resident 30 was unable to reach her/his call light. Staff 25 stated the placement of the resident's call light needed to be frequently adjusted due to her/his level of strength and after care was completed.-á On 12/17/25 at 3:28 PM, Staff 26 (LPN Resident Care Manager) stated she expected Resident 30's call light to be placed on her/his left side and in a place where she/he could reach it. Staff 26 further stated staff were to ""do a return demonstration if they moved"" the resident's call light. On 12/18/25 at 10:23 AM, Staff 2 (DNS) stated Resident 30's mobility was so limited that he expected staff to ensure the resident was able to reach it before exiting the resident's room.-á -á

CNAs and Nursing educated on return  demonstrations  to confirm call light  within reach.  Both pull cords for  both   beds over-the-bed light  were installed   immediately  following identification. All residents residing in the facility have the potential to be impacted by this deficiency. All certified nursing assistants and charge nurses will be in-serviced on the process to address missing over the bed light pull cord and the process to put in work order s  into TELS. All certified nursing assistants and charge nurses will be in-serviced on the interventions for call light within reach emphasizing return demonstration for residents with limited mobility. An initial  audit has been conducted for all residents  residing  in the facility. Each room has been observed  for over  the bed call light to ensure all residents have the ability to independently turn on/off over the bed light. To prevent further recurrence, DNS or designee will conduct a spot audit of 3 residents with limited mobility to ensure call lights are within reach  (return demonstration)  and spot audit 3 residents for over the bed light pull cord in place x 4 weeks and then monthly thereafter until substantial compliance is achieved. Date of compliance: 1/22/2026

3. Resident 67 was admitted to facility in 11/2023 with diagnoses including anoxic brain damage (lack of oxygen to the brain leading to severe cognitive, physical and emotional issues) and spastic quadriplegic cerebral palsy (severe stiffness in limbs and severe mobility limitations).-á -á The Annual MDS with an ARD of 12/1/25 revealed Resident 67 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. The resident was in a persistent vegetative state with no discernible consciousness.-á -á On 12/15/25 at 2:55 PM, Resident 67GÇÖs bedside table was observed to have a fan covered in a thick layer of dust and cobwebs. The fan was off and pointed towards Resident 67GÇÖs face.-á -á On 12/16/25 at 2:13 PM and on 12/17/25 at 9:04 AM, Resident 67GÇÖs fan was observed to have a thick layer of dust, was turned on and pointed towards her/his face. Resident 67GÇÖs mouth was observed to be open on both occasions.-á -á On 12/17/25 at 11:53 AM, Staff 39 (Lead CNA) stated nursing staff only cleaned bodily fluids in a residentGÇÖs room. -á On 12/17/25 at 12:11 PM, Staff 37 (Housekeeping) stated she and housekeeping staff were not responsible for cleaning the personal fans of residents. -á On 12/17/25 at 1:35 PM, Staff 38 (Housekeeping Manager) and at 3:14 PM Staff 15 (Maintenance Director) both entered Resident 67's room acknowledged the thick layer of dust on Resident 67GÇÖs fan. Staff 38 and Staff 15 both stated they were not responsible for cleaning the personal fans in resident's rooms. -á On 12/17/25 at 3:26 PM, Staff 2 (DNS) entered Resident 67's room and acknowledged her/his fan was on, dirty and pointed towards Resident 67's face.-á , 1.Resident 10 admitted to the facility in 9/2025 with diagnoses including diabetes. Resident 10GÇÖs 12/2/25 Significant Change MDS assessment indicated she/he was cognitively intact. On 12/15/25 at 12:41 PM and 12/17/25 at 11:37 AM Resident 10GÇÖs privacy curtain was observed with multiple small stains on the lower half of the curtain and a large brownish stain in the bottom right corner of the curtain. Resident 10 stated the curtain was dirty for many weeks and had asked multiple staff to have dirty curtain washed. Resident 10 stated she/he did not like to look at the dirty curtain. On 12/17/25 at 12:10 PM Staff 17 (Housekeeping) stated her department was responsible to ensure the residentGÇÖs privacy curtains were washed and clean in resident rooms.-á On 12/17/25 at 3:32 PM Staff 2 (DNS) and Staff 14 (Regional Corporate Nurse) confirmed Resident 10GÇÖs privacy curtain was not clean and needed to be changed. Staff 2 stated he expected all residents to have clean privacy curtains.-á 2. Resident 44 was admitted to the facility in 2023 with diagnoses including a stroke. On 12/17/25 at 11:38 AM Resident 44GÇÖs room door was observed with a black box fan positioned in front of it. The fan was coated with a layer of dust and dirty, dust layered coated with visible strings of dust were blowing from the fan. On 12/17/25 at 1:35 PM, Staff 38 (Housekeeping Manager) and at 3:14 PM Staff 15 (Maintenance Director) stated they were not responsible for cleaning residents' personal fans. Staff 38 stated she had not cleaned the personal fans for approximately the past six months. On 12/17/25 at 3:26 PM, Staff 2 (DNS) and Staff 14 (Regional Corporate Nurse) confirmed Resident 44 had a dirty personal box fan in her/his room. They stated staff were expected to keep the fan clean and free from dust. , 1.Resident 10 admitted to the facility in 9/2025 with diagnoses including diabetes. Resident 10GÇÖs 12/2/25 Significant Change MDS assessment indicated she/he was cognitively intact. On 12/15/25 at 12:41 PM and 12/17/25 at 11:37 AM Resident 10GÇÖs privacy curtain was observed with multiple small stains on the lower half of the curtain and a large brownish stain in the bottom right corner of the curtain. Resident 10 stated the curtain was dirty for many weeks and had asked multiple staff to have dirty curtain washed. Resident 10 stated she/he did not like to look at the dirty curtain. On 12/17/25 at 12:10 PM Staff 17 (Housekeeping) stated her department was responsible to ensure the residentGÇÖs privacy curtains were washed and clean in resident rooms.-á On 12/17/25 at 3:32 PM Staff 2 (DNS) and Staff 14 (Regional Corporate Nurse) confirmed Resident 10GÇÖs privacy curtain was not clean and needed to be changed. Staff 2 stated he expected all residents to have clean privacy curtains.-á 2. Resident 44 was admitted to the facility in 2023 with diagnoses including a stroke. On 12/17/25 at 11:38 AM Resident 44GÇÖs room door was observed with a black box fan positioned in front of it. The fan was coated with a layer of dust and dirty, dust layered coated with visible strings of dust were blowing from the fan. On 12/17/25 at 1:35 PM, Staff 38 (Housekeeping Manager) and at 3:14 PM Staff 15 (Maintenance Director) stated they were not responsible for cleaning residents' personal fans. Staff 38 stated she had not cleaned the personal fans for approximately the past six months. On 12/17/25 at 3:26 PM, Staff 2 (DNS) and Staff 14 (Regional Corporate Nurse) confirmed Resident 44 had a dirty personal box fan in her/his room. They stated staff were expected to keep the fan clean and free from dust. -á 3. Resident 67 was admitted to facility in 11/2023 with diagnoses including anoxic brain damage (lack of oxygen to the brain leading to severe cognitive, physical and emotional issues) and spastic quadriplegic cerebral palsy (severe stiffness in limbs and severe mobility limitations).-á -á The Annual MDS with an ARD of 12/1/25 revealed Resident 67 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. The resident was in a persistent vegetative state with no discernible consciousness.-á -á On 12/15/25 at 2:55 PM, Resident 67GÇÖs bedside table was observed to have a fan covered in a thick layer of dust and cobwebs. The fan was off and pointed towards Resident 67GÇÖs face.-á -á On 12/16/25 at 2:13 PM and on 12/17/25 at 9:04 AM, Resident 67GÇÖs fan was observed to have a thick layer of dust, was turned on and pointed towards her/his face. Resident 67GÇÖs mouth was observed to be open on both occasions.-á -á On 12/17/25 at 11:53 AM, Staff 39 (Lead CNA) stated nursing staff only cleaned bodily fluids in a residentGÇÖs room. -á On 12/17/25 at 12:11 PM, Staff 37 (Housekeeping) stated she and housekeeping staff were not responsible for cleaning the personal fans of residents. -á On 12/17/25 at 1:35 PM, Staff 38 (Housekeeping Manager) and at 3:14 PM Staff 15 (Maintenance Director) both entered Resident 67's room acknowledged the thick layer of dust on Resident 67GÇÖs fan. Staff 38 and Staff 15 both stated they were not responsible for cleaning the personal fans in resident's rooms. -á On 12/17/25 at 3:26 PM, Staff 2 (DNS) entered Resident 67's room and acknowledged her/his fan was on, dirty and pointed towards Resident 67's face.-á

Resident 10's curtain immediately  replaced with a new/clean curtain. Resident 44's fan was  immediately  cleaned of all debris and dust.  Process for  new cleaning routine for personal fans was established . All residents residing in the facility have the potential to be impacted by this deficiency. An initial  audit will be conducted  of  all fans and curtains to ensure  they are  clean and in good condition. An in-service will be provided to nursing staff, certified nursing  assistance , and maintenance  on   Maintaining Clean, Hygienic, and Comfortable Resident Environments (Fans and Privacy Curtains). To prevent further recurrence, DNS or designee will conduct a spot audit of 3 resident rooms for a safe, comfortable, and homelike environment , weekly  x4 weeks and then monthly thereafter until substantial compliance is achieved. Date of compliance: 1/22/2026

Resident 58 was admitted to the facility in 11/2023 with diagnoses including diffuse traumatic brain injury (widespread damage to the brain). A review of progress notes from Resident 58GÇÖs date of admission through 12/18/25 revealed Resident 58 had a mitten hand restraint on her/his left hand since 11/3/23. Review of physician orders for Resident 58 revealed the resident had a weighted mitten hand restraint in use on her/his left hand since 3/14/24, which demonstrated the facility utilized the restraint prior to obtaining a physicianGÇÖs order. The current order dated 2/20/25 directed staff to use the restraint mitten on the residentGÇÖs left hand; remove every two hours to assess skin and to wash the mitten every shift. Review of the SNF Managed Risk Agreement dated 4/16/24 revealed Witness 1 (Family Member) requested a mitten be used on Resident 58GÇÖs left hand, a weighted elbow sleeve used on the residentGÇÖs left elbow, and, as a last resort, soft wrist restraints to keep the resident safe. -á The reason for the restraints was because the resident frequently pulled out her/his tracheostomy tube, injured self, and pulled out her/his g-tube (tube inserted into the abdomen for feeding). -á A 1/13/25 revised care plan indicated Resident 58GÇÖs physical restraint use interventions were initiated on 12/13/23. The care plan directed staff to monitor/document/report PRN any changes regarding effectiveness of the restraint, less restrictive devices attempted, and, if appropriate any negative or adverse effects noted. Review of care conference notes dated 7/15/25 and 9/11/25 revealed the question for GÇÿAssistive/Restrictive device(s) continue to be appropriateGÇÖ was marked as yes. -á There were no details documented of what was reviewed including, alternate options to restraint use, any monitoring or reassessment of the restraint need, or any risks associated with the restraint use. -á Review of the 11/2025 and 12/2025 MAR/TAR and task logs revealed the resident had no documented targeted behavior of restlessness or fidgeting, pulling or grabbing at equipment or staff, or erratic movements. The 11/2025 and 12/2025 MAR/TAR revealed the restraint was used daily. An Annual MDS dated 12/8/25 assessed Resident 58 with no physical restraints in place, no behaviors that posed a risk to self or others, and cognitive function was not assessed due to the resident being in a persistent vegetative stated. -á There was no evidence found in Resident 58's clinical record to indicate the resident's mitten was re-assessed for continued need or if less-restrictive alternate options were explored. Random observations between 12/15/25 through 12/19/25 between 8:00 AM to 4:30 PM each day -á revealed Resident 58 had the mitten on her/his left hand. -á No observations were made of the resident as restless or attempting to pull on her/his g-tube. -á-á On 12/17/25 at 3:32 PM, Resident 58 was observed without the mitten during an activity. The resident did not attempt to remove her/his g-tube, be combative, or attempt self-inflicted harm. -á During interviews on 12/16/25 at 2:24 with Staff 5 (LPN), and at 3:08 PM with Staff 16 (CNA), 12/17/25 at 9:29 AM with Staff 17 (CNA), and 12/18/25 at 9:22 AM with Staff18 (CNA) all staff stated the reason for continued use of the mitten was Resident 58 was combative with cares and in the past tried to pull out tubes. On 12/18/25 at 1:15 PM Staff 20 (Resident Care Manager/LPN) confirmed a reassessment of the restraint was not completed and a discussion with the family regarding the appropriateness of continued use or alternative options were needed. -á On 12/19/25 at 8:07 AM Staff 27 (CNA/Restorative Aide) stated Resident 58 was more active with her left hand and used her/his left hand to communicate with others. She stated Resident 58 could not see or speak, so the resident used a left thumbs up signal or raised her/his left hand to respond yes to questions, would lower her/his thumb to answer no to questions, would reach out to touch Staff 27, and would stick up her/his middle finger to express frustration.

Resident 58 was trialed off restraints,  demonstrated  safety without restraints and currently out of restraints  with  a goal  to remain out of restraints. All residents residing in the facility have the potential to be impacted by this deficiency. All resident care managers will be in-serviced on facility policies and procedures for restraint use and when to trial off. A n initial  facility wi de audit  completed  for all  resident s  with res traints  identifying  consent, care  plan  and plan to trial off. To prevent further recurrence, DNS or designee will conduct an audit of all residents on restraints or newly placed in restraints. Date of compliance: 1/22/2026

Resident 58 was admitted to the facility in 11/2023 with diagnoses including diffuse traumatic brain injury (widespread damage to the brain). Review of progress notes revealed Resident 58 had a mitten hand restraint in use on her/his left hand since 11/3/23. Review of physician orders for Resident 58 revealed the resident had a weighted mitten hand restraint in use on her/his left hand since 3/14/24. Review of the 11/2025 and 12/2025 MAR/TAR revealed documentation demonstrating the restraint was used on every Day and NOC shift. -á The Annual MDS dated 12/8/25 indicated Resident 58 had no physical restraints in place. Random observations from 12/15/25 through 12/19/25 between the hours of 8:00 AM to 4:30 PM each day revealed Resident 58 had the mitten on her/his left hand. On 12/19/25 at 10:55 AM Staff 29 (MDS Coordinator/LPN) confirmed she completed the comprehensive MDS on 12/8/25 and the restraint section was inaccurately coded.

Annual MDS section P updated to reflect  use  of restraints. All residents  residing  in the facility have the potential to be  impacted  by this deficiency . MDS coordinator will be in-serviced on how to code restraint use accurately and what constitutes a restraint. DNS or designee will audit 3 MDSs weekly x4 weeks and then monthly thereafter until substantial compliance is achieved. Date of compliance: 1/22/2026

2. Resident 5 was admitted to facility in 3/2025 with diagnoses including muscle weakness and somatoform disorder (a mental illness that causes bodily symptoms, including pain).-á -á -áThe Quarterly MDS dated 12/2/25 revealed Resident 5 was cognitively intact and dependent with personal hygiene, including shaving. -á Resident 5GÇÖs Care Plan dated 6/1/25 revealed Resident 5 required one staff person to assist with shaving. -á On 12/15/25 at 3:20 PM, Resident 5 was observed to have unshaven facial hair above her/his upper lip area. -á On 12/15/25 at 3:52 PM, Resident 5 was observed covering her/his unshaven facial hair when the resident was about it. Resident 5 stated she/he used to shave her/his facial hair every two or three weeks and did not know staff could perform the task for her/him.-á -á On 12/18/25 at 9:40 AM, Staff 17 (CNA) stated she was not comfortable asking Resident 5 if she/he would like to be shaved and did not offer the service to her/him.-á -á On 12/18/25 at 10:20 AM, Staff 20 (LPN Care Manager) stated staff were uncomfortable to ask Resident 5 if she/he would like her/his facial hair shaved. Staff 20 stated she expected staff to implement Resident 5's care plan when providing care, including performing shaving tasks.-á -á On 12/19/25 at 10:31 AM, Staff 2 (DNS) and Staff 40 (RN Regional Nurse Coordinator) acknowledged Resident 5 required one staff person assist with shaving because Staff 5 was dependent on staff for ADL care. Staff 40 stated although it was a sensitive topic, she expected staff to offer shaving services to residents who required assistance.-á , 1. Resident 58 was admitted to the facility in 11/2023 with diagnoses including diffuse traumatic brain injury (widespread damage to the brain). A review of Resident 58's 12/8/25 annual comprehensive MDS revealed she/he was dependent on staff for personal hygiene tasks and did not have any rejection of care. Resident 58's care plan dated 1/23/25 revealed the resident was dependent on staff and required two staff members for ADL care and for daily shaving. Care conference notes dated 7/15/25 and 9/11/25 revealed Witness 3 (Family Member) had raised concerns of Resident 58 not receiving personal hygiene cares daily. Daily observations from 12/15/25 through 12/18/25 from the hours of 9:00 AM to 12:00 PM revealed Resident 58 to have dark hairs of varying lengths up to one half inch growing from her/his chin. On 12/16/25 at 9:22 AM Witness 3 stated Resident 58 was unable to shave independently and relied on facility staff to complete the care. Witness 3 stated she/he reported concerns to facility staff that daily hygiene cares were not being completed, and she/he purchased an electric razor to make it easier for staff to shave Resident 58. -á Witness 3 stated prior to the brain injury, it was important to Resident 58 to always look good and would not have wanted visible facial hair. On 12/16/25 at 3:08 PM Staff 16 (CNA) reported Resident 58 liked to be shaved after showers and sometimes refused to be shaved by shaking her/his hands. -á Staff 18 stated female residents were shaved after showers and male residents were shaved when they want to be shaved. On 12/17/25 at 9:29 AM Staff 17 (CNA) reported she never shaved Resident 58 because she was scared to shave her/him due to the resident swinging her/his arms during cares. -á Staff 17 stated she had not noticed Resident 58 had facial hair when she provided cares and stated the resident would not have wanted to have facial hair. On 12/18/25 at 9:22 AM Staff 18 (CNA) stated she and a second CNA assisted Resident 58 on 12/18/25 in the morning had not shaved the resident because the activity department shaved Resident 58. On 12/18/25 at 10:46 AM Staff 19 (LPN) reported Resident 58 was to be shaved daily and as needed. -á She stated it was not okay to leave Resident 58 with facial hair. -á On 12/18/25 at 1:15 PM Staff 20 (Resident Care Manager/LPN) stated staffed were expected to shave Resident 58 daily during morning cares. Staff 20 stated staff were expected to review and implement the care plan for Resident 58.

Resident 5 and resident 5 8 were shaved All residents residing in the facility have the potential to be impacted by this deficiency. Certified nursing assistants and charge nurses will be in-serviced on grooming/hygiene, offering shave, how to offer, and how to  identify  need for shave. Resident care managers will be in-serviced on how to identify   the need  for a shave during rounds. To prevent further recurrence, DNS or designee will conduct a spot audit of 3 residents for cleanliness and need for shave x 4 weeks, then monthly until substantial compliance. Date of compliance: 1/22/2026

3.Resident 8 admitted to the facility in 2016 with diagnoses including a stroke. Resident 8GÇÖs 10/22/25 Annual MDS Assessment indicated she/he was cognitively intact and used no suction machine (a medical device that creates a vacuum to remove fluids for a personGÇÖs airway). On 12/15/25 at 12:44 PM Resident 8 stated she/he used the suction machine at her/his bedside. A suction machine was observed on the left side of her/his bedside table. Record review of Resident 8GÇÖs health record on 12/16/25 revealed there was no physician order for the use of a suction machine and no plan of care was found for the use of a suction machine. On 12/17/25 at 11:16 AM Staff 20 (Resident Care Manager/LPN) stated Resident 8 had previously used a suction machine and acknowledged the suction machine was on Resident 8's bedside table. Staff 20 stated the resident did not have a physician order for the use of the suction machine and stated the ongoing use of a suction machine required a physician order. She stated Resident 8 did not have any health indication or assessment in her/his health record which indicated the need for the use of a suction machine.-á , 1. Resident 6 was admitted to the facility in 2/2025 with a diagnosis of cerebellar ataxia (a neurological condition causing poor muscle control (ataxia) due to damage or disease in the cerebellum, leading to issues with balance, walking (unsteady gait), speech (slurring), swallowing, and fine motor skills like writing, often described as appearing drunk). A review of progress notes revealed Resident 6 had the following falls: -On 9/20/25 an unwitnessed fall and hit her/his head -On 10/15/25 an unwitnessed fall -On 10/18/25 an unwitnessed fall -On 10/20/25 a witnessed fall and hit her/his face -On 10/25/25 an unwitnessed fall and hit her/his forehead -On 11/3/25 an unwitnessed fall A review of the Neurological Assessment Flow Sheets revealed incomplete neurological assessments with missing assessments on the following dates: -9/20/25 -10/15/25 -10/18/25 -10/20/25 -10/25/25 -11/3/25 On 12/18/25 at 9:42 AM Staff 3 (LPN Resident Care Manager) stated neurological assessments were to be completed after unwitnessed falls and after witnessed falls if the resident hit their head. On 12/18/25 at 10:13 AM, Staff 3 stated neurological assessments were to be completed every 15 minutes for one hour, every 30 minutes for an hour, every hour for four hours, and every four hours for 24 hours. On 12/18/25 at 10:33 AM, Staff 3 acknowledged the neurological assessments on 9/20/25, 10/15/25, 10/18/25, 10/20/25, 10/25/25, and 11/3/25 were incomplete. On 12/19/25 at 8:35 AM, Staff 2 (DNS) stated neurological assessments were to be completed per the above schedule, so issues were identified and acted on promptly. Staff 2 acknowledged the neurological assessments on 9/20/25, 10/15/25, 10/18/25, 10/20/25, 10/25/25, and 11/3/25 were not completed per the schedule and were missing assessments. 2. Resident 12 was admitted to the facility on 12/4/25 with diagnoses including dysphagia (difficulty swallowing) and BellGÇÖs Palsy (a sudden, temporary weakness or paralysis of the muscles on one side of the face). A review of physician orders revealed a 12/4/25 order for speech therapy to evaluate and treat Resident 12. A review of the 12/5/25 speech therapy notes evaluation indicated Resident 12GÇÖs plan of treatment was to be seen three times a week for treatment of swallowing dysfunction. A review of the speech therapy progress notes revealed the following: -On 12/8/25 resident was unable to be seen due to a scheduling conflict. -On 12/10/25 resident was in bed asleep, not alert enough for safe oral intake trial or to participate in swallow exercises. -On 12/12/25 resident was in bed asleep, not alert enough for safe oral intake trial or to participate in swallow exercises. -On 12/15/25 resident was unable to be seen due to a scheduling conflict. -On 12/17/25 resident refused treatment, was in bed, not alert enough for safe oral intake trial or to participate in swallow exercises. A review of physician orders revealed a 12/12/25 order to hold all of Resident 12GÇÖs medication from 12/12/25 until 12/15/25. A review of the meal monitor task revealed Resident 12 consumed the following meals: -On 12/12/25 76-100% dinner. -On 12/13/25 51-75% breakfast and lunch. -On 12/14/25 76-100% breakfast and 51-75% dinner. A review of Resident 12GÇÖs medical record showed no documentation of increased swallowing difficulty on 12/12/25 and no evidence of any reassessment of swallowing ability. On 12/15/25 at 10:41 AM, Witness 4 (Family Member) stated the facility put a hold on Resident 12GÇÖs medications over the weekend due to her/his inability to swallow. Witness 4 stated the facility was giving Resident 12 her/his medications crushed in pudding, and they tried to get her/him to take the medication in one big bite, which was too much for Resident 12 to swallow. On 12/17/25 at 10:58 AM, Staff 32 (CNA) stated Resident 12 was having a hard time swallowing last week but was eating and swallowing better this week. On 12/17/25 at 11:51 AM, Staff 3 (LPN Resident Care Manager) stated she placed Resident 12GÇÖs medications on hold on 12/12/25 because Resident 12 was having a hard time swallowing anything and everyone was scared, she/he would aspirate. Staff 3 stated she was unsure if Resident 12 had speech therapy since admission. On 12/18/25 Staff 31 (Speech Therapist) stated Resident 12 was overall very weak and had delayed swallowing. Staff 31 stated she had not seen Resident 12 since the evaluation on 12/5/25 due to days where Resident 12 was too sleepy to participate or there were scheduling conflicts. Staff 31 stated she was the only speech therapist in the facility and attempted to see residents as often as she was able. Staff 31 stated she was not informed about Resident 12GÇÖs inability to swallow on 12/12/25 and was not informed Resident 12GÇÖs medications were held over the weekend. On 12/19/25 at 8:32 AM Staff 2 (DNS) acknowledged Resident 12GÇÖs speech therapy plan of care was to be seen three times a week for dysphagia. Staff 2 stated he expected Resident 12 to be seen per the plan of care and acknowledged Resident 12 was not seen three days a week per the plan of care. Staff 2 stated Resident 12 was eating over the weekend per the documentation, and he expected Resident 12GÇÖs swallowing to be reassessed for her/his ability to swallow medications as she/he was able to swallow food. Staff 2 acknowledged there was no evidence Resident 12GÇÖs swallowing ability was assessed or reassessed from 12/12/25 through 12/15/25.

Suction machine removed from resident  8’s room. Suction machine not  indicated  for  resident's  care. No other residents  require  re-evaluation of swallowing ability. All residents residing in the facility have the potential to be impacted by this deficiency. All charge nurses and resident care managers will be in-serviced on procedure for  reassessing  swallowing ability, procedure for neurological checks post-fall, and procedure for use o f suction machines. To prevent further recurrence, DNS or designee will conduct an audit of  neurologica l  flowsheets for all new falls. DNS or designee will do a walk-through of the facility to ensure we  identify  all suction machines currently in use. DNS or designee will conduct an audit of all residents with a suction machine to ensure we have a physician order and i ntegration into the care plan . Date of compliance: 1/22/2026

Resident 6 was admitted to the facility in 2/2025 with a diagnosis of bilateral hearing loss. An 8/29/25 care plan indicated Resident 6 had a hearing deficit and to assist her/him with putting the hearing aids in every morning. An 8/29/25 care conference indicated Resident 6 had hearing aids but requested a new pair. On 12/15/25 at 11:43 AM, Resident 6 stated she/he was eligible for new hearing aids and requested assistance with getting them. Resident 6 stated she/he was eligible in 7/2025. Resident 6 stated her/his old pair of hearing aids were lost during one of the room moves. On 12/17/25 at 11:34 AM, Staff 33 (Social Service Director) stated she was unaware of Resident 6GÇÖs hearing aids missing. Staff 33 stated Resident 6 requested a new pair during the care conference in 8/2025. Staff 33 acknowledged she had not followed up on this request. On 12/17/25 at 11:38 AM, Staff 32 (CNA) stated Resident 6 was hard of hearing but did not have hearing aids. On 12/17/25 at 11:57 AM, Staff 3 (LPN Resident Care Manager) stated she was unaware of if Resident 6 had hearing aids, but she/he was care planned for hearing aids. On 12/17/25 at 12:35 AM, Staff 4 (Social Service Director) stated she was unaware Resident 6GÇÖs hearing aids were missing. Staff 4 stated when a resident request new hearing aids, it was expected staff complete as soon as possible. Staff 4 stated Resident 6 requested new hearing aids on 8/29/25 and there was no follow up. On 12/19/25 at 8:42 AM, Staff 2 (DNS) stated when residents requested new hearing aids the request should be followed up immediately including if they are eligible for new hearing aids. Staff 2 stated Resident 6 requested new hearing aids on 8/29/25 and acknowledged there was no follow regarding the request.

Grievance form completed for resident  6 ’ s  missing hearing aids, appointment with Hearing USA scheduled for 1/8/26 for repla cement. Residents hearing aids were replaced on 1/8/26 All residents residing in the facility have the potential to be impacted by this deficiency. An initial  audit has been conducted for all residents with hearing aids to ensure hearing aids are  functional;  hearing aids meet residents' hearing  needs and  start  processing  to replace missing hearing aids. All social services will be in-serviced on expectation for resident requests for new hearing aids. All certified nursing assistants and charge nurses will be in-serviced on reporting missing hearing aids to social services and resident care managers and how to complete  grievance  form. All resident care managers will be in-serviced on quarterly reviews on hearing aids and glasses. To prevent further recurrence, DNS or designee will conduct spot audit on 3 residents with hearing aids to  identify  if hearing aids are  functional;  hearing aids meet the resident's hearing needs, and hearing aids  aren’t  missing. Date of compliance: 1/22/2026

The facility's 10/2024 Skin Management Policy and Procedure directed the following: -If new skin impairments are found, the licensed nurse will notify the resident, notify the provider, obtain treatment orders, initiate and document pertinent details in the risk management, document findings in the clinical record and place the resident on alert.-á -Wounds rounds and photo documentation will be completed within seven days for a pressure ulcer/injury.-á -If a resident refuses skin evaluation, education will be provided and documented. If the resident continues to refuse for 24 hours, staff will notify the RCM or designee who will meet with the resident and complete a managed risk agreement.-á Resident 30 was admitted to the facility in 11/2022 with diagnoses including quadriplegia (paralysis affecting all four limbs and the torso) and dependence on a ventilator (when a person cannot breathe adequately on their own and relies on a machine for life).-á Resident 30's 9/25/25 Braden Scale for Predicting Pressure Sore Risk indicated the resident was at high risk to develop pressure ulcers.-á Resident 30's 10/1/25 Annual MDS revealed the resident was cognitively intact, experienced upper and lower extremity impairment on both sides, was dependent upon staff assistance to complete all ADLs and was at risk of developing pressure ulcers.-á Resident 30's 12/2/25 Skin Impairment Care Plan revealed the following: -The resident had pressure ulcers on her/his right gluteus (buttocks), left plantar great toe (bottom of her/his big toe), left medial (inner part) ankle and right elbow.-á -The licensed nurse was to be notified of any new skin issues.-á -Weekly treatment documentation was to include measurement of each area of skin's breakdown's width, length, depth and type of tissue, exudate (fluid that leaks from blood vessels into nearby tissues, often in response to injury, infection or inflammation) and any other notable changes or observations.-á -Abnormalities, failure to heal, signs and symptoms of infection and maceration (skin breakdown from being too wet) were to be reported to the physician.-á A 12/13/25 Skin Integrity Form initiated by Staff 21 (LPN) revealed a pressure ulcer was found by Staff 21 on Resident 30's right ring finger after the resident requested the dressing on her/his right hand to be changed. The form did not indicate any additional details about the wound including staging, size, wound bed appearance, exudate (fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) or presence of signs of infection. The form did not provide any information regarding who or why a dressing was placed on the resident's right ring finger prior to it being changed on 12/13/25. A 12/13/25 Progress Note indicated Resident 30 had a pressure ulcer on her/his right ring finger, and the resident's right hand was to be elevated in order to relieve pressure on the area. On 12/15/25 at 10:12 AM, Resident 30 was observed in her/his room in bed. The back of the resident's right hand was observed to push into the mattress on her/his bed. No pillow or padding was observed in place to help reduce the pressure to the resident's pressure ulcer on her/his right hand. Resident 30 stated she/he was dependent on assistance from staff to move her/his right arm/hand and regularly requested staff to place a pillow under her/his right wrist to help reduce pressure, but staff refused.-á On 12/15/25 at 12:34 PM, Resident 30 was observed in her/his room in bed. The resident's right hand was pushed into the mattress without any pillow or padding in place to help alleviate pressure to the resident's pressure ulcer.-á Random observations of Resident 30 on 12/16/25 from 1:20 PM to 5:03 PM revealed the resident was in her/his room in bed. A pillow was placed under the resident's right wrist in such a way that the pressure ulcer on the resident's right ring finger pushed into the bed.-á On 12/16/25 at 5:10 PM, Staff 21 stated Resident 30 refused most care but would allow staff to prop up her/his right hand on a pillow for pressure relief.-á On 12/17/25 at 1:28 PM, Staff 22 (RN) observed Resident 30 in her/his room in bed with a pillow placed under the resident's right wrist. Staff 22 stated the resident's pressure ulcer on her/his right hand was directly on the bed and did not receive any pressure relief because of how the pillow was positioned. With Resident 30's permission, Staff 22 removed the dressing that covered the resident's pressure ulcer on her/his ring finger. The wound bed was bright red and blood dripped from the wound. The wound was approximately the size of a quarter in diameter. Staff 22 completed the treatment to the wound and then propped the resident's right wrist on a pillow to offload Resident 30's right hand/ring finger.-á On 12/17/25 at 6:58 AM, Staff 23 (CNA) stated Staff 24 (RN) informed her Resident 30's right hand was to be floated as the resident had a wound on her/his hand. Staff 23 stated she had not had the opportunity to float the resident's right hand, and she had not ""seen a pillow"" used to offload the resident's right hand when she had been in the resident's room.-á On 12/17/25 at 7:16 AM, Staff 25 (CNA) stated Resident 30 wanted a pillow placed under her/his right hand and did not refuse when it was offered. Staff 25 stated he last saw a pillow used to offload the resident's right hand on 12/13/25 but had not seen the resident since this time.-á On 12/17/25 at 9:44 AM and 12/19/25 at 8:03 AM, Staff 24 stated she observed the pressure ulcer on Resident 30's knuckle on her/his right ring finger approximately two-to-three weeks ago during wound rounds. Staff 24 stated she did not obtain measurements of the wound, assess the wound, initiate a Skin Integrity Form or obtain treatment orders. Staff 24 stated she ""was just waiting for orders"" so she ""was just treating it on my own."" Staff 24 stated when she initially observed the wound, it was a Stage 2 pressure ulcer and was approximately the size of a pencil eraser in diameter. Staff 24 stated she completed treatments to the resident's right hand and ensured the resident's right hand was offloaded for the two days after the wound was discovered, and the resident's wound improved. Staff 24 stated the resident wound ""got worse again"" because treatments were not completed on the days she did not work at the facility. Staff 24 stated the wound was currently a Stage 2 but had increased to approximately the size of a quarter in diameter. Staff 24 stated she informed Resident 30 she/he had a pressure ulcer on her/his fourth right finger a few weeks ago as a result of her/his hand being ""smashed into the bed."" Staff 24 stated she educated the resident on the importance of off-loading pressure on her/his right hand. Staff 24 further stated she was the nurse assigned to Resident 30's care on 12/15/25, and no staff reported to her that Resident 30 refused to elevate her/his right hand.-á On 12/17/25 at 3:28 PM, Staff 26 (LPN Resident Care Manager) stated she expected Resident 30's right hand to be elevated at all times to provide pressure relief, and if the resident refused her/his hand to be elevated, staff should notify the nurse. Staff 26 further stated a Skin Integrity Form should have been initiated at the time the resident's wound was initially discovered to ensure the resident received timely treatment.-á On 12/18/25 at 3:01 PM Staff 21 stated the wound on the resident's right hand was beefy red but did not bleed when she initially observed it on 12/13/25. Staff 21 stated she could not remember if she measured the wound on 12/13/25 and could not provide any additional details. On 12/19/25 at 8:13 AM Staff 2 (DNS) stated a Skin Integrity Form should have been initiated at the time Resident 30's right hand wound was initially discovered so a root cause analysis could have been completed, appropriate treatments put in place and a timely assessment of the resident's wound, including staging and measurement information, was obtained.-á

Wound assessed and staged by RN. Appropriate wound care orders  were  implemented. Risk management  completed . Wound currently healing appropriately  as evidence by a decrease in size. All residents residing in the facility have the potential to be impacted by this deficiency. All charge nurses and resident care managers will be in-serviced on  Pressure Ulcer Prevention, Assessment, Treatment, and Monitoring. All certified nursing assistants will be in-serviced on  Reporting New Skin Impairments & Placing Residents on Alert. To prevent further recurrence, DNS  or designee   will conduct an audit  during weekly wound review  meeting  of  existing pressure wounds and treatments for effectiveness and improvement . The findings of this audit will be brought to QAPI and reviewed weekly with nurse management staff. Date of compliance: 1/22/2026

Resident 12 was admitted to the facility on 12/4/25 with diagnoses including dementia and mixed incontinence (when a person experiences symptoms of both-ástress incontinence-áand-áurge incontinence-áat the same time). On 12/15/25 at 10:32 AM, Witness 4 (Family Member) stated Resident 12 was continent of bowel and bladder at home. Witness 4 stated Resident 12 had been in the facility for two weeks, and they did not take Resident 12 to the bathroom, they just let her/him be incontinent. A review of Resident 12GÇÖs care plan revealed a 12/5/25 care plan indicating Resident 12 needed one-person extensive assist for toileting and was at risk for incontinence with a goal to always remain continent but no evidence of interventions to assist Resident 12 with remaining continent. -á On 12/15/25 at 10:44 AM, Resident 12 stated the staff waited until she/he was incontinent and then changed her/him instead of taking her/him to the bathroom. On 12/17/25 at 10:58 AM, Staff 32 (CNA) stated she thought Resident 12 was incontinent and Resident 12 did not ask to use the bathroom. On 12/17/25 at 11:51 AM, Staff 3 (LPN Resident Care Manager) stated Resident 12 requested and got up to the bathroom on 12/16/25, On 12/17/25 at 12:03 PM, Staff 3 stated when a resident admitted to the facility and were continent, the care plan indicated staff were to ask the resident every time they were in the room and if the resident needed to use the bathroom. Staff 3 stated there were no interventions on Resident 12GÇÖs care plan to assist her/him to remain continent. On 12/18/25 at 11:35 PM, Staff 29 (LPN Resident Care Manager/MDS Coordinator) stated she assessed Resident 12GÇÖs continent status by reviewing CNA charting. Staff 29 stated the facility does not initiate toileting programs to assist residents in remaining continent. On 12/18/25 at 12:11 PM, Witness 5 (Family Member) stated at home Resident 12 was continent of bowel and bladder. On 12/18/25 at 12:23 PM, Staff 3 stated residents should be assessed for continence upon admission to the facility. Staff 3 stated Resident 12 was not assessed for continence when she/he admitted to the facility. On 12/19/25 at 8:32 AM, Staff 2 (DNS) stated residents should be assessed for continence upon admission and residents should have a care plan based on the completed assessment. Staff 2 stated a record review of CNA charting was not sufficient for an assessment and acknowledged Resident 12 was not assessed for continence upon admission.

Resident  12  discharged home with family . All residents residing in the facility have the potential to be impacted by this deficiency. All charge nurses and resident care managers will be in-serviced on bowel and bladder assessments on admission. Resident care managers will be in-serviced on checking bowel and bladder assessments on admission and quarterly; if resident is baseline continent and currently incontinent, how to implement a toileting program and expectations for toileting program Certified nursing assistants will be in-serviced on toileting programs. To prevent further recurrence, DNS or designee will conduct an audit for all new admissions to ensure bowel and bladder assessment completed on admission and  identify  if a toileting program is indicated x4 weeks and then monthly until substantial compliance is achieved. Date of compliance: 1/22/2026

Resident 58 was admitted to the facility in 11/2023 with diagnoses including diffuse traumatic brain injury (widespread damage to the brain), persistent vegetative state, and dysphagia (difficulty swallowing). The care plan dated 1/23/25 revealed the following interventions regarding tube feeding: *Tube Feed: Continuous 24 hours. Isosource 1.5 total amount: 1440mls Flow Rate 60ml/hr. Flush Rate: 50ml/hr.-á *Two licensed nurses are required to verify the correct tube feed and formula when placing a new bag. *Labeling system (All TF [Tube feeding] bags labeled with 2 LN signatures and date/time hung). A physicianGÇÖs order dated 11/10/25 indicated the residentGÇÖs tube feeding was to run continuously for 24 hours at a rate of 60ml per hour for a total of 1440 ml per day.-á On 12/15/25 at 11:42 AM Resident 58 was observed in bed. The residentGÇÖs tube feeding was connected but the pump used to administer the feeding was turned off. Two bags were attached to the pump. One was labeled Isosource and dated/timed 12/14/25 6:30 AM. The other unlabeled bag contained clear liquid.-áThe bag was not observed changed until 12/15/25 at 2:45 PM. Staff 5 (LPN) confirmed on 12/16/25 at 2:24 PM Resident 58GÇÖs tube feed should have run continuously for 24 hours. She stated the bag was changed when it ran out and the only time the pump was turned off was for showers and bed baths or if Resident 58 was full or vomiting. On 12/16/25 at 3:08 PM Staff 16 (CNA) stated she would make sure the pump was always running and would notify the nurse if there were issues. She stated the nurses would disconnect the pump when it became blocked and during showers. On 12/17/25 at 10:29 AM the tube feeding was observed to be disconnected from Resident 58 when she/he was assisted to the dining room for an activity.-á On 12/17/25 at 3:32 PM Resident 58 was returned to her/his room by two CNAs with the pump connected and running. At 3:58 PM the pump was observed to be beeping with the alarm on the screen showing the pump had been idle for ten minutes. The nurse was not observed to respond to the alarm until 4:26 PM. On 12/18/25 at 8:57 AM Resident 58 was observed on a stretcher without her/his tube feeding attached. The resident was being transported to a medical appointment and returned to the facility within 2 hours. -á-á In an interview with Staff 18 (CNA) on 12/18/25 at 9:22 AM she reported the pump was always running and the pump would not be turned off except when the resident went out to appointments. She stated the pump was supposed to go with the resident when she/he went to the dining room.-á On 12/18/25 at 4:01 PM Staff 28 (LPN) confirmed she had worked with Resident 58 on 12/15/25 for the 6:00 AM to 6:00 PM shift but had not observed the pump not running until she changed the bag. She stated the last time she recalled seeing the pump running before she changed the bag was between 8:00 AM and 9:00 AM on 12/15/25 when she had given Resident 58 her/his medications.-á Staff 20 (Resident Care Manager/LPN) confirmed on 12/18/25 at 1:15 PM Resident 58GÇÖs tube feed should run for 24 hours and there were no orders to stop the feeding or administer a bolus feeding, so the resident would not have made up missing fluid and nutrients when the pump was stopped for extended periods of time. Staff 20 stated she unaware there were time periods Resident 58 was not receiving tube feeding and confirmed the nurse should have noticed the pump was off for at least three hours on 12/15/25. -á

All residents residing in the facility have the potential to be impacted by this deficiency. All certified nursing assistants will be in-serviced on how to respond to tube feed alarms. All the charge nurses will be in-serviced on labeling of tube feed bags including flush bag,  policy  and procedures, responding to alarms, and  procedure  for appointments, activities,  ect . To prevent further recurrence, DNS or designee will conduct a spot audit of 3 residents on TF weekly  for  appropriate labeling  of TF bags x 4 weeks and monthly until substantial compliance. Date of compliance: 1/22/2026

2. Resident 68 admitted to the facility in 10/2019 with diagnoses including congestive heart failure and dysphagia (difficulty swallowing foods or liquids). The 9/14/25 Quarterly MDS indicated Resident 68 had severe cognitive impairment. Resident 68GÇÖs physician order dated 1/7/25 revealed she/he required oxygen as needed. On 12/15/25 at 9:55 AM the oxygen concentrator was observed to have a foam filter with a thick layer of dust. On 12/16/25 at 12:47 PM Staff 41 (CNA) stated checking and cleaning oxygen filters was the responsibility of the nurse and not an assigned duty for CNAs.-á On 12/16/25 at 1:02 PM Staff 15 (RN) observed Resident 68GÇÖs oxygen concentrator and acknowledged the foam filter was very dirty and needed to be cleaned. On 12/16/25 at 12:28 PM Staff 2 (DNS) stated the facility did not have a cleaning schedule for Resident 68GÇÖs oxygen filter and his expectation was oxygen filters would be cleaned weekly. , 1.Resident 10 admitted to the facility in 9/2025 with diagnoses including diabetes. -á Resident 10GÇÖs 12/2/25 Significant Change MDS assessment indicated she/he was cognitively intact, and the resident did not require the use of oxygen services. -á A review of Resident 10's health record revealed no current physician order for ongoing oxygen use unless the oxygen level dropped below 92% -á On 12/15/25 at 12:41 PM Resident 10 was observed with an oxygen nasal cannula (tube with two prongs that fit in the nostrils to deliver supplemental oxygen) in her/his left nostril and connected to an oxygen concentrator (medical device that provides concentrated oxygen). -á On 12/17/25 at 9:54 AM Staff 5 (LPN) stated residents needed a physician order for the ongoing use of oxygen and they were expected to be followed as written. Staff 5 was not aware the resident was using the oxygen ongoing. -á On 12/17/25 at 10:10 AM Resident 10 was observed sitting in bed with an oxygen nasal cannula in her/his nose and was connected to an oxygen concentrator. -á On 12/17/25 at 10:12 AM Staff 20 (Resident Care Manager/LPN) stated she completed an audit of all residents on 12/16/25, during which she discovered Resident 10 had an oxygen concentrator in the room and directed staff to remove it. Staff 20 walked to Resident 10's room, confirmed the concentrator was still present and observed the resident receiving oxygen via nasal cannula. Staff 20 stated Resident 10 had a physician order to receive oxygen only if her/his oxygen saturations dropped below 92% and her/his vital signs did not indicate the need for oxygen.

Resident 68 concentrator  filters were   immediately  clean. RCMs  audited  all residents' concentrators and cleaned all filters that were identifie d as dirty.  A new  filter cleaning process was established . Resident 10  oxygen  order  updated  to :   1 lpm  for comfort while in bed (no parameters) . New order for labs every 3 months to check Co2 levels  to  monitor  for adverse side  effect  of oxygen use . All residents residing in the facility have the potential to be impacted by this deficiency. All charge nurses will be in-serviced on policy and procedures, orders, parameters, and concentrator filter cleaning. To prevent further recurrence, DNS or designee will conduct an audit of 3 residents  oxygen orders, parameters, and concentrator filters x 4 weeks and then monthly until substantial compliance  achieved . Date of compliance: 1/22/2026

The facilityGÇÖs undated Trauma Informed Care and Culturally Competent Care policy revealed the resident assessment process involved an in-depth evaluation of trauma-related symptoms and the identification of triggers. -á The policy revealed the facilityGÇÖs process involved the development of an individualized care plan to address past trauma, and to identify and decrease exposure to triggers that may re-traumatize the resident. Resident 55 was admitted to the facility on 9/2/25 with diagnoses including Post-Traumatic Stress Disorder (PTSD) and sleep terrors. Resident 55GÇÖs 9/11/25 Social Service History, Trauma, and Substance Use Disorder (SUD) Assessment indicated no trauma history. Resident 55GÇÖs 9/16/25 Admission Minimum Data Set (MDS) indicated the resident was cognitively intact and had a diagnosis of PTSD. No evidence was found in Resident 55GÇÖs clinical record to indicate an assessment of the residentGÇÖs trauma was completed or a care plan was developed to address the residentGÇÖs potential trauma triggers. In interviews on 12/15/25 at 9:58 AM and 12/16/25 at 1:31 PM in the residentGÇÖs room while she/he was in bed, Resident 55 stated she/he had a diagnosis of PTSD and experienced startle responses to loud noises that triggered increased respirations and pain levels. -á Resident 55 stated these symptoms were triggered when staff spoke loudly when waking the resident from sleep. On 12/17/25 at 12:07 PM Staff 7 (CNA) stated she was not aware of any trauma-related concerns for Resident 55 and was not aware of any triggers. On 12/17/25 at 12:27 PM Staff 5 (LPN) stated Resident 55 had a history of war-related trauma. Staff 5 was unaware of any issues for Resident 55 around loud noises. On 12/18/25 at 10:22 AM Staff 3 (LPN Resident Care Manager) confirmed Resident 55GÇÖs care plan did not include any information related to trauma or triggers. On 12/18/25 at 10:49 AM Staff 4 (Social Services Director) stated Resident 55 denied trauma during the 9/11/25 Social Service History, Trauma, and SUD Assessment. -á Staff 4 stated no further investigation of Resident 55GÇÖs trauma history was completed as Resident 55 answered no to the trauma question on the assessment. -á Staff 4 confirmed Resident 55GÇÖs care plan did not include information related to Resident 55GÇÖs diagnosis of PTSD, trauma history, or triggers.

Resident 55 had a Social Service History, Trauma, and SUD Assessment completed on 9/11/25 .  No triggers  identified .  Care Plan updated. All residents residing in the facility have the potential to be impacted by this deficiency. All social services and resident care managers will be in-serviced on trauma informed care policy and procedures, assessments, and care plan development. An initial  audit will be conducted of all residents with a diagnosis of PTSD or trauma to ensure assessments and care plan completion. To prevent further recurrence, DNS or designee will conduct an audit of new admissions to identify  if they have a diagnosis of PTSD or trauma and ensure that assessment and care plan are completed  per policy . Date of compliance: 1/22/2026

Resident 18 was admitted to the facility in 10/2025 with diagnoses including osteoporosis (condition which bones become weak and brittle) and muscle weakness. The Admission MDS Assessment 10/28/25 indicated Resident 18 required substantial assistance for bed mobility and transfer out of bed. Resident 18GÇÖs current Care Plan did not include the use of bed rails, and no evidence was found in the resident's clinical record an evaluation was completed for the use of bed rails.-á On 12/15/25 at 12:42 PM Resident 18 was observed in bed with bilateral quarter rails in the upright position. On 12/16/25 at 3:13 PM Staff 13 (CNA) stated she was aware Resident 18 had bilateral bed rails in place on her/his bed. Staff 13 was unable to locate an order or care plan supporting the use of bilateral bed rails. On 12/16/25 at 3:25 PM Staff 3 (LPN Care Manager) confirmed there was no physician order in place for Resident 18GÇÖs bilateral bed rails. Staff 3 acknowledged the bed rails should not have been in place without an order and stated this was an oversight on her part. Staff 3 further stated the use of bilateral bed rails for Resident 18 was not care planned.-á On 12/16/25 at 3:40 PM Staff 2 (DNS) stated his expectation was that prior to the use of bed rails, the resident would have a physician order in place, an assessment completed, and the care plan updated to reflect their use. Staff 2 confirmed appropriated steps were not completed prior to Resident 18's bed rails being in place.

Assistive Device Assessment and consent completed with the resident. Orders for side rails are obtained. Care plan updated. All residents residing in the facility have the potential to be impacted by this deficiency. All resident care managers and charge nurses will be in-serviced on mobility bars policies and procedures, orders, consent, and care plan. An initial  audit has been conducted for all residents  residing  in the facility with mobility bars ensuring consent, assessment,  orders  and care plan are in place. To prevent further recurrence, DNS or designee will conduct an audit of all new admissions for consent, assessment, orders, and care plan x 4 weeks and then monthly until substantial compliance. Date of compliance: 1/22/2026

Resident 3 was admitted to the facility in 11/2025 with diagnoses including Amyotrophic Lateral Sclerosis (ALS, a progressive and fatal neurological disorder that causes weakness, paralysis and respiratory failure). -á Resident 3's 11/10/25 Pharmacist's Admission Medication Regimen Review revealed the following recommendations:-á -Rivaroxaban (an anticoagulant medication that reduces the blood's clotting ability and places people at increased risk of bleeding) should be administered with food to increase its efficacy. -The resident should be monitored for signs and symptoms of bleeding due to her/his use of rivaroxaban.-á Resident 3's 12/1/25 Pharmacist's Medication Regimen Review recommended ""give with evening meal"" be added to the resident's physician orders for the rivaroxaban and/or adjust the medication's administration time if needed.-á Resident 3's 12/2025 Physician Orders directed the resident to receive rivaroxaban once daily at bedtime for a clotting event.-á No evidence was found in Resident 3's clinical record to indicate the resident was being monitored for signs and symptoms of bleeding or follow up to the pharmacist's recommendations was implemented. On 12/19/25 at 7:44 AM, Staff 21 (LPN) stated she was unfamiliar with rivaroxaban and was unaware Resident 3 received the medication. Staff 21 stated she did not know what the medication was used for, if it required monitoring or if it was to be administered with food.-á On 12/19/25 at 7:49 AM, Staff 24 (RN) stated she was unfamiliar with rivaroxaban and was unable to answer any questions about the medication without first ""looking it up."" Staff 24 stated residents who received an anticoagulant medication required monitoring and Resident 3 did not have monitoring in place for an anticoagulant. Staff 24 further stated any medication that needed to be administered with food should be notated in the resident's MAR/TAR and no such indication was noted in Resident 3's MAR/TAR for the rivaroxaban.-á On 12/19/25 at 8:31 AM, Staff 26 (LPN Resident Care Manager) stated Resident Care Managers followed up on recommendations from the pharmacist ""as quick as we can."" Staff 26 stated Resident 3 was supposed to be monitored for bleeding due to her/his anticoagulant use and confirmed she/he was not. Staff 26 further stated the pharmacist's recommendation to administer rivaroxaban with food did not need to be added to the resident's clinical record as the resident received continuous nutrition via a feeding tube.-á On 12/19/25 at 8:37 AM, Staff 2 (DNS) stated pharmacy recommendations were to be responded to within a week of receipt. Staff 2 stated Resident 3's physician orders should be updated to include ""not to be given on an empty stomach"" for the rivaroxaban and the resident's TAR and care plan should be updated to include anticoagulant monitoring.-á

Anticoagulant adverse side effect monitor placed for resident 3. All residents residing in the facility have the potential to be impacted by this deficiency. All resident care managers will be in-serviced on Medication Regimen Reviews policy and procedure. To prevent further recurrence, DNS or designee will conduct random audits weekly x4 weeks and then monthly x3 months to ensure timely  follow-up to the  pharmacist ’s  MRR. Results brought to QAPI monthly. Date of compliance: 1/22/2026

Resident 62 was admitted to the facility in 2/2025 with a diagnosis of heart failure. A review of physician orders revealed a 12/16/25 order for potassium chloride oral packet 20 MEQ give 2 packets twice a day and torsemide 100 mg, give 0.5 tablet twice a day. On 12/17/25 at 8:28 AM, Staff 34 (CMA) was observed to administer torsemide 100 mg and potassium chloride 20 MEQ, 1 packet. On 12/17/25 at 9:42 AM, Staff 34 confirmed Resident 34 had orders to administer torsemide 50 mg and potassium chloride 20 MEQ two packets. Staff 34 stated she was unaware the order changed and acknowledged she administered the wrong dose of torsemide and potassium chloride. On 12/19/25 at 8:45 AM, Staff 2 (DNS) stated staff are expected to administer medications per physician orders.

CMA responsible for medication errors was provided  with  a  write up and assigned SNF Clinic modules  regarding  medication administration All residents residing in the facility have the potential to be impacted by this deficiency. CMA responsible for medication errors was  provided with   a  write up and assigned SNF Clinic modules  regarding  medication administration. All certified medication administrators and charge nurses will be in-serviced on Facility expectations and best practices for medication administration. To prevent further recurrence, DNS or designee will conduct an  internal medication pass observation  of  one  CMA or Nurse ;  weekly x4 weeks and then monthly until substantial compliance. Date of compliance: 1/22/2026

On 12/16/25 at 9:56 AM, an expired bottle of vitamin B 12 was observed in the 100-hall medication cart. Staff 35 (CMA) confirmed the bottle of vitamin B 12 expired in 8/2025. On 12/18/25 at 1:29 PM two undated open vials of Tubersol were observed in the 200-hall medication room. Staff 3 (LPN Resident Care Manager) stated Tubersol was good for 30 days after opening. Staff 3 confirmed there was no open date on either open vial of Tubersol and stated there was no indication when the vials were open. On 12/18/25 at 1:41 PM, Staff 2 (DNS) stated medications must be destroyed when expired. Staff 2 stated Tubersol was good for 30 days after the vial was open and confirmed the two opened, undated vials of Tubersol had no indication of an open date and were to be destroyed.

Following survey  identifying  expired  medications,  the RCM audited the medication cart, medication room, and fridge and pulled all expired medications All residents residing in the facility have the potential to be impacted by this deficiency. All charge nurse s  and CMAs will be in-serviced on medication labeling and storage. To prevent further recurrence, DNS or designee will conduct an audit of one medication cart weekly for expired medications and unlabeled medications x 4 weeks and then monthly until substantial compliance. Date of compliance: 1/22/2026

Resident 68 admitted to the facility in 10/2019 with diagnoses including congestive heart failure and dysphagia (difficulty swallowing foods or liquids). The 9/14/25 Quarterly MDS indicated Resident 68 had severe cognitive impairment. Resident 68GÇÖs physician order dated 1/7/25 revealed she/he required oxygen as needed. On 12/17/25 at 8:57 AM Resident 68GÇÖs oxygen cannula and tubing were observed on the floor next to her/his bed. On 12/17/25 at 9:04 AM Staff 12 (RN) was observed to provide care for Resident 68. After the provision of care, Staff 12 was observed to pick up the residentGÇÖs nasal cannula and oxygen tubing from the floor. Staff 12 wiped the nasal cannula with an alcohol wipe and placed the nasal cannula and tubing on the residentGÇÖs bed. On 12/17/25 at 9:12PM Staff 12 stated when Resident 68GÇÖs nasal cannula and oxygen tubing were found on the floor; her process was to wipe the nasal cannula with an alcohol wipe to disinfect it before placing it back on the resident or on the residentGÇÖs bed. On 12/17/25 at 12:39 PM Staff 11 (Infection Preventionist) and Staff 14 (Regional Infection Preventionist) stated oxygen tubing and nasal cannulas found on the floor were considered contaminated. Staff 14 stated the tubing and nasal cannula should not have been wiped with an alcohol wipe and reused but should have been discarded and replaced. Staff 14 further stated wiping equipment with an alcohol wipe did not meet infection prevention standards.-á

Staff 12 was  immediately  educated on infection control practices for respiratory care equipment following t he incident.   Nasal  cannula  was replaced . All residents residing in the facility have the potential to be impacted by this deficiency. All charge nurses and certified nursing assistants will be in-serviced on appropriate infection  control practices for   respiratory care equipment . To prevent further recurrence, DNS or designee will conduct an audit  of 3 random residents on oxygen weekly x4 weeks and then monthly until  substantial  compliance  is achieved . Date of compliance: 1/22/2026

1. Review of Respiratory Therapist Staffing Assignments from 11/2/25 through 12/15/25 revealed Respiratory Therapist staffing did not meet a maximum ratio of one Respiratory Therapist per 12 residents for the following dates and times: 11/12/25 from 12:00 AM to 6:30 AM. 11/23/25 from 7:00 PM to 10:30 PM. 12/2/25 to 12/3/25 from 6:30 PM to 6:30 AM. 12/10/25 from 4:30 AM to 6:30 AM. 12/13/25 from 7:00 AM to 12:30 PM. On 12/17/25 at 11:59 AM Staff 9 (Respiratory Therapist Manager) reviewed the Respiratory Therapy Staffing Assignments and acknowledged the failure to assign no more than one Respiratory Therapist per 12 residents for the above dates and times. On 12/17/25 at 3:08 PM Staff 1 (Administrator) confirmed the insufficient Respiratory Therapist coverage on the Ventilator Assisted Unit.-á 2. Review of the DCSDRs for the Ventilator Assisted Unit from 11/1/25 through 12/15/25 revealed the reports did not include Respiratory Therapists as part of the posted daily staff responsible for care of ventilator dependent residents. On 12/17/25 at 2:11 PM Staff 30 (Staffing Coordinator) acknowledged the DCSDRs for the Ventilator Assisted Unit did not include Respiratory Therapists and the number of daily Respiratory Therapists on duty was not posted anywhere in the building. On 12/17/25 at 3:08 Staff 1 confirmed the DCSDRs did not include Respiratory Therapists.

No Residents were identified as affected by this tag. All Vent/Trach Residents could have been affected had there been an emergency that required two Respiratory therapists to be present. Daily Staffing sheets will be posted with Respiratory Therapists hours working by shift for the Vent Unit. The Administrator or the designee will ensure that all posted Daily staffing sheets in the Vent unit have the Respiratory Therapists hours by shift posted. This will be completed daily for one week, then once a week for a month. Additional Respiratory therapist PRN staffing have been hired to assist with unplanned call offs and any emergency situations. If PRN staff are unavailable to provide coverage the R/T Director will provide coverage until replacement staff can be brought in. The Administrator or designee will ensure compliance DOC: 1/22/2026

Resident 1 admitted to the facility on 9/2025, with diagnoses including seizures and respiratory failure. -á A 9/22/25 Physician Order noted felbamate (an anti-seizure medication) was to be administered twice a day for seizures.-á A 9/24/25 Progress Note noted staff were working on obtaining Resident 1GÇÖs anti-seizure medication and that there were complications with receiving the medication, which as not delivered until 9/25/25. -á Resident 1's 9/2025 MAR indicated the resident's felbamate medication was not administered until 9/25/25 (three days, and five doses after the order date of 9/22/25).-á On 10/22/25 at 8:56 AM, Staff 3 (Resident Care Manager) stated orders were not reviewed and staff missed the nurses struggle to obtain the medication from the pharmacy. Staff 3 also stated the pharmacy did not have the medication felbamate on hand and struggled to obtain the medication as well.-á On 10/22/25 at 10:22 AM, Staff 5 (Director of Respiratory therapy) stated they were not a nurse and does not review newly admitted residents' medications. Staff 5 stated when Staff 3 was not available, a nurse or the DNS would review medications for new admits. Staff 5 confirmed this did not occur.-á On 10/22/25 at 10:41 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 1's medication was not administered timely and there continue to be pharmacy difficulties that still needed to be addressed.-á-á

Affected resident was admitted to the facility after regular pharmacy hours on September 22, 2025. Facility staff made multiple, persistent attempts to obtain prescribed seizure medication, Felbamate, from the primary pharmacy. The pharmacy experienced delays in processing billing permissions, did not have the specific medication in stock, and failed to meet multiple STAT delivery commitments likely contributed to the rare use of this medication. This resulted in the resident missing five scheduled doses of Felbamate between admission and September 25, 2025 when home supply was received by staff. Facility staff contacted provider and were able to secure an order and administer alternative medication while awaiting Felbamate. Resident has since discharged from the facility, however all residents have the potential to be affected DNS and RCM to be in-serviced on pharmacy process, procedures and and trouble shooting when obtaining medications All Nursing staff will be in-serviced on the pharmacy process and procedures for obtaining medications Facility wide audit will be conducted for all anti-convulsant medications to ensure stock on hand RCMs will review all new admissions next business day to confirm all medications have been received- DNS will audit weekly X 4, then monthly X 3 or until back in compliance DOC: 12/12/2025

Based on interview and record review it was determined the facility failed to ensure residents received treatment and services necessary to prevent constipation for 1 of 3 sampled residents (#100) reviewed for bowel care. This failure resulted in the resident experiencing no bowel movements for seven days, which led to the need for emergency department evaluation and treatment due to a fecal impaction (a severe form of constipation where a large, hard mass of stool becomes lodged in the colon or rectum, preventing normal bowel movements). The facility's Bowel Management policy dated 4/2025 indicated the following: -Resident's bowel movements were recorded daily and reviewed by the licensed nurse. -If a resident had no bowel movement for six 12 hour shifts (three days) or nine eight hour shifts (three days) or within their routine bowel pattern, the facility bowel program would be initiated and the resident would be placed on the laxative list. -If the facility bowel program was not effective within 24 to 32 hours of the resident being placed on the bowel list, the licensed nurse would notify the resident's physician and request further orders. Resident 100 was admitted to the facility on 5/19/25 with diagnoses including central cord syndrome (an incomplete spinal cord injury which the spinal cord's ability to transmit messages to or from the brain is damaged) and toxic encephalopathy (a neurological disorder characterized by altered mental status, cognitive impairments, memory loss, personality and behavioral changes). Resident 100's 5/23/25 Admission MDS indicated the resident had severe cognitive impairments, was incontinent of bowel and required substantial to maximal assistance for toileting. Resident 100's 5/19/25 through 5/31/25 Oral Intake monitor indicated the resident ate between zero to 75% of meals until 5/26/25 when her/his intakes declined consistently to zero to 25%. Resident 100's 5/19/25 through 5/31/25 MAR indicated the resident was prescribed polyethylene glycol (laxative) one time in the morning for constipation and sennosides (stimulant laxative) one time in the morning and at bedtime for constipation. According to Resident 100's MAR, the resident accepted the prescribed polyethylene glycol on 12 out of 12 administration attempts and the sennosides on 18 out of 24 administration attempts. Resident 100's 5/19/25 through 5/31/25 Bowel Records indicated the resident had no bowel movements on the following days. -5/25/25; -5/26/25; -5/27/25; -5/28/25; -5/29/25; -5/30/25 and -5/31/25. A review of Resident 100's electronic health record indicated no evidence the resident's medical provider was notified of Resident 100's lack of bowel movements and no new orders for bowel care interventions were prescribed prior to 5/31/25. A 5/31/25 progress note written at 2:29 PM, indicated Resident 100 had not had a bowel movement since 5/24/25 [seven days] and continued to refuse to eat and drink so the resident's on-call provider was contacted and orders were obtained to send Resident 100 to the emergency department for evaluation and treatment. A 5/31/25 progress note written at 11:29 PM, indicated Resident 100 returned to the facility with new prescriptions for a UTI (an infection affecting the urinary system) and constipation. Resident 100's 5/31/25 CT Scan (a diagnostic imaging procedure) of the abdomen and pelvis revealed a large/copious amount of stool seen throughout the colon and rectum with significant rectal distention due to fecal impaction. Resident 100's Emergency Department's After Visit Summary indicated the resident was diagnosed and treated for slow transit constipation, dehydration and a UTI. On 6/16/25 at 9:04 AM, Staff 18 (LPN) reported a resident should not go more than two or three days without a bowel movement. Staff 18 stated three days with no bowel movement was the maximum and after three days the bowel protocol would be initiated. Staff 18 stated if there was no bowel movement after administering the bowel protocol (PRN medication or enema depending on the physician orders) then the medical provider should be contacted for additional instructions and orders. Staff 18 stated the facility was very strict on following the bowel protocol and if a resident did not have a bowel movement for seven days, that would be "a very serious issue." On 6/16/25 at 11:15 AM, Staff 16 (LPN) stated each morning she checked the daily bowel list to determine which residents had not had a bowel movement for three days. Staff 16 stated the resident would be assessed by the nurse and a PRN bowel medication (in addition to the resident's routine bowel medications) would be administered to the resident. Staff 16 stated if there was still no bowel movement, she would contact the medical provider for further direction and interventions. On 6/16/25 at 1:43 PM and 6/17/25 at 2:53 PM, Staff 3 (RNCM) stated on 5/28/25, Resident 100 "triggered" on the daily bowel list. She reported the resident did not consistently eat or drink and refused her/his bowel medications at times. Staff 3 reported when a resident did not have a bowel movement for three full days, there would be a "go to" bowel medication depending on the resident's physician order and if the resident still did not have a bowel movement, the medical provider would be called for further orders. Staff 3 stated Resident 100 had no bowel movements since 5/24/25. Staff 3 reviewed Resident 100's bowel records and stated staff should have contacted the resident's medical provider on 5/28/25, 5/29/25 and 5/30/25 since the resident had not had a bowel movement for several days. Staff 3 stated on 5/31/25, Resident 100 was sent to the emergency department for evaluation and treatment. On 6/17/25 at 12:04 PM, Staff 9 (LPN) stated when residents did not have a bowel movement for three days, she would notify the medical provider to get further instructions. Staff 9 stated she cared for Resident 100 on 5/28/25 but was unable to recall if she contacted the resident's medical provider to notify them the resident did not have a bowel movement for four days. On 6/17/25 at 12:25 PM, Staff 8 (LPN) reviewed Resident 100's bowel records and reported on 5/28/25, Resident 100 should have been given a PRN bowel medication and the resident's medical provider should have been notified. Staff 8 stated she had been the assigned day nurse for Resident 100 on 5/29/25 and 5/30/25. She stated the resident's medical provider should have been notified of the resident's lack of bowel movements for the previous five and six days, respectively. However, she was unable to recall whether she had contacted the provider, and there was no documentation in the electronic health record indicating the provider was contacted. On 6/17/25 at 9:58 AM, Staff 4 ( Nurse Practitioner) stated he was the primary medical provider for managing Resident 100's medical care. Staff 4 stated he had not been "involved much" with the resident but she/he had significant cognitive deficits and was "sundowning." Staff 4 stated he was also aware Resident 100 was not eating or drinking and refused medications. Staff 4 stated he was unaware Resident 100 had no bowel movements from 5/25/25 through 5/31/25 (seven days). Staff 4 stated nursing staff usually communicated with him via an SBAR (a communication tool which stands for Situation, Background, Assessment and Recommendations) but he was unaware of any communications related to Resident 100's constipation prior to 5/31/25. Staff 4 stated Resident 100 was not eating or drinking much thus he would not have expected the resident to have bowel movements so there would have been no interventions needed. On 6/17/25 at 2:53 PM, Staff 2 (Interim DNS) confirmed Resident 100 had no bowel movements from 5/25/25 through 5/31/25. Staff 2 stated nursing staff should have contacted the resident's medical provider on 5/28/25 to notify them of the resident's bowel status and obtained orders for a PRN bowel medication. She confirmed nursing did not contact the medical provider on 5/28/25. Staff 2 reported nursing should have contacted the medical provider on 5/29/25 and 5/30/25, as the resident had gone several days without a bowel movement. She confirmed Resident 100's medical provider was not contacted regarding the resident's lack of bowel movements. Staff 2 further stated on 5/31/25, Resident 100 required emergency evaluation and treatment for a fecal impaction.

Resident #100 has been discharged from the facility. Residents who reside in the facility are at potential risk for this deficient practice. Facility residents audited for the most recent bowel movement and bowel protocol intervention if needed. Staff re-education completed regarding quality of care and bowel management policy. To ensure ongoing compliance, DNS/designee will perform random audits weekly x 4 weeks, monthly x 2 months. Results of audits will be brought to QAPI for review.

********************* 411-086-0110 Nursing Services: Resident Care Refer to F684 *********************

Based on interview and record review it was determined the facility failed to inform residents and/or resident's responsible party of the risks and benefits, and to ensure consent was obtained for the use of psychotropic medications for 3 of 5 sampled residents (#s 14, 26, and 66) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent. Findings include: 1. Resident 66 was admitted to the facility in 7/2024 with diagnoses including major depressive disorder. Resident 66's 7/20/24 Physician Order indicated the resident was prescribed citalopram hydrobromide (antidepressant medication) to be taken each morning related to major depressive disorder. Resident 66's 8/2024 MAR revealed the resident received citalopram hydrobromide, daily. Review of Resident 66's health record revealed no documentation to indicate the resident or her/his representative was informed of the risks and benefits of citalopram hydrobromide and no evidence the resident consented to receive the medication until 8/27/24. On 8/28/24 at 2:23 PM Staff 7 (LPN-Care Manager) reported it was the nursing staff's responsibility to review the risks and benefits of psychotropic medications with residents prior to residents taking the medications and confirmed Resident 66 received citalopram hydrobromide without consent being obtained prior to administration. , 2. Resident 26 was admitted to the facility in 1/2020 with diagnoses including depression and anxiety. Resident 26's 8/4/22 Physician Order indicated the resident was prescribed aripiprazole (antidepressant medication) to be taken at bedtime related to depression. Resident 26's 8/2024 MAR revealed the resident received aripiprazole, daily. Review of Resident 26's health record revealed no documentation to indicate the resident or her/his representative was informed of the risks and benefits of aripiprazole and no evidence the resident consented to receive the medication until 8/27/24. On 8/28/24 at 2:23 PM Staff 7 (LPN-Care Manager) reported it was the nursing staff's responsibility to review the risks and benefits of psychotropic medications with residents prior to residents taking the medications and confirmed Resident 26 received aripiprazole without consent being obtained prior to administration. , 3. Resident 14 was admitted to the facility in 7/2024 with diagnoses including anxiety disorder and major depressive disorder. The 8/2024 MAR revealed Resident 14 received Fluoxetine (an antidepressant) daily. A review of the Psychotropic Disclosure and Consent dated 7/12/24 revealed no verbal or written consent for Fluoxetine. No information was found in the resident record which showed the risks and benefits of the medication's use was reviewed with Resident 14 prior to administration. On 8/30/24 at 10:27 AM Staff 3 (RCM) verified the Consent date 7/12/24 did not include Fluoxetine. Staff 3 stated the resident should have received a consent with a review of the risks and benefits of Fluoxitine.

Psychotropic consents were not obtained prior to administration of medications. This affected Residents #14, 26, 66 who still reside in the facility. Consents obtained for the above Residents. All Residents who receive psychotropic medications are at risk. Baseline Audits completed to identify Residents who are currently receiving psychotropic medications to ensure consents were obtained. Re-Education provided to LN staff on Obtaining Consents prior to administration of all psychotropic medications. (On Admission, New Prescriptions) Continued Audits of Consents of Psychotropic medications will be performed by designated RCM weekly x4 then monthly x2 for ongoing compliance. Results will be brought to QAPI for review. DNS or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 2 of 2 sampled residents (#s 42 and 44) reviewed for hospitalizations. This placed residents at risk for lack of information regarding their options, rights and lack of advocacy from the Ombudsman Office. Findings include: 1. Resident 44 was admitted to the facility in 11/2022 with diagnoses including chronic respiratory failure (a condition resulting in the inability to effectively exchange carbon dioxide and oxygen in the body) and quadriplegia (paralysis that effects the torso and all four limbs). A review of Resident 44's health record revealed she/he was transferred to the hospital on 3/19/24, 6/19/24 and 7/15/24. No evidence was found in Resident 44's health record to indicate a transfer notice with appeal rights was provided in writing to her/him upon transfer to the hospital or that the Office of the State Long-Term Care Ombudsman was notified of the resident's transfers to the hospital. On 8/29/24 at 1:40 PM Staff 25 (Social Service Director) indicated she was not aware the Office of the State Long-Term Ombudsman had to be notified when residents were transferred to the hospital or discharged from the facility. On 8/29/24 at 2:40 PM Staff 26 (Social Service Director) indicated she was aware the Office of the State Long-Term Ombudsman needed to be notified when residents transferred to the hospital or discharged from the facility but she did not know which facility staff was responsible for this. On 8/30/24 at 9:36 AM Staff 1 (Administrator) confirmed transfer notices with appeal rights were not being provided to residents when they transferred to the hospital and the Office of the State Long-Term Care Ombudsman was not being notified when residents transferred to the hospital or discharged from the facility. , 2. Resident 42 was admitted to the facility in 3/2024 with diagnoses including chronic respiratory failure. A review of Resident 42's health record revealed the resident was sent to the hospital on 5/29/24, 6/12/24, 7/11/24 and 8/23/24. No evidence was found in Resident 42's health record to indicate transfer notices with appeal rights were provided in writing to her/him and their representatives or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfers to the hospital. On 8/30/24 at 9:34 AM Staff 6 (LPN) stated he did not provide residents or their representatives with transfer notices with appeal rights in writing at the time of a resident transfer. On 8/30/24 at 10:05 AM Staff 26 (Social Services Director) stated she did not provide residents or their representatives with transfer notices with appeal rights in writing at the time of a resident transfer or notify the Office of the State Long-Term Care Ombudsman of resident transfers or discharges. On 8/30/24 at 10:27 AM Staff 1 (Administrator) confirmed the facility did not provide written transfer notices with appeal rights to residents or their representatives following a resident transfer or inform the Ombudsman of resident transfers and discharges.

Failure to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations. This affected residents #42, 44. Both still reside in the facility. All Residents who have transferred/discharged from the facility are at risk. Inservice Education was provided to LN staff regarding the new Transfer/Discharge Process on 9/24/2024. Implementation of SNF Nursing Home Transfer or Discharge Notice for LN to complete prior to Resident transfers to acute care hospital. Documentation that the written notice of transfer was given to resident to be documented in progress notes. Social Services will notify the Office of the State Long-Term Care Ombudsman monthly of all transfers/discharges from the facility. Rehospitalization Audits will be completed weekly x4, then Monthly x2. DNS or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 2 of 2 sampled residents (#s 42 and 44) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: 1. Resident 44 was admitted to the facility in 11/2022 with diagnoses including chronic respiratory failure (a condition resulting in the inability to effectively exchange carbon dioxide and oxygen in the body) and quadriplegia (paralysis that effects the torso and all four limbs). A review of Resident 44's health record revealed she/he was discharged to the hospital on 3/19/24, 6/19/24 and 7/15/24. No evidence was found in Resident 4's health record to indicate written notice of the facility's bed hold policy was provided to Resident 44 when she/he was transferred to the hospital on 3/19/24, 6/19/24 or 7/15/24. On 8/27/24 at 2:30 PM Staff 26 (Social Service Director) stated she was unfamiliar with the bed hold policy and how to complete it. She stated a written bed hold policy was not provided to Resident 44 upon her/his transfer to the hospital on 3/19/24, 6/19/24 or 7/15/24. On 8/30/24 at 9:36 AM Staff 1 (Administrator) confirmed a written bed hold policy was not provided to Resident 44 when she/he was transferred to the hospital on 3/19/24, 6/19/24 or 7/15/24. , 2. Resident 42 was admitted to the facility in 3/2024 with diagnoses including chronic respiratory failure. A review of Resident 42's health record revealed the resident was sent to the hospital on 5/29/24, 6/12/24, 7/11/24 and 8/23/24. No evidence was found in Resident 42's health record to indicate written notice of the facility's bed hold policy was provided to the resident or their representative on 5/29/24, 6/12/24, 7/11/24 or 8/23/24. On 8/30/24 at 9:34 AM Staff 6 (LPN) stated he did not provide residents or their representatives with a copy of the facility's bed hold policy at the time of a resident transfer. On 8/30/24 at 10:14 AM Staff 1 (Administrator) acknowledged these findings and confirmed the facility did not provide residents or their representatives with any written notification of the facility's bed hold policy at the time of a resident transfer.

Failure to provide Residents with a written notice of the facilities bed hold policy at the time of transfer to the hospital. Residents affected are #42, 44 All Residents who have been transferred out of the facility are at risk. Inservice Education was provided to LN staff regarding the new Transfer/Discharge Process on 9/24/2024. Implementation of written copy of Bed Hold will be presented/given to Resident on Transfer to acute care hospital. Documentation that the bed hold was given to resident to be completed in progress notes. Social Services will notify family of Bed Hold next business day after transfer to acute care hospital. Rehospitalization Audits will be completed weekly x4, then Monthly x2. Social Services Director or designee will be Responsible for ongoing compliance.

Based on record review and interview it was determined the facility failed to complete MDS assessments which reflected accurate mental health diagnoses for 1 of 5 sampled residents (#33) reviewed for unnecessary medications. This placed residents at risk for inaccurate assessment and care. Findings include: Resident 33 was readmitted in 10/2023 with diagnoses including generalized anxiety disorder and major depressive disorder-recurrent. A 3/13/24 physician's note (internal medicine) identified the resident reported significant anxiety and depression with psychiatric treatment in the past. Resident 33 did not recall the use of antipsychotic medication. The physician suggested a diagnosis of schizoaffective disorder (a chronic mental health disorder characterized by symptoms of both schizophrenia and mood disorder) but it was unclear if the resident met the diagnostic criteria. Further consultation with a colleague was planned. On 3/14/24, a diagnosis of schizoaffective disorder, depressive type was entered in the medical record. According to the record, the diagnosis was made by Staff 34 (Former Nurse Practitioner). There was no evidence in the medical record a mental health practitioner was involved when determining the diagnosis or that the resident met the criterion for schizoaffective disorder. The 4/2024 Pharmacy Review identified the resident had no history of schizoaffective disorder and the diagnosis was inappropriate. On the 5/8/24 Significant Change MDS and the 8/6/24 Quarterly MDS, Schizophrenia was coded in Section I. The medical record did not support the coding of this diagnosis. On 8/29/24 at 2:46 PM, Staff 2 (DNS) stated there was no evidence in the medical record that a mental health professional was involved in the diagnosis of the resident and the diagnosis had been questioned by both the pharmacist and physician. Staff 2 acknowledged the diagnosis should not have been coded on the MDS.

MDS assessments failed to reflect accurate mental health diagnoses. Resident affected #33 who still resides in the facility. On 3/14/24 the Physician suggested a diagnosis of schizoaffective disorder, but it was unclear if the resident met the diagnostic criteria. Notifications made to Rogue Valley Psych with request for resident #33 to be seen on next visit regarding new Diagnosis of Schizoaffective Disorder, Depressive Type. Resident will also be discussed at next Psychotropic Review with IDT, Pharm, PCP, and Rogue Valley Psych. This is scheduled for Oct 14th 2024. All Residents who receive a new mental health diagnosis without involvement of a mental health practitioner are at risk. IDT, Pharm, PCP, and Rogue Valley Psych will be involved in monthly meetings going forward to ensure Psych input/diagnosis review. Continued Audits of antipsychotic usage will be performed by designated RCM weekly x4 then monthly x2 for ongoing compliance. DNS or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to ensure a baseline care plan was sufficient to meet the needs of a resident admitted with a pressure injury for 1 of 2 sampled residents (#173) reviewed for pressure ulcers. This placed residents at risk for a delay in treatment. Findings include: Resident 173 was admitted to the facility in 8/2024 with diagnoses including recent onset of paralysis of the lower extremities and a documented history of pressure injury to the sacrum that occurred during hospitalization. A Hospital History and Physical dated 8/16/24 indicated Resident 173 had a "new pressure injury to sacrum" (area above the tailbone) found on 8/14/24. The wound was described as an "intact, discolored DTI" (deep tissue Injury). Treatment included protective ointment, a foam dressing, frequent repositioning and pressure reduction. Documentation on the facility Clinical Admission Form dated 8/21/24 did not identify the presence of the wound on the resident's sacrum. Resident 173's Initial Care Plan dated 8/22/24 did not identify the presence of an actual pressure injury. A Care Plan focus area related to potential impairment to skin integrity related to immobility was initiated on 8/26/24, five days after admission. On 8/27/24 at 10:53 AM Staff 4 (LPN) stated she completed the resident's admission but was unable to visualize the resident's sacrum at that time. Staff 4 confirmed she received information regarding a pressure wound in a report received from the hospital. On 8/28/24 at 3:54 PM Staff 2 (DNS) and Staff 3 (LPN, Resident Care Manager) stated the Baseline Care Plan was derived from data entered on the Clinical Admission Form. Resident 173 refused a full assessment at the time of admission. The refusal was not documented and the next shifts did not follow up.

Failure to Implement of Baseline Care Plans that was sufficient to meet the needs of a resident admitted with a pressure injury placing resident at risk for delay in treatment. Resident affected #173 who still resides in the facility. Facility implemented baseline care plan reflective of pressure injury, including use of air mattress, turn/position program, wound treatment orders and followed by United Wound Healing. All Residents who admit with pressure related injuries are at risk. Inservice of Skin & Wounds on Admission Completed 8/27/2024 @1300, Educator Jailee Head, RN Inservice Baseline Care Plan Training Scheduled 9/20/2024 @ 11:00, Educator Sarah Lewis Inservice to LN staff on Admission Process and Baseline Care Plan Implementation, LN must provide Resident/Representative with baseline Care Plan & Progress Note once completed. Continued Admission Audit Reviews will be performed by designated RCM weekly x4, then monthly for ongoing compliance. DNS or designee will be responsible for ongoing compliance.

Based on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately to reflect the needs of residents for 3 of 7 sampled residents (#s 19, 66 and 67) reviewed for accidents, care plans and nutrition. This placed residents at risk for unmet needs. Findings include: 1. Resident 19 admitted to the facility in 11/2017 with diagnoses including dysphagia (difficulty swallowing) and epilepsy (seizure disorder). A Care Plan initiated on 3/3/21 revealed Resident 19 used bilateral fall mats related to risk of injury from seizure activity and was to be shaved daily. A 8/16/24 Quarterly MDS revealed Resident 19 had severe cognitive impairment. Observations on 8/28/24 from 8:00 AM to 3:00 PM revealed Resident 19 did not have bilateral fall mats in place in her/his room while the resident was in bed and she/he had facial hair growth that was a quarter to half an inch long. On 8/28/24 at 12:29 PM Staff 5 (CNA) stated Resident 19 was to have bilateral fall mats in place at all times. Staff 5 also stated he did not shave Resident 19 on a daily basis. On 8/28/24 at 12:44 PM Staff 3 (LPN-Resident Care Manager) stated Resident 19 no longer required bilateral fall mats and was not to be shaved daily. Staff 3 stated Resident 19's family assisted the resident with shaving or staff took care of it on her/his shower days. Staff 3 stated she expected the care plan to accurately reflect Resident 19's current needs. , 2. Resident 66 was admitted to the facility in 7/2024 with diagnoses including compression of the brain. Resident 66's 8/26/24 Care Plan indicated the following: -The resident was to wear a protective helmet when out of bed as tolerated related to the surgical wound to her/his scalp. -Staff were to ensure the resident's helmet was on when she/he was out of bed as the resident was at risk to fall. -The resident was to wear a helmet when out of bed and when sitting at the edge of the bed related to her/his ADL performance deficit. On 8/27/24 at 9:04 AM the resident was observed to sit in her/his wheelchair in her/his room. The resident's protective helmet was on top of her/his bedside table. On 8/30/24 at 9:13 AM Staff 5 (CNA) stated Resident 66 wore her/his helmet when she/he was in her/his wheelchair. Staff 5 further stated she obtained information about when the resident wore her/his helmet in the resident's care plan. On 8/30/24 at 11:07 AM Staff 7 (LPN-Care Manager) stated she needed to review the physician's orders to determine which intervention was appropriate for the resident's care plan. On 8/30/24 at 11:19 AM Staff 2 (DNS) acknowledged the findings of this investigation and stated Resident 66's care plan was in need of revision. 3. Resident 67 was admitted to the facility in 7/2024 with diagnoses including acute kidney failure. Resident 67's 7/5/24 Admission MDS indicated the resident was cognitively intact. Resident 67's 7/12/24 Care Plan indicated the resident received dialysis treatments three times weekly. On 8/29/24 at 10:57 AM Resident 67 stated she/he was on dialysis when she/he came to the facility but had been off of dialysis "for weeks." On 8/30/24 at 11:15 AM Staff 2 (DNS) stated Resident 67's care plan should have been revised in 7/2024 when she/he stopped receiving dialysis treatments.

Failure to ensure care plans were revised accurately to reflect the needs of Resident. This affected Residents #19, 66, 67. Resident #67 no longer resides in the facility. Care Plans Revised for above residents to reflect Resident specific care needs. All Residents who reside in the facility are at risk. Inservice of Comprehensive Care Planning October 3rd Thursday with All RCMs completing Care Plans. Continued Care Plan Revisions will be performed by designated RCMs for ongoing compliance. Complete care plan reviews will be completed quarterly and revisions will be updated as the needs of the resident changes or new orders are obtained. DNS or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to ensure 1 of 1 Nurse Practitioner's (Former Staff 34) diagnostic practices were confined to his specified clinical discipline. This placed residents at risk for diagnosis by unqualified staff. Findings include: According to OAR 851-050-0005, Nurse Practitioner Scope of Practice: (7)The nurse practitioner is responsible for recognizing limits of knowledge and experience, and for resolving situations beyond his/her nurse practitioner expertise by consulting with or referring clients to other health care providers. (8)The nurse practitioner will only provide health care services within the nurse practitioner's scope of practice for which he/she is educationally prepared and for which competency has been established and maintained. Educational preparation includes academic coursework, workshops or seminars, provided both theory and clinical experience are included. (9)The scope of practice as previously defined is incorporated into the following specialty categories and further delineates the population served: (d)Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP): Independently provides comprehensive primary health care for adolescents to the older adults; Resident 33 was readmitted to the facility in 10/2023 with diagnoses including generalized anxiety disorder and major depressive disorder-recurrent. A 3/13/24 physician's note (internal medicine) identified the resident reported significant anxiety and depression with psychiatric treatment in the past. Resident 33 did not recall the use of antipsychotic medication. The physician suggested a diagnosis of schizoaffective disorder (a chronic mental health disorder characterized by symptoms of both schizophrenia and mood disorder)might be appropriate but it was unclear if the resident met the diagnostic criteria. Further consultation with a colleague was planned. On 3/14/24, a diagnosis of schizoaffective disorder, depressive type was entered in the medical record. The diagnosis was made by the Staff 34 (Former Nurse Practitioner). Staff 34 was accredited as an AGNP (Adult-Gerontology Primary Care Nurse Practitioner). There was no evidence a mental health practitioner was involved when determining the diagnosis. The same day, quetiapine (an antipsychotic medication) was ordered related to the diagnosis of schizoaffective disorder. A 4/3/24 Pharmacy Review noted "65 year old patient's Seroquel [quetiapine] was increased to 400 mg daily for schizoaffective disorder. Patient has NO HISTORY OF schizoaffective disorder.... Use of the diagnosis of schizoaffective disorder is INAPPROPRIATE for this patient ..." A 6/17/24 Pharmacy Review noted no response had been provided in regards to the April recommendations. At the time of survey, the diagnosis of schizoaffective disorder remained on Resident 33's active diagnoses list. On 8/9/24 at 2:47 PM, Staff 2 (DNS) stated the diagnosis of schizoaffective disorder had been made by Staff 34 and she could find no evidence a mental health professional had been involved when determining the diagnosis. Staff 2 was aware the diagnosis had been questioned by the pharmacist and the physician, but could provide no additional follow up to their concerns. Staff 34 no longer worked in the facility.

Nurse Practitioner Diagnostic Practices were not Confined to his specified clinical discipline. Resident #33 Received new Diagnosis of Schizoaffective Disorder, Depressive Type with no evidence of an overseeing mental health practitioner. Notifications made to Rogue Valley Psych with request Resident #33 to be seen on next visit regarding new Diagnosis of Schizoaffective Disorder, Depressive Type. Resident will also be discussed at next Psychotropic Review with IDT, Pharm, PCP, and Rogue Valley Psych. This is scheduled for Oct 14th 2024. All Residents who receive a new mental health diagnosis without involvement of a mental health practitioner are at risk. Staff 34 is no longer overseeing residents at the facility. RCMs educated on need for psych consultation for all new diagnosis of schizophrenia and that psych services will be involved in all monthly psychotropic medication reviews to ensure proper diagnosis. Education to be completed on 10-3-2024. IDT, Pharm, PCP, and Rogue Valley Psych will be involved in monthly meetings going forward to ensure Psych input/diagnosis review. Continued Audits of antipsychotic usage will be performed by designated RCM weekly x4 then monthly x2 for ongoing compliance. DNS or designee will be responsible for ongoing compliance.

Based on observation, interview and record review it was determined the facility failed to initiate treatment for a pressure injury present upon admission for 1 of 2 sampled residents (#173) reviewed for pressure ulcers. The wound progressed from a DTI (deep tissue injury) to unstageable and required medical intervention for debridement. Findings include: Resident 173 was admitted to the facility on 8/21/24 with diagnoses including recent onset of paralysis of the lower extremities, diabetes, obesity, and a documented history of pressure injury to the sacrum that occurred during hospitalization. A Hospital History and Physical dated 8/16/24 indicated Resident 173 had a "new pressure injury to sacrum" (area above the tailbone) found on 8/14/24. The wound was described as an intact, discolored DTI (deep tissue injury). Treatment included protective ointment, a foam dressing, frequent repositioning and pressure reduction. The admission orders to the facility did not include orders for wound care. The facility Clinical Admission form dated 8/21/24 did not identify the presence of the wound to the resident's sacral area. A Braden Scale (standard form used to determine level of risk for developing pressure ulcers) dated 8/21/24 identified the resident to have no sensory perception impairment although resident had a spinal cord injury with paralysis from the waist down. The form indicated the resident had "slightly limited mobility and a potential problem with friction and shearing." Resident 173's Care Plan was revised on 8/22/24 to indicate the need for the extensive assistance of two persons for bed mobility, bathing and toileting. The resident had an indwelling urinary catheter and was incontinent of bowel. The care plan was updated on 8/26/24 to include a focus area for potential skin impairment related to immobility. On 8/26/24 a therapy note indicated OT and PT collaborated with nursing staff regarding [the resident's] sacral wound. On 8/27/24 at 10:53 AM Staff 4 (LPN) confirmed she completed the resident's Clinical Admission form but was unable to visualize the resident's sacrum at that time. Staff 4 stated she received information regarding the wound in a report received from the hospital. She visualized the pressure injury on 8/26/24 and described it as "crusted over and greenish" and with an adjacent superficial open area. Resident 173 was scheduled to be seen by the facility wound nurse, who would recommend treatment. Staff 4 confirmed there were no current orders for treatment. On 8/27/24 the facility's certified wound specialist, Staff 6 (LPN) assessed the wound and initiated treatment. There was no documented evidence in the resident's record to indicate treatment was initiated prior to 8/27/24. On 8/27/24 at 10:57 AM Staff 6 stated Resident 173 had two wounds, one to her/his sacrum and another adjacent wound near the coccyx (tailbone). The pressure ulcers were unstageable ( full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured) and covered with slough (non-viable yellow, tan, gray, green or brown tissue). Treatment was to include initiation of an air mattress and Santyl ointment to remove the slough through enzymatic debridement. On 8/28/24 at 12:11 PM Staff 3 (LPN, Resident Care Manager) stated if a resident was admitted with no wound care orders, the nurse was to enter a generic order to "clean and cover" then contact the provider for a more specific order. The expectation was for the generic order be entered "right away" and more specific orders entered by the second day. On 8/28/24 at 12:20 PM Resident 173 who was alert and oriented, confirmed the pressure wound started at the hospital. The area was not painful due to a general lack of sensation below the waist. On 8/28/24 at 3:54 PM Staff 2 (DNS) and Staff 3 (LPN, Resident Care Manager) stated the resident may have had a sacral dressing at the time of admission and refused a full assessment. The refusal was not documented and the next shifts did not follow up. They confirmed the Braden Scale completed at the time of admission was inaccurate and the resident did not receive wound care until 8/27/24, six days after admission.

Failure to initiate treatment for a pressure injury present upon admission. Wound progressed from DTI to unstageable. Skin Assessment Refused on Admit but was not documented and no follow up, Braden Assessment on Admit inaccurate. Residents affected #173 who still resides in the facility. Incident Report Started Immediately with implementation of Treatment Orders, Air Mattress, Wound Rounds All Residents with Pressure Related injuries are at risk. Inservice LNs completed 8/27/24, Educator Jailee Head, RN LN Re-Education on the Admission Process Skin Checks is Scheduled on 9/24/2024 Wound Round Audits will be completed by designated RCM Weekly x4, then Monthly x2 DNS or designee will be responsible for ongoing compliance.

Based on observation, interview, and record review it was determined the facility failed to maintain oxygen equipment for 1 of 1 sampled resident (#5) reviewed for oxygen therapy. This placed residents at increased risk for respiratory failure. Findings include: Resident 5 was admitted to the facility in 6/2024 with diagnoses including chronic obstructive pulmonary disease (chronic lung disease that causes breathing difficulty). The 6/7/24 Admission MDS indicated Resident 5 was cognitively intact. The 6/3/24 physician order revealed the resident used continuous oxygen and to clean the oxygen concentrator and filter every Tuesday NOC (night) shift. Observations on 8/26/24 at 11:26 AM revealed Resident 5's oxygen concentrator was covered in dust and the external filter had a thick gray layer of dust. On 8/26/24 at 11:28 AM Resident 5 stated she/he did not recall staff cleaning the concentrator or filter "the whole time" she/he has been in the facility. The 6/2024 TAR revealed no documentation for 6/4/24, 6/11/24, 6/18/24 or 6/28/24 to indicate NOC shift staff cleaned Resident 5's oxygen concentrator and filter as ordered. The 7/2024 TAR revealed no documentation for 7/2/24, 7/9/24, 7/16/24, 723/24, or 7/30/24 to indicate NOC shift staff cleaned Resident 5's oxygen concentrator and filter as ordered. The 8/2024 TAR revealed no documentation for 8/6/24, 8/13/24 or 8/20/24 to indicate NOC shift staff cleaned Resident 5's oxygen concentrator and filter as ordered. On 8/28/24 at 4:07 PM Staff 14 (LPN) stated NOC shift was responsible to clean Resident 5's concentrator and filter. On 8/29/24 at 10:53 AM Staff 7 (LPN-Resident Care Manager) acknowledged Resident 5's concentrator and filter were not cleaned. Staff 7 stated it was her expectation staff cleaned the concentrator and filter every week as ordered.

Failure to maintain oxygen equipment, concentrator covered in dust and filter with thick gray layer of dust. Maintenance was scheduled for Tuesday Noc Shift, TAR revealed no documentation on multiple occasions. This affected Resident #5 who no longer residents in the facility. Oxygen concentrator and filter cleaned for above patient All Residents who receive supplemental oxygen therapy are at risk. Baseline Audits completed to identify Residents who are currently receiving Oxygen Therapy Implementation of Missed Documentation follow up form will be completed by LN staff and RCM oversight. Continued Audits for Supplemental Oxygen usage will be completed weekly x4, then monthly x2 by Designated RCM/RT. DNS or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to identify clinical indications for the use of an antipsychotic medication for 1 of 5 sampled residents (#33) reviewed for unnecessary medications. This placed residents at risk for the unnecessary use of psychotropic medication. Findings include: Resident 33 was readmitted in 10/2023 with diagnoses including cancer, generalized anxiety disorder and major depressive disorder-recurrent. The Behavior Monitor for Resident 33 tracked behaviors of: Withdrawal, difficulty sleeping, a history of accusations, easily overwhelmed, irritability and tangential. The 2/2024 Behavior Monitor identified two episodes of difficulty sleeping during the month and no behaviors/concerns were identified in progress notes. A 2/29/24 nurse practitioner visit described Resident 33's behavior as appropriate, with an open attitude, anxious mood, clear speech and concrete thought process. The resident's focus during the visit was her/his pain which was "all the time", anxiety and insomnia. A GAD (Generalized Anxiety Disorder) scale was completed and identified a score of 16, indicating anxiety symptoms were severe. On 3/1/24 quetiapine (an antipsychotic medication) 25 mg BID for depression was ordered. There was no rationale provided in the medical record which identified the clinical indications for the use of an antipsychotic medication or how the effectiveness of the medication would be evaluated. On 3/12/24, the quetiapine dose was increased to 100 mg BID. No clinical rationale was found for the increase in dose. A 3/14/24 progress note identified the resident as having a pleasant mood, being compliant with care and experiencing no changes in behavior or mood. On the same day, Staff 34 (Former Nurse Practitioner) changed the quetiapine dose to 200 mg one time a day for the diagnosis of schizoaffective disorder, depressive type. This was a new diagnosis for the resident which was not supported by a mental health practitioner's evaluation or diagnostic criterion. On 3/21/24, the quetiapine dose was increased to 400 mg at bedtime. No clinical rationale was found for the increase in dose. The 3/2024 Behavior Monitor identified no targeted behaviors during the month and progress notes reflected no behavior or mood concerns. On 8/29/24 at 2:47 PM, Staff 2 (DNS) provided information regarding the prescription of quetiapine but was unable to locate supporting documentation which identified why the quetiapine was ordered, what symptoms it treated, or how effectiveness was determined. Staff 2 stated there was no evidence of a mental health professional involved in the diagnosis of schizoaffective disorder and agreed the diagnosis had been questioned by the pharmacist and physician.

Failure to identify clinical indications for the use of an antipsychotic medication. New diagnosis of schizoaffective disorder, depressive type with no support from mental health practitioner evaluation or diagnostic criterion. No behaviors/concerns were identified in progress notes, behavior monitor identified no targeted behaviors. This affected Resident #33 who still resides in the facility. Notifications made to Rogue Valley Psych with request to be seen on next visit regarding new Diagnosis of Schizoaffective Disorder, Depressive Type. Resident will also be discussed at next Psychotropic Review with IDT, Pharm, PCP, and Rogue Valley Psych. This is scheduled for Oct 14th 2024. All Residents who receive a new mental health diagnosis without involvement of a mental health practitioner are at risk. IDT, Pharm, PCP, and Rogue Valley Psych will be involved in monthly meetings going forward to ensure Psych input/diagnosis review. Additional Education Provided to LN/CNA staff on importance of accurate documentation. Required to document all behaviors and avoid normalizing behaviors often seen. Continued Audits of antipsychotic usage will be performed by designated RCM weekly x4 then monthly x2 for ongoing compliance. DNS or designee will be responsible for ongoing compliance.

Based on observation and interview it was determined the facility failed to ensure staff wore appropriate hair restraints during meal preparation for 1 of 1 kitchen reviewed for sanitation and properly stored and labeled food for 2 of 2 resident refrigerators reviewed for storage. This placed residents at risk for unsanitary food and cross contamination. 1. Resident 4 admitted to the facility in 12/2022 with diagnoses including osteomyelitis (bone infection) and malnutrition. A 7/28/24 Annual MDS revealed Resident 4 was cognitively intact. On 8/28/24 at 10:44 AM Resident 4's personal refrigerator was observed to contain three covered cups of milk not labeled or dated, three plastic facility containers of chocolate pudding dated 7/19/24, 8/1/24 and 8/3/24, one facility container of vanilla pudding dated 8/17/24, one facility container of butterscotch pudding dated 8/3/24 and one small container of ranch dip not labeled or dated. On 8/28/24 at 10:50 AM Resident 4 stated no one in the facility checked the temperatures or expiration dates for her/his refrigerator. On 8/28/24 at 11:14 AM Staff 7 (LPN-Resident Care Manager) stated the items should have been dated or thrown away. Staff 7 took the undated and expired foods out of the refrigerator to dispose of them. On 8/28/24 at 11:23 AM Staff 1 (Administrator) stated there had been a lot of staff turnover and some things had "fallen through the cracks." Staff 1 also stated the facility did not have a policy or procedure for residents' personal refrigerators. 2. Resident 21 admitted to the facility in 10/2016 with diagnoses including kidney disease and hypertension. A 7/22/24 Quarterly MDS revealed Resident 21 was cognitively intact. On 8/28/24 at 10:58 AM Resident 21's personal refrigerator was observed to have three covered cups of orange juice not labeled or dated, one peach yogurt in a facility plastic container dated 6/3/24 and a paper container of Jack in the Box chicken nuggets with an opened sauce container not labeled or dated. On 8/28/24 at 11:00 AM Resident 21 stated staff did not check the refrigerator temperatures or for expired foods. On 8/28/24 at 11:14 AM Staff (LPN-Resident Care Manager) stated the items should have been dated or thrown away. Staff 7 took the undated and expired foods out of the refrigerator to dispose of them. On 8/28/24 at 11:23 AM Staff 1 (Administrator) stated there had been a lot of staff turnover and some things had "fallen through the cracks." Staff 1 also stated the facility did not have a policy or procedure for resident personal refrigerators. , 3. Review of the US FDA Food Code 2022 revealed: -food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. Observations on 8/28/24 at 11:28 AM for lunch time tray line plating Staff 32 (Dietary Aide) was observed in the kitchen area not wearing a hair restraint and preparing the lunch trays for the start of meal service. Staff 33 (Cook) was observed in the kitchen area not wearing a hair restraint while cooking. Staff 31 (Dietary Manager) was observed walking around the kitchen area without a hair restraint. On 8/28/24 at 11:35 AM Staff 31 acknowledged certain kitchen staff were not wearing hair restraints and stated it was her expectation that all staff wear hair restraints at all times when in the kitchen area.

Failure to ensure staff wore appropriate hair restraints during meal preparation. Failure to properly store and label food in resident refrigerators. Failure to check temperatures, failure to discard expired food. This affected Residents #4, 21, both still residing in the facility. Expired Food Discarded for the above Residents All Residents who receive food provided by the facility kitchen are at risk. All Residents who store food in personal refrigerators in their rooms are at risk. Baseline audit completed for all Residents with in-room refrigerators. All Kitchen staff in food preparation areas will wear hair restraints and clothing that covers body hair. Temperature Checks will be recorded on a daily basis by staff. Order implemented in the TAR All Personal Refrigerators will be checked every Sunday NOC shift for expired food & discarded if indicated. Task Implemented to Clean refrigerators in the POC. Continued Personal Refrigerator Audits will be completed by designated RCM weekly x4, then monthly x2. DNS or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of annual in-service training for 4 of 5 randomly selected staff members (#s 19, 20, 21 and 22) reviewed for evidence of in-service training. This placed residents at risk for a lack of quality care. Findings include: On 8/29/24 at 1:06 PM Staff 24 (Human Resources) provided a list of training hours for nurse aid staff which revealed the following: -Staff 19 (CNA): 1.1 annual training hours; -Staff 20 (CNA): 0 annual training hours; -Staff 21 (CNA): 0 annual training hours and -Staff 22 (CNA): 0 annual training hours. On 8/29/24 at 1:10 PM Staff 24 acknowledged Staff 19, Staff 20, Staff 21 and Staff 22 did not complete the required 12 hours of annual in-service training. On 8/30/24 at 10:51 AM Staff 1 (Administrator) acknowledged CNA staff were required to have 12 hours of annual in-service training and stated the facility needed to develop a tracking system for monitoring the hours.

No residents were identified as being affected by this regulation All residents could have been affected due to the lack of ongoing training for the CNA staff. An Audit will be performed to identify all Aides that are out compliance with training, and they will be given the training necessary to bring them current. A review of employees' training will be conducted once a week for four weeks then twice a month for one month to verify that the training is being completed timely. ED or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to ensure background checks were completed for newly hired staff for 1 of 5 sampled staff (#7) reviewed for background checks. This placed residents at risk for abuse. Findings include: An employee Detail report revealed Staff 7 (Respiratory Therapist) was hired on 5/20/24. Staff 30 (Regional HR Manager) was unable to locate Staff 7's background check. On 8/28/24 at 1:30 PM Staff 30 stated Staff 7 never completed the consent portion of the background check form and therefore no background check was completed. Staff 30 confirmed Staff 7 was on the schedule and working.

No residents were identified as being affected by this regulation All residents could have been affected due to the lack of a completed background check. An Audit was performed, and no other employees were without a completed background check An employee review form has been created and will be used for all Background renewals by HR. A review of this for will be conducted once a week for four weeks then twice a month for one month to verify that the backgrounds are being completed timely and the staff are not on the floor if the background has not been finished prior to their anniversary date. ED or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 31 of 56 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident care and services. Findings include: A review of the Direct Care Staff Daily Reports from 7/1/24 through 8/25/24 revealed there was no designated RN charge nurse on duty for eight consecutive hours between the start of day shift and the end of evening shift for the following days: -7/1/24 -7/2/24 -7/4/24; -7/5/24; -7/6/24; -7/8/24; -7/9/24; -7/14/24; -7/15/24; -7/18/24; -7/19/24; -7/20/24; -7/25/24; -7/26/24; -7/27/24; -7/31/24; -8/1/24; -8/2/24; -8/3/24; -8/5/24; -8/6/24; -8/8/24; -8/9/24; -8/11/24; -8/12/24; -8/13/24; -8/15/24; -8/18/24; -8/19/24; -8/23/24 and -8/25/24. On 8/29/24 at 11:03 AM Staff 23 (Staffing Coordinator) reviewed the DCSDRs and acknowledged the facility lacked RN coverage on the identified days. On 8/30/24 at 9:36 AM Staff 1 (Administrator) stated he was aware of the lack of RN coverage.

No residents were identified as being affected by this regulation All residents could have been affected due to the lack of RN staff on the floor Gresham Post Acute will by applying for the RN waiver (OAR 411-085-0040) due to a lack of being able to hire RNs for our open positions. We will also focus on RNs to fill open shifts at the facility through Agency usage until we can hire RNs. A review for nursing staffing will be conducted once a week for four weeks then twice a month for one month to verify that Gresham has the minimum hours or RN coverage. ED or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to ensure the State minimum bariatric CNA staffing ratios were maintained for 11 out of 25 days reviewed for sufficient staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: On 8/26/24, the facility had four residents approved for the State bariatric rate. A review of the Direct Care Staff Daily Reports (DCSDRs) from 8/1/24 through 8/25/24 revealed the following days when State minimum bariatric CNA staffing ratios were not met for one or more shifts: -8/15/24, 8/16/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/24/24 and 8/25/24. On 8/29/24 at 11:03 AM Staff 23 (Staffing Coordinator) reviewed the DCSDRs and acknowledged the failure to meet State minimum bariatric CNA staffing ratios on 8/15, 8/16, 8/17, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24 and 8/25.

No residents were identified as being affected by this regulation All residents could have been affected due to the lack of CNA staff on the floor The scheduler will verify that the proper number of staff are on the floor based upon the minimum staffing criteria and the added hours for Bariatric residents per OAR 411-086-0100 (5). An audit for CNAs will be conducted once a week for four weeks then twice a month for one month to verify that Gresham has the minimum hours or CNA coverage with the additional Bariatric hours. ED or designee will be responsible for ongoing compliance.

********************* 411-085-0310 Residents' Rights: General Refer to F552 ********************* 411-088-0080 Notice Requirements Refer to F623 ********************* 411-088-0050 Right to Return from Hospital Refer to F625 ********************* 411-086-0300 Clinical Records Refer to F641 ********************* 411-086-0040 Admission of Residents Refer to F655 ********************* 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ********************* 411-086-0110 Nursing Services: Resident Care Refer to F658 and F695 ********************* 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686 and F758 ********************* 411-086-0250 Dietary Services Refer to F812 ********************* 411-086-0310 Employee Orientation and In-Service Training Refer to F947 *********************

Based on interview and record review it was determined the facility failed to ensure an RN was on duty for at least 16 hours a day for 14 of 56 days reviewed for sufficient staffing on the Ventilator Assisted Unit. This placed residents at risk for a lack of comprehensive assessments and unmet needs. Findings include: Review of the Ventilator Assisted Unit's Direct Care Staff Daily Reports (DCSDRs) from 7/1/24 through 8/25/24 revealed the Ventilator Assisted Unit did not have an RN on duty for 16 hours on the following dates: -7/2, 7/13, 7/19, 7/20, 8/6, 8/7, 8/9, 8/10, 8/12, 8/14, 8/16, 8/17, 8/19 and 8/21. On 8/29/24 at 11:03 AM Staff 23 (Staffing Coordinator) reviewed the Ventilator Assisted Unit DCSDRs and acknowledged the failure to have an RN on duty for 16 hours a day on 7/2, 7/13, 7/19, 7/20, 8/6, 8/7, 8/9, 8/10, 8/12, 8/14, 8/16, 8/17, 8/19 and 8/21. On 8/30/24 at 9:36 AM Staff 1 (Administrator) confirmed the lack of RN coverage on the Ventilator Assisted Unit.

No residents were identified as being affected by this regulation All residents could have been affected due to the lack of RN staff on the floor Gresham will also focus on RNs to fill open shifts at the facility through short and long term contracted Agency usage until we can hire RNs. A review for RN nursing staffing will be conducted once a week for four weeks then twice a month for one month to verify that Gresham has the minimum hours or RN coverage. ED or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to ensure nursing staff caring for residents on the Ventilator Assisted Unit received 8 hours of pre-service training provided by a licensed Respiratory Therapist (RT) and 8 hours of annual training, thereafter, for 10 of 10 randomly selected staff (#s 6, 8, 9, 10, 11, 12, 13, 14, 16 and 17 ) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 8/29/24 at 10:12 AM Staff 27 (RT Manager) provided a list of training hours for the sampled staff and confirmed the following: -Staff 6 (LPN): 5 hours of pre-service training provided by a licensed RT and 4.75 hours of annual training; -Staff 8 (CNA): 2 hours of pre-service training provided by a licensed RT and 3.75 hours of annual training; -Staff 9 (CMA): 2 hours of pre-service training provided by a licensed RT and 0 hours of annual training; -Staff 10 (CNA): 0 hours of pre-service training provided by a licensed RT and 0 hours of annual training; -Staff 11 (CNA): 2 hours of pre-service training provided by a licensed RT and 3.75 hours annual training; -Staff 12 (CNA): 2 hours of pre-service training provided by a licensed RT; -Staff 13 (Agency RN): 0 hours of pre-service training provided by a licensed RT; -Staff 14 (Agency LPN): 0 hours of pre-service training provided by a licensed RT; -Staff 16 (LPN): 5 hours of pre-service training provided by a licensed RT and 4.5 hours of annual training and -Staff 17 (CNA): 2 hours of pre-service training provided by a licensed RT and 3.75 hours of annual training. On 8/29/24 at 11:21 AM Staff 28 (Logistics Specialist for the Ventilator Assisted Unit) stated the licensed RT provided licensed nurses with five hours of pre-service training hours and CNA/CMA staff with two hours of pre-service training hours. Staff 28 acknowledged staff did not receive eight hours of pre-service training by a licensed RT and the sampled staff did not complete the required eight hours of annual training. On 8/30/24 at 9:36 AM Staff 1 (Administrator) confirmed staff caring for ventilator dependent residents did not receive the required pre-service and annual training hours.

No residents were identified as being affected by this regulation All residents could have been affected due to the lack of trained staff on the floor All current clinical staff in the Vent unit will be given 8 hours of in-person R/T led training and all future Clinical staff will be trained by the R/T before the staff can work on the vent unit. In addition, all Vent Clinical staff will be assigned 8 hours of annual R/T classes via an on-line portal. An audit will be conducted once a week for four weeks then twice a month for one month to verify that R/T staff have their initial 8 hours of in person training and their ongoing classes are assigned and completed prior to the due date. ED or designee will be responsible for ongoing compliance.

Based on interview and record review it was determined the facility failed to provide timely incontinence care for 1 of 1 resident (# 5) reviewed for incontinence care. This placed residents at risk for unmet care needs. Findings include: Resident 5 was admitted to the facility in 8/2023 with diagnoses including brain damage. Resident 5's 8/31/23 care plan included Resident 5 required two person total assist with incontinence care. Bowel Movement Documentation from 9/2023 indicated Resident 5 received incontinence care and incontinence care checks three times on 9/1/23 and twice on 9/2/23. On 10/26/23 at 1:59 PM and 2:34 PM, Staff 19 (CNA) and Staff 20 (CNA) stated incontinence checks were suppose to be performed every two hours but they were usually only able to perform incontinence checks twice during an eight hour shift. Staff 19 stated CNAs document whenever a resident's brief is checked regardless of if it needed to be changed. On 10/27/23 at 10:42 AM Staff 17 (RCM) stated the expectation was to have incontinent residents checked every two hours. Staff 17 confirmed it was unacceptable these checks were only able to be performed twice during a shift.

1. Enhanced Care Plan for Resident #5: The care plan and assessment for Resident #5 has been thoroughly updated to include a comprehensive schedule for regular checks and changes. 2. Proactive Risk Management for Incontinent Residents: Recognizing the heightened risk of urinary tract infections and skin breakdown in incontinent residents, timely and regular checks are prioritized. Our team is dedicated to ensuring that these essential checks are performed with utmost diligence to maintain resident health and comfort. 3. Comprehensive Audits for Vent Unit Residents: All residents in the Vent unit will undergo detailed audits to verify the currency and adequacy of their incontinence assessments, care plans, and the setup of CNA tasks. This initiative aims to ensure that each resident's unique needs are accurately identified and addressed. 4. Targeted Staff Training and Meetings: Staff meetings, with a completion target of December 5, 2023, will focus intensively on incontinence care, catheter care, and the specifics of the Plan of Correction for F690. These meetings are designed to enhance the care team's competencies and adherence to best practices. 5. Systematic Audit and Quality Assurance Process: A structured audit process will be implemented, involving weekly assessments of 8 randomly chosen residents for four weeks, followed by monthly assessments for three months. These audits will encompass incontinence assessments, care plan reviews, and CNA task setups. The outcomes of these audits will be rigorously analyzed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings, facilitating root cause analysis and the refinement of Performance Improvement Plans (PIPs). DNS or designee will bring results of these audits and assessments to QAPI. 6. Compliance Deadline: The established deadline for achieving full compliance with this Plan of Correction is December 5, 2023. This date underscores our commitment to timely implementation and the highest standards of resident care and regulatory adherence.

******************** 411-0086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F690 ********************

Based on interview and record review it was determined the facility failed to protect residents' rights to make personal care decisions for 1 of 3 sampled residents (#267) reviewed for choices. This placed residents at risk for lack of personal care decisions for resident choices. Findings include: Resident 267 admitted to the facility in 10/2022 with diagnoses including metabolic encephalopathy (a medical problem in the brain caused by a blood imbalance) and diabetes mellitus. Resident 267's Admission MDS dated 11/3/22 revealed a BIMS score of 13, indicating no cognitive impairment. The facility's Resident Rights policy, revised 2/2021 stated "Employees shall treat all residents with kindness, respect and dignity" and residents have the right of self determination. Resident 267's care plan dated 11/16/22 indicated the resident was resistant to ADL care at times due to pain. Interventions were to negotiate a time with the resident to provide care, leave the resident's room and return five to ten minutes later and offer care again. On 5/16/23 at 12:21 PM Witness 1 (Complainant) stated she/he was contacted by Resident 267 on 11/12/22 around 2:00 AM, and the resident was crying and upset. Resident 267 told Witness 1 Staff 24 (CNA) and Staff 25 (CNA) had "tussled" with her/him because they wanted to change Resident 267's bedding and she/he did not want the bedding changed. Resident 267 told Witness 1 the bedding was not wet and one of the CNAs was rough as they turned her/him during the bedding change. Witness 1 stated the resident complained of back pain as a result of the incident and she/he requested the resident be sent to the hospital for assessment. Resident 267 returned to the facility later that morning with no reported injuries. On 5/17/23 at 3:53 PM Staff 24 stated on the date of the incident, she passed by Resident 267's room and saw her/him standing by the bed and ran to her/him because Resident 267 was a high fall risk. She requested Staff 25 to help put the resident back to bed. She did not recall whether the bedding was changed. On 5/17/23 at 4:24 PM Staff 25 stated he was called to Resident 267's room by Staff 24 due to the resident falling out of bed. Staff 25 recalled Resident 267's bed sheets were wet and he advised the resident they needed to change the bedding. Staff 25 stated Resident 267 did not want the bedding change but he and Staff 24 changed the bedding because the sheets were soaked with urine. Staff 25 stated Resident 267 wanted to be left alone but they "had to change the sheets." On 5/22/23 at 2:48 PM Staff 2 (DNS) was advised of the investigative findings and provided no additional information.

F 550 Resident Rights/Exercise of Rights How the corrective action will be accomplished for identified affected individuals: Resident 267 no longer resides at the facility. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents have the potential to be affected if the facility fails to honor resident rights in regard to personal care decisions. Social Services or Designee will interview able residents to ensure that residents have the right to make personal care decisions. What systemic changes will ensure that the deficient practice will not recur: Administrator or DNS educated the Licensed Nurses, CMA and CNA on resident rights and the Right to Refuse, reapproach and getting the Nurse, Family or MD involved as needed for education to the resident or further interventions. How the facility will monitor its corrective actions/performance: Administrator or Designee will complete a weekly audit for 4 weeks, then monthly audits for 3 months on resident rights to make personal care decisions. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to provide written information to residents concerning the right to formulate an advance directive for 1 of 3 sampled residents (#9) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: Resident 9 was admitted to the facility in 2023 with diagnoses including acute kidney failure and chronic kidney disease. A 4/2023 Admission MDS indicated Resident 9 was cognitively intact. The 4/20/23 Care Plan indicated: "Resident states that the orders on the POLST reflect their advance directive wishes and they do not wish to fill out the Advance Directive form." On 5/15/23 at 12:23 PM Witness 1 (Family) stated the facility had not asked Resident 9 if she/had an advance directive or if one could have been obtained. On 5/16/23 at 8:20 AM Resident 9 stated she/he had an advance directive through her/his physician's office and the facility had not asked if she/he had an advance directive or if she/he would like to fill one out. Resident 9's clinical record did not contain a copy of her/his advance directive. On 5/17/23 at 3:05 PM Staff 36 (Social Services Director) stated she obtained a POLST upon admission but not an advance directive. Staff 36 stated she marked in the resident records if the residents declined an advance directive and indicated upon admission there was not a form for the residents to fill out. On 5/18/23 at 11:22 AM Staff 29 (Regional RN) indicated upon admission staff were to ask residents if they had an advance directive. If the resident had one, staff were to obtain a copy for the resident's clinical record. Staff 29 stated she expected residents to be offered an advance directive upon admission and for it to be charted accurately in the residents' clinical record.

F 578 Request/Refuse/Discontinue Treatment: Formulate Advance Directive How the corrective action will be accomplished for identified affected individuals: Resident # 9; Advance Directive was obtained by social services on 6/1/2023 and the chart was updated to reflect the advanced directive wishes. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents have the potential to be affected if the facility does not provide written information to residents concerning the right to formulate an advanced directive or are at risk of not having their health care decisions honored. Social Services will complete an audit to ensure that advanced directives have been offered and documented per the requirements and resident wishes. What systemic changes will ensure that the deficient practice will not recur: Administrator provided education to the Social Service department, DNS and RCMs on the process of filling out the advanced directive assessment, obtaining advanced directives and updating the Care Plan. How the facility will monitor its corrective actions/performance: Administrator/Designee will complete a weekly audit for 4 weeks, then monthly audits for 3 to ensure that resident have been offered and provided an advanced directive. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to provide a Notice of Medicare Non-coverage to 1 of 3 sampled residents (#118) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include: Resident 118 was admitted to the facility on 12/27/22 with diagnoses including leg fracture. Resident 118's Clinical Census (reviewed on 5/18/23) indicated the resident's last covered day of Medicare Part A services (skilled services including therapy) was 1/13/23. On 5/18/23 at 3:07 PM Staff 1 stated Resident 118 was not provided with a Notice of Medicare Non Coverage prior to discharge, but a notice should have been provided.

F 582 Medicaid/Medicare Coverage/Liability Notice How the corrective action will be accomplished for identified affected individuals: Resident 118 has been discharged from the facility. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other Residents residing at the facility with Medicare Coverage as a Payor have the potential to be affected if they were not notified of their Medicare coverage ending, potentially causing unknown financial liabilities. Administrator will also be auditing current resident to ensure that NOMNC are being issue according to CMS guidelines. What systemic changes will ensure that the deficient practice will not recur: Administrator re-educated Social Services Director regarding NOMNC policy and guidelines. How the facility will monitor its corrective actions/performance: Administrator/Designee will complete a weekly audit for 4 weeks, then monthly audits for 3 to ensure that NOMNC are being issued timely. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to provide ADL care to dependent residents for 1 of 5 sampled residents (#217) reviewed for ADL care. This placed residents at risk for lack of ADL care. Findings include: Resident 217 was admitted to the facility in 3/2023 with diagnoses including hypertension (high blood pressure) and congestive heart failure. Resident 217's 3/21/23 Admission MDS revealed a BIMS score of 9, indicating moderate cognitive impairment. Resident 217's care plan revealed she/he was incontinent of bowel and bladder and was dependent on staff for most ADL's. There were no care planned interventions for fecal smearing. The facility's ADL policy, revised 3/2018 indicated "Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, including support and assistance with hygiene (bathing, dressing, grooming and oral care) and elimination (toileting)." On 5/15/23 at 12:33 PM Witness 4 (Complainant) stated she/he visited Resident 217 a few days after she/he admitted to the facility. During the visit she/he witnessed Resident 217 digging her/his hands in her/his incontinent brief, the resident smelled of feces and had fecal matter on her/his hands. Witness 4 spoke to facility staff and they told her Resident 217 was "fingerpainting." On 5/15/23 at 3:42 PM Witness 6 (Visitor) stated she/he visited Resident 217 a day or so before she/he discharged from the facility. During the visit she/he observed dark material under Resident 217's nails, what appeared to be fecal matter on the resident's bed sheet and noted Resident 217 smelled strongly of urine. On 5/17/23 at 10:57 AM Staff 31 (CNA) recalled Resident 217 and confirmed she/he frequently placed her/his hands in her/his incontinence brief. He stated staff would observe feces on the resident's hands and washed the feces off the resident's hands almost daily. Staff 30 did not recall if this behavior was documented in the care plan. On 5/18/23 at 10:08 AM Staff 26 (CNA) recalled Resident 217 and confirmed she/he frequently "dug" in her/his incontinence brief and he frequently washed the feces off her/his hands. He stated the resident did not do it as much in common areas but if she/he were in bed, she/he would take off the incontinence brief because she/he did not like to wear soiled briefs. On 5/18/23 at 12:14 PM Staff 5 (RNCM) confirmed she had observed Resident 217 digging in her/his brief one time and this was a frequent behavior. On 5/22/23 at 3:06 PM Staff 2 (DNS) was advised of the investigative findings and provided no additional information.

F 677 ADL care provided for Dependent Residents How the corrective action will be accomplished for identified affected individuals: Resident 217 no longer resides at the facility. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents have the potential to be affected if ADLs for nail care is not provided for dependent residents, causing lack of ADL care. DON or designee will audit residents who are dependent for ADL care related to nail care. Resident ADL care plan will be updated to reflect appropriate interventions. What systemic changes will ensure that the deficient practice will not recur: DNS provided education to the Nursing Staff on providing nail care with showers and in between when residents are dependent and are unable to clean their nails after they are soiled. How the facility will monitor its corrective actions/performance: DON/Designee will complete a weekly audit for 4 weeks, then monthly audits for 3 to ensure that nail care for ADLs has been provided in a timely manner. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being for 1 of 2 sampled residents (#56) reviewed for activities. This placed residents at risk for unmet psychosocial needs and isolation. Findings include: The facility's 6/2018 Activity Programs policy and procedure specified the following: -The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. -Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. -Activities are documented in the resident's medical record. Resident 56 was admitted to the facility in 1/2023 with diagnoses including depression, anxiety and respiratory failure. Resident 56's 1/16/23 Admission MDS indicated the resident was cognitively intact. Her/his activity preferences indicated it was important or very important to go outside when the weather was good and to do things with groups of people. Resident 56's health care record showed no evidence the resident was provided with or participated in one-on-one or group activities. Observations from 5/15/23 through 5/19/23 between the hours of 8:00 AM and 4:00 PM revealed Resident 56 resided on the Ventilator Assisted Unit (VAP). No activities were observed on the VAP unit. Additional observations included: -On 5/17/23 at 1:57 PM and 11:45 AM Staff 12 (Activity Director) was observed notifying Resident 56 of a karaoke activity later that day and stated she would take Resident 56 to the activity. At 1:57 PM a karaoke activity was observed in the main dining room with several residents but Resident 56 was not present. At 1:59 PM Resident 56 stated she wanted to go to the karaoke group but nobody came to take her/him to the activity group and she/he was unable to get there on her/his own. -On 5/18/23 at 4:00 PM a nail care activity group was observed outside in the front of the facility. Resident 56 was not in attendance. -On 5/19/23 at 12:29 PM a facility luncheon and dunk tank was observed set up in front of the facility with many residents participating. Resident 56 was not in attendance. On 5/15/23 at 1:42 PM and 5/18/23 at 12:29 PM Resident 56 stated there were no activities on the unit and she/he would participate in some activities if they were offered. Resident 56 stated she/he was "going crazy" and just wanted to spend time outside. Resident 56 stated she/he asked to go outside several times and was told no because she/he was not allowed to be outside by herself/himself. Resident 56 stated there was nothing to do all day. On 5/16/23 at 2:40 PM Staff 10 (RN) stated the other side of the facility had an activity program but no activities occurred on the VAP unit. On 5/18/23 at 8:17 AM Staff 7 (CNA) stated there was no activity program on the VAP unit. Staff 7 stated she knew of at least five residents who would benefit from an ongoing activities program. Staff 7 stated CNA staff could not take residents outside because they did not have enough staff. On 5/18/23 at 9:31 AM Staff 6 (CNA) stated there were no one-on-one or group activities on the VAP unit. She stated she sometimes polished resident's nails on her own time and gathered the VAP unit staff to sing, "Happy Birthday" to residents on their birthdays. On 5/18/23 at 9:55 AM Staff 12 stated there was currently no activity program for the VAP unit.

F 679 Activities Meet Interest/Needs of Each Resident How the corrective action will be accomplished for identified affected individuals: Resident 56was interviewed on 6/5/2023 and the care plan has been updated to meet her psychosocial and activities needs. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected if the activities program does not meet the interest of the resident we served. Administrator/Designee will complete audits of current resident activities program and to ensure that resident activity needs are being met. What systemic changes will ensure that the deficient practice will not recur: Administrator re-educated activities director on re vamping the activities program on the vent unit to accommodate the complex needs of the residents. How the facility will monitor its corrective actions/performance: Administrator or Designee will complete a weekly audit for 4 weeks, then monthly audits for 3 months to ensure residents are receiving individualized activities program timely manner. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to follow physician's orders for 3 of 6 sampled residents (#s 4, 9 and 319) reviewed for medication administration, bowel care and daily weights. This placed residents at risk for adverse medical consequences. Findings include: 1. Resident 319 was admitted to the facility in 2023 with diagnoses including fracture. Resident 319's 5/2023 physician's orders revealed an order for calcium carbonate-vitamin D3 600 mg-12.5 mcg every morning after a meal. Resident 319's 5/2023 MAR revealed the medication was charted as having been administered from 5/5/2023 through 5/17/23, including by Staff 35 (CMA) on 5/17/23. On 5/18/23 at 9:36 AM Staff 35 was observed administering medications to Resident 319. She stated she could not administer the resident's ordered calcium carbonate-vitamin D3 600 mg-12.5 mcg because the medication was not available. Staff 35 stated she would notify Staff 3 (LPN) to either obtain the medication or adjust the dose. Staff 35 stated the ordered dosage was not on the medication cart and staff were probably administering calcium carbonate-vitamin D3 600 mg-10 mcg which was available on the medication cart. Staff 35 acknowledged she documented that she had administered the ordered dosage of carbonate-vitamin D3 to the resident on 5/17/23. On 5/18/23 at 9:50 AM Staff 3 inspected the medication cart and did not find the ordered calcium carbonate-vitamin D3 600 mg-12.5 mcg. Staff 3 stated staff were probably administering calcium carbonate-vitamin D3 600 mg-10 mcg to the resident. 2. Resident 4 was admitted to the facility in 2022 with diagnoses including bone infection. Resident 4's bowel record from 4/16/23 through 5/14/23 revealed the resident did not have a bowel movement for six days from 4/16/23 through 4/21/23. Resident 4's 4/2023 MAR revealed the resident did not have any PRN bowel care medications ordered. A review of Resident 4's Progress Notes from 4/16/23 through 4/21/23 revealed no assessment of the resident related to potential constipation or a submitted request to the physician for bowel care orders. On 5/22/23 at 10:11 AM Staff 5 (RNCM) stated the expectation was for nurses to run a report in the morning for all residents who had not had a bowel movement for three days so the residents could be offered bowel care medication. If a resident refused bowel care medication the nurse should conduct an assessment. Staff 5 verified there were no bowel assessments of Resident 4 from 4/16/23 through 4/21/23. , 3. Resident 9 admitted to the facility in 2023 with diagnoses including acute kidney failure and chronic kidney disease. The 4/2023 Physician Order revealed an order to measure weight daily and report to the physician any weight gain over three pounds from the admission weight of 294 pounds. The May 2024 TARs revealed Resident 9 was to be weighed every Monday for four weeks. The TARs records reviewed for 4/2023 and 5/2023 revealed Resident 9's weights were not charted on: -4/19, 4/20, 4/21, 4/23, 4/24, 4/25, 4/26, 4/27 and 4/29 -5/4, 5/7 and 5/12. The daily weights record dated 4/17/23 through 5/22/23 indicated Resident 9 had a weight gain of over 3 pounds from her/his admission weight on: -5/13, 5/15, 5/16, 5/17 and 5/18 as well as no evidence the physician was contacted on those dates. On 5/17/23 at 10:28 AM Staff 3 (LPN) confirmed the physician orders were not entered correctly for Resident 9 and weights were not obtained on the dates listed. Staff 3 also stated the physician was not notified of the weight gain.

F 684 Quality of Care How the corrective action will be accomplished for identified affected individuals: Resident 319 no longer resides at the facility. Resident 4 bowel regimen has been reviewed, chart updated to current needs and no adverse effect noted on missing bowel protocol. Resident 9 weight gains were notified to physician on 5/19/2023, no negative outcomes noted, and the chart reflects the current needs of the resident. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected by failing to follow physicians order for medication administration, bowel care protocol, and daily weights. See on-going audits. What systemic changes will ensure that the deficient practice will not recur: DNS or Designee re-educated Med Aide and LN on the importance of following physicians order for medication administration, bowel care, and completing daily weights. How the facility will monitor its corrective actions/performance: DON or Designee will complete a weekly audit for 4 weeks, then monthly audits for 3 months to ensure that staff is following physician orders for Medication administration, bowel care protocol, and completing daily weights. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to accurately assess a pressure ulcer and provide ordered pressure ulcer wound care for 3 of 6 sampled residents (#s 4, 32 and 168) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: 1. Resident 32 was admitted to the facility in 2021 with diagnoses including paralysis. a. On 5/16/23 at 10:42 AM Resident 32 stated the facility did not perform her/his pressure ulcer wound care on 5/12/23. Resident 32's 5/2023 physician's orders revealed wound care instructions for the resident's left buttock pressure wound including wound vac (A device which creates negative pressure on a wound to help the wound heal) settings. Resident 32's 5/9/23 Skin & Wound Evaluation revealed the resident had a Stage 4 (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone) pressure wound over the left trochanter (bony prominence near the end of the thigh bone). Resident 32's 5/2023 TAR revealed on 5/12/23 the resident's left buttock wound care was not completed and was documented as "9" for "Other/See Nurses Notes." Resident 32's Progress Note dated 5/12/23 at 7:01 PM revealed "Wasn't able to perform wound care during shift due to other occurrences with other patients." On 5/17/23 at 12:35 PM Staff 2 (DNS) verified the wound care was not performed on 5/12/23. b. Resident 32's 5/2023 TAR revealed a wound care intervention of "Document Daily nursing note due to complex wounds and wound vac. Document progress of wounds/skin/pain/mobility and any changes in condition or refusals of care." Resident 32's Progress Notes from 5/1/23 through 5/16/23 revealed no notes which fully addressed the intervention on 5/1/23, 5/2/23, 5/6/23, 5/7/23, 5/8/23, 5/10/23, 5/11/23, 5/13/23, 5/14/23, 5/15/23 and 5/16/23. On 5/17/23 at 12:35 PM the missing chart notes were discussed with Staff 2 (DNS) who did not provide any additional information. 2. Resident 4 was admitted to the facility in 2022 with diagnoses including bone infection. A review of Resident 4's Skin & Wound Evaluations revealed on 4/25/23 the resident was assessed with Stage 2 pressure ulcer (partial thickness skin loss) on the right iliac crest (part of the pelvic bone). The size of the wound was described as 4.6 cm by 8.3 cm with a depth of 1.0 cm (a depth of 1 cm is not consistent with a Stage 2 pressure ulcer) and no wound bed description. On 5/22/23 at 9:51 AM Staff 5 (RNCM) stated Resident 4 had a Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone) and the 4/25/23 assessment was not accurate. , 3. Resident 168 was admitted to the facility on 4/19/23 with diagnoses including chronic respiratory failure. The 4/19/23 Admission Nurse Database (nursing assessment) indicated the resident had a right iliac crest blister. The 4/19/23 Skin and Wound Assessment revealed an "undiagnosed" wound which measured 8.29 cm by 4.55 cm. The assessment indicated current treatment included wound cleanser and a foam dressing. The accompanied picture of Resident 168's buttocks revealed two Stage II (partial thickness skin loss) pressure ulcers with red skin surrounding and between the two wounds. The 4/20/23 Provider Note revealed no evidence the provider was aware of Resident 168's two pressure ulcers. The 4/20/23 Care Plan revealed Resident 168 had actual skin impairment to skin integrity related to blisters and instructed staff to encourage the resident to change position frequently. The Care Plan further revealed the resident had potential for pressure ulcer development related to decreased mobility, the need for assistance with bed mobility and included an intervention to remind/assist the resident to turn and reposition frequently or more often as needed or requested. The April 2023 CNA Point of Care documentation revealed Resident 168 did not receive any bathing or skin observations between admission on 4/19/23 through her/his discharge on 4/23/23 and did not receive any reminders or assistance with turning and repositioning on 4/21/23 and 4/22/23 night shift. A review of the April 2023 TARs revealed no scheduled treatments for the two wounds. A PRN order for house barrier cream at least BID and to initiate preventive measures (offloading) for any reddened areas of skin until healed was not administered. Hospital records revealed on 4/24/23 Resident 168 had a Stage II pressure ulcer to the superior right flank and a deep tissue pressure injury (a pressure related injury to subcutaneous tissues under intact skin) to the inferior right flank. There was no evidence in Resident 168's medical record the family was notified of the two pressure ulcers. On 5/18/23 at 11:49 AM and 5/22/23 at 11:43 AM Staff 3 (RNCM) verified the 4/19/23 Admission Database documented a single blister for Resident 168's admission skin issues and the 4/19/23 Wound and Skin Assessment picture revealed two Stage II pressure ulcers. Staff 3 acknowledged only the larger wound was assessed, no wound treatments were in place or completed for the two wounds and staff did not remind or assist Resident 168 with turning and repositioning during the night shift on 4/21/23 and 4/22/23.

F 686 Treatment/Services to prevent/Heal Pressure Ulcers How the corrective action will be accomplished for identified affected individuals: Resident 32 wounds have been assessed and interventions are in place to monitor effectiveness. Resident 168 no longer resides at the facility. Resident 4 wounds were reviewed and updated to reflect correct staging. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected by inaccurate assessments, staging of wounds or if wound care is not provided as ordered. DNS or Designee will complete an audit of resident wounds, stages, and assessments to ensure that wounds are staging is accurate and assessments and treatments are appropriate for the specific wounds. What systemic changes will ensure that the deficient practice will not recur: DNS or Designee re-educated LN and RCMs on wound assessment/staging and treatments are completed per order to ensure that its accurate and treatments are appropriate. How the facility will monitor its corrective actions/performance: DON or Designee will complete a weekly audit for 4 weeks, then monthly audits for 3 months to ensure that wound assessments and staging are accurate. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to provide nail care for 1 of 2 sampled residents (# 41) reviewed for nail care. This placed residents at risk for inadequate foot care. Findings include: Resident 41 was admitted to the facility in 7/2022 with diagnoses including type 2 diabetes. Physician orders from 7/8/22 stated Resident 41 was to receive podiatry (foot and toenail) services as needed. On 5/17/23 at 9:44 AM Resident 41 reported she/he had "not received toe nail care for a few months." Resident 41's big toe nails were observed to be extended one inch, half an inch thick, yellow, crusted and excessively curved. All other toenails were also extended half an inch, a quarter of an inch thick, yellow, crusted and excessively curved. On 5/17/23 at 10:02 AM Staff 3 (LPN/Resident Care Manager) reported Resident 41 had requested to receive nail care during her/his last care conference on 4/12/23. Staff 3 stated Staff 32 (Social Services) was responsible for setting up nail care services for Resident 41. On 5/17/23 at 10:12 AM Staff 32 stated she was aware Resident 41 required specialized nail care but stated she was unaware when Resident 41 was last seen by a podiatrist. On 5/17/23 at 11:47 AM Staff 3 stated Resident 41 required specialized nail care due to her/his diabetes. Staff 3 stated she was unsure when Resident 41 last received podiatry nail care. Upon review of records, Staff 3 stated she was unable to find records of podiatry nail care. Staff 3 stated the lack of toe nail care services for Resident 41 was unacceptable.

F 687 Foot Care How the corrective action will be accomplished for identified affected individuals: Resident 41 podiatry appointment was re-scheduled to 6/12/2023. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected by not receiving proper foot care. RCMs or Designee will complete an audit of resident needing to be seen by podiatry and to ensure resident is on the podiatry list. What systemic changes will ensure that the deficient practice will not recur: Administrator re-educated the IDT team on podiatry policy and procedures. How the facility will monitor its corrective actions/performance: Administrator or Designee will complete monthly audits for 3 months to ensure podiatry process is being followed. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to provide eating assistance and to monitor for aspiration for 1 of 2 sampled residents (#168) reviewed for nutrition. The facility's failure was determined to be an immediate jeopardy situation because it resulted in Resident 168's 4/23/23 hospitalization for aspiration pneumonia and a subsequent death on 4/27/23. Findings include: Resident 168 admitted to the facility on 4/19/23 with diagnoses including dysphagia (difficulty swallowing) and chronic respiratory failure. The 4/19/23 Admission Orders included an order for oxygen three liters via nasal cannula during the day. The 4/20/23 Physician Order revealed Resident 168 was to be alert and to sit up at 90 degrees for all meals. Staff were to monitor for coughing and choking throughout the meal. The 4/22/23 Nutrition Care Plan revealed Resident 168 was to have one person assistance with meals and staff were to monitor, document and report as needed any signs or symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in (the) mouth, several attempts at swallowing, refusing to eat or appeared concerned during the meal. Resident 168 was to be alert and sit up for all meals. The CNA Point of Care documentation revealed on 4/22/23 and 4/23/23 Resident 168 ate independently after set up for breakfast. The Narcotic Log Book revealed Resident 168 was administered Morphine (narcotic medication which may suppress respiratory effort) at 1:16 PM by Staff 20 (CNA/CMA). [There was no evidence in the resident's medical record or facility records that any other staff member observed the resident after this medication administration.] The facility call light logs revealed Resident 168's call light was activated at 1:49 PM and not reset until 4:31 PM. The 4/23/23 at 1:53 PM Progress Note revealed Resident 168 had trouble swallowing and informed staff food got stuck in her/his throat. The 4/23/23 at 5:45 PM Progress Note revealed Resident 168's family arrived at 4:30 PM to visit and requested Resident 168 be transferred to the hospital because she/he had a gurgling voice and was very sleepy. The nurse assessed Resident 168 to be lethargic, have an upper airway gurgle and clammy skin. The nurse contacted the physician who gave a verbal order to transfer Resident 168 to the hospital. The paramedics arrived and took the resident to the hospital at 5:30 PM. The 4/23/23 Hospital Records revealed upon EMS (Emergency Medical Service) arrival Resident 168 oxygen saturation (O2 sat) was in the 70's while on two liters per minute of oxygen and was somnolent. [Normal oxygen saturation is 95 - 100%. Oxygen order was for three liters.] The resident's O2 sat improved to the 90's on a non-rebreather mask. A physical exam was conducted in the Emergency Department and found the resident alert and oriented on oxygen at six liters via nasal cannula. The resident reported she/he choked on food at the facility. The resident had a vomit stain on the chest of her/his clothing. The 4/27/23 Hospital Discharge Summary revealed Resident 168 died on 4/27/23 due to acute on chronic hypoxemic (low blood oxygen) and hypercapnic (higher than normal carbon dioxide level in the blood) respiratory failure due to recurrent aspiration pneumonia, approximate interval five days. On 5/19/23 at 7:59 AM Staff 31 (Agency CNA) verified she intermittently assisted Resident 168 with the breakfast meal on 4/23/23. Staff 31 stated Resident 168 was tired, did not really want to eat and was in bed with the head of the bed up 40 to 50 degrees. Staff 31 stated she did not read Resident 168's care plan, she was not aware Resident 168 required assistance with eating and returned to Resident 168's room sporadically to offer the resident something to eat. The resident had difficulty with eating, coughed, cleared her/his throat and choked a lot. The resident continued to cough when she/he was laid down for incontinence care. Staff 31 said on 4/23/23, the day was "ridiculous." She checked on the resident after lunch but was unable to recall what time, was unaware Resident 168 activated her/his call light at 1:49 PM and further stated no staff replaced her at the change of shift (2:00 PM) so she stayed at the facility assisting in the care of other residents but did not observe Resident 168 again. On 5/18/23 at 11:05 AM Staff 30 (CNA) stated he assisted Resident 168 with the lunch meal on 4/23/23. Resident 168 was exhausted and experienced difficulty swallowing so he reported the swallowing difficulty to the nurse. On 5/18/23 at 11:08 AM Staff 32 (RN) stated the CNA reported Resident 168 had issues with swallowing, she assessed Resident 168 and she/he "was fine." She downgraded the resident's diet and notified both Resident 168's family and physician. Staff 32 further stated after the family arrived, they called me to the room and requested to send the resident to the hospital. Resident 168 was gurgling and her/his voice was "gargling". The family reported the resident's sleepiness was different. Staff 32 stated she called the physician and then sent the resident to the hospital. Staff 32 stated the last time she checked on Resident 168 was when she assessed Resident 168 at lunch time. On 5/18/23 at 11:49 AM and 5/19/23 at 9:00 AM Staff 3 (RNCM) stated staff are expected to review care plans daily and should be aware of any care plan revisions. Staff 3 verified Resident 168's 4/22/23 Nutrition Care Plan indicated Resident 168 was to be alert and to sit up for all meals and to monitor, document and report any signs or symptoms of dysphagia. Staff 3 further verified the 4/20/23 Physician Order indicated the resident was to be alert and sit up at 90 degrees for all meals. Staff 3 verified the CNA documentation on 4/22/23 and 4/23/23 for the breakfast meal revealed the resident ate independently with set-up assistance and the CNAs did not follow Resident 168's care plan to provide one person assistance or to monitor, document and report signs or symptoms of dysphagia including coughing or choking. Staff 3 stated Resident 168 "had a big sign above [her/his] bed saying [she/he] had to sit up at 90 degrees." On 5/19/23 at 12:30 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 5/19/23 at 2:41 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *Resident 168 was no longer a resident in the facility. *Other residents in the facility had the potential risk for aspiration, transfer to the hospital or death if the facility did not provide adequate supervision. Other residents who required assistance or supervision with meals would be reassessed for needs. Care plans would be revised as indicated. *The DNS or designee would educate the facility staff on Care Plan interventions and Kardex (CNA specific care plan) location and to know high risk items for each resident. An education binder would be created for agency staff to be educated on aspiration risk, monitoring, and education and would add Kardex locations and the need to be familiar with high-risk conditions of the residents they were assigned. Education was started and would be on-going as each staff and agency staff arrived on duty. Agency staff would sign into the Agency Education binder and sign the Kardex for their assigned residents. *The DNS or designee would audit two meals per day to ensure adequate supervision and proper interventions were in place for residents who have aspiration risks identified. Two meals per day for four weeks, then five meals per week for eight weeks. Meal observations would start with dinner on 5/19/23. *The findings would be brought to QAPI (Quality Assurance and Performance Improvement) monthly until resolved. One to one remediation would be done for any negative findings. On 5/23/23 at 10:50 AM it was determined through observations, staff interviews and review of the facility documentation all aspects of the plan of correction were implemented and completed. . ,

F 689 Free of Accident Hazards/Supervision/Devices How the corrective action will be accomplished for identified affected individuals: Resident 168 no longer resides at the facility. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected if the facility fails to monitor residents at risk for aspiration during meals or if the Aspiration Precautions are not in place. DON or Designee will complete audits of current residents and ensure that residents who have aspiration risks are being monitored during meals and that aspiration precautions are in place. What systemic changes will ensure that the deficient practice will not recur: DNS re-educated all staff on aspiration risk precautions and to ensure that resident is getting assistance during meals based on their care plans. DNS has educated the LNs on assisting the Agency staff with access to review the Kardexs for their assigned residents. How the facility will monitor its corrective actions/performance: DNS/Designee will complete 6 meal observation per week, then weekly for 12 weeks; to ensure residents who are considered aspiration risks are being monitored. Any issues identified through the audits will be brought to QAPI monthly until resolved. One to one remediation would be done for any negative findings.

Based on interview and record review it was determined the facility failed to provide urinary catheter care as ordered for 1 of 3 sampled residents (#32) reviewed for urinary catheters. This placed residents at risk for UTI. Findings include: Resident 32 was admitted to the facility in 2021 with diagnoses including paralysis. Resident 32's 5/2023 physician's orders revealed the resident's suprapubic catheter (a tube inserted through the abdominal wall into the bladder to drain urine) was ordered to be changed monthly. Resident 32's 5/2023 TAR revealed on 5/13/23 the resident's suprapubic catheter was not changed and was documented as "7" for "Resident temporarily not available." A review of the resident's clinical record revealed no Progress Notes to indicate why the catheter was not changed or rescheduled. On 5/17/23 at 12:23 PM Staff 2 (DNS) verified the resident's catheter was not changed as ordered. No additional information was provided.

F 690 Bowel/Bladder Incontinence, Catheter, UTI How the corrective action will be accomplished for identified affected individuals: Resident 32 catheter was changed on 5/19/2023. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected if the facility fails to provide catheter care per physician orders. What systemic changes will ensure that the deficient practice will not recur: DNS or Designee re-educated RCMs, LNs on catheter care policy and following physician orders. How the facility will monitor its corrective actions/performance: DNS or Designee will complete a weekly audit for 4 weeks, then monthly audits for 3 months to ensure that orders for catheter care are being followed. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to assess residents after dialysis for 1 of 1 sampled resident (#18) reviewed for dialysis. This placed residents at risk for complications related to dialysis. Findings include: Resident 18 was admitted to the facility in 2022 with diagnoses including end-stage kidney disease. Resident 18's 4/6/23 Cognitive Patterns MDS BIMS score was 4 which indicated the resident was severely cognitively impaired. Resident 18's Care Plan initiated on 12/28/22 revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week at a clinic outside the facility. A review of Resident 18's clinical record revealed six Dialysis Communication Reports (a document designed to share information between the facility and the dialysis clinic and to document pre and post dialysis assessments of the resident by both the facility and the dialysis clinic). Of the six reports, three were from 1/2023, one from 2/2023 and two were undated. None of the six included a post dialysis assessment by the facility. No other post-dialysis assessments were found in the clinical record. On 5/18/23 at 11:33 AM Staff 2 (DNS) was asked to provide the location of the Dialysis Communication Reports. Staff 2 stated they should be in the medical records department. On 5/18/23 at 11:40 AM Staff 30 (Medical Records Director) was asked to provide Resident 18's Dialysis Communication Reports. Staff 30 stated she could not find any but she would look through her unscanned documents. No further documentation was provided. On 5/18/23 at 11:43 AM and 1:55 PM Staff 5 (RNCM) was asked where the resident's Dialysis Communication Reports were located. Staff 5 stated they were probably in the resident's dialysis communication binder. Staff 5 stated the dialysis center was not filling out the forms and the resident did not always remember to give them the form. On 5/18/23 at 2:25 PM Staff 2 confirmed there were no additional Dialysis Communication Reports. Staff 2 acknowledged facility staff could still perform a post-dialysis assessment and document in the progress notes if the resident did not return with a Dialysis Communication Report from dialysis. Staff 2 was informed no post-dialysis assessments were found in the resident's Progress Notes. No additional documentation was provided. On 5/18/23 at 4:19 PM Resident 18 returned to the facility from dialysis with her/his dialysis communication binder. Staff 2 was informed the binder did not contain any previously completed Dialysis Communication Reports. No additional information was provided.

F 698 Dialysis How the corrective action will be accomplished for identified affected individuals: Resident 18 no longer resides at the facility. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected if dialysis protocol is not being implemented, and residents are not assessed post dialysis. DON or Designee will complete an audit of residents who are on dialysis to ensure that all their components are being addressed and followed up on. What systemic changes will ensure that the deficient practice will not recur: DNS re-educated Licensed Nurses on the dialysis policy to include pre and post dialysis assessments. How the facility will monitor its corrective actions/performance: DNS/Designee will audit weekly for 4 weeks and monthly for 3 months to ensure that dialysis process is being implemented according to the policy. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

1.

Based on interview and record review it was determined the facility failed to respond to a residents call lights timely for 4 of 12 sampled residents (#s 32, 39, 41 and 168) reviewed for staffing. This facility's failure was determined to be an immediate jeopardy situation because it resulted in Resident 168's in delay of care, transfer to the hospital, subsequent death and placed all residents at risk for untimely and unmet care needs. Findings include: 1. Resident 168 admitted to the facility on 4/19/23 with diagnoses including dysphagia (difficulty swallowing) and chronic respiratory failure. a. The Direct Care Staff Daily Report revealed the facility had eight CNAs on duty for day shift on 4/23/23 which was the State minimum requirement. The facility's daily assignment sheet revealed Staff 24 (CNA) was assigned to Resident 168's care for the 4/23/23 evening shift. The 4/19/23 Admission Orders included an order for oxygen three liters via nasal cannula during the day. The 4/20/23 Physician Order revealed Resident 168 was to be alert and to sit up at 90 degrees for all meals. Staff were to monitor for coughing and choking throughout the meal. The 4/22/23 Nutrition Care Plan revealed Resident 168 was to have one person assistance with meals and staff were to monitor, document and report as needed any signs or symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat or if she/he appeared concerned during the meal. Resident 168 was to be alert and sit up for all meals. The CNA Point of Care documentation revealed on 4/22/23 and 4/23/23 Resident 168 ate independently after set up for breakfast. The Narcotic Log Book revealed Resident 168 was administered Morphine (narcotic medication which could suppress respiratory effort) at 1:16 PM. [There was no evidence in the resident's medical record or facility records any staff member observed the resident after the medication administration.] The facility call light logs revealed Resident 168's call light was activated at 1:49 PM and not reset until 4:31 PM. The 4/23/23 at 1:53 PM Progress Note revealed Resident 168 had trouble swallowing and informed staff food got stuck in her/his throat. The 4/23/23 at 5:45 PM Progress Note revealed Resident 168's family arrived at 4:30 PM to visit with the resident and requested Resident 168 be transferred to the hospital because she/he had a gurgling voice and was very sleepy. The nurse assessed Resident 168 to be lethargic, have an upper airway gurgle and clammy skin. The nurse contacted the physician who gave a verbal order to transfer Resident 168 to the hospital. The paramedics arrived and took the resident to the hospital at 5:30 PM. There was no evidence in Resident 168's medical record a full respiratory assessment was completed. The 4/23/23 Hospital Records revealed on EMS (Emergency Medical Service) arrival Resident 168 oxygen saturation (O2 sat) was in the 70's while on two liters per minute of oxygen and was somnolent. [Normal oxygen saturation is 95 - 100%. Oxygen order was for three liters.] The resident's O2 sat improved to the 90's on a non-rebreather mask. A physical exam was conducted in the Emergency Department found the resident alert and oriented on oxygen at six liters via nasal cannula. The resident reported she/he choked on food at the facility. The resident had a vomit stain on the chest of her/his clothing. The 4/27/23 Hospital Discharge Summary revealed Resident 168 died on 4/27/23 due to acute on chronic hypoxemic (low blood oxygen) and hypercapnic (high carbon dioxide level in the blood) respiratory failure due to recurrent aspiration pneumonia, approximate interval five days. On 5/19/23 at 7:59 AM Staff 31 (Agency CNA) verified she assisted Resident 168 with the breakfast meal on 4/23/23. Staff 31 stated Resident 168 was tired, did not really want to eat and was in bed with the head of the bed up 40 to 50 degrees. Staff 31 stated she had not read Resident 168's care plan, she was not aware Resident 168 required assistance with eating and returned to Resident 168's room sporadically to offer the resident something to eat. The resident had difficulty with eating, coughed, cleared her/his throat and choked a lot. The resident continued to cough when she/he was laid down for incontinence care. Staff 31 said on 4/23/23, the day was "ridiculous", she checked on the resident after lunch but was unable to recall what time, was unaware Resident 168 activated her/his call light at 1:49 PM and further stated no staff replaced her at the change of shift (2:00 PM) so she stayed at the facility assisting in the care of other residents but did not observe Resident 168 again. On 5/18/23 at 11:08 AM Staff 32 (RN) stated a CNA reported Resident 168 had issues with swallowing, she assessed Resident 168 and she/he "was fine." She downgraded the resident's diet and notified both Resident 168's family and physician. Staff 32 further stated after the family arrived, they called her to the room and requested to send the resident to the hospital. Resident 168 was gurgling and her/his voice was "gargling". The family reported the resident's sleepiness was different. Staff 32 stated she called the physician and then sent the resident to the hospital. Staff 32 stated the last time she checked on Resident 168 was when she assessed Resident 168 at lunch time. On 5/18/23 at 11:49 AM and 5/19/23 at 9:00 AM Staff 3 (RNCM) stated staff were expected to review care plans daily and be aware of any care plan revisions. Staff 3 verified Resident 168's 4/22/23 Nutrition Care Plan indicated Resident 168 was to be alert and to sit up for all meals and to monitor, document and report and signs or symptoms of dysphagia. Staff 3 further verified the 4/20/23 Physician Order indicated the resident was to be alert and sit up at 90 degrees for all meals. Staff 3 verified the CNA documentation on 4/22/23 and 4/23/23 for the breakfast meal revealed the resident ate independently with set-up assistance and the CNAs did not follow Resident 168's care plan to provide one person assistance or to monitor, document and report signs or symptoms of dysphagia including coughing or choking. Staff 3 verified Resident 168's call light went unanswered for two hours and 42 minutes between 1:49 PM and 4:31 PM on 4/23/23. On 5/18/23 at 4:05 PM Staff 24 (CNA) stated she only worked night shifts and did not work the 4/23/23 evening shift. On the morning of 5/19/23 Staff 1 (Administrator) stated Staff 24 was assigned to care for Resident 168 on evening shift on 4/23/23, she talked to Staff 24 who did not remember working that shift. She asked Staff 24 to come in to figure out if Staff 24 worked as scheduled or not. No additional information was provided. On 5/19/23 at 12:30 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 5/19/23 at 2:41 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: * Resident 168 was no longer a resident in the facility. * Other residents requiring assistance had the risk of unmet care needs and negative outcomes if adequate staff were not provided or call lights were not answered timely. See on-going audits. * The Administrator and DNS would provide education to staff and agency staff on the call light system, the volume would be turned on and up on all monitors and kiosks for call lights to be heard. The assigned charge nurse would monitor the call light board and triage the call lights between assigned staff and available resources of the IDT (interdisciplinary team) and float staff. Charge Nurses would be educated on the call light responsibilities of their duty to ensure all care needs were met on their shift. Education had started and would continue as staff and agency staff came on shift. The Administrator, DNS and RNCMs would meet on Monday, Wednesday and Friday after stand-up to review the acuity needs and adjust staffing levels accordingly to ensure all care needs could be met with toileting, turning, repositioning and ADL needs. * The Administrator or DNS would pull the call light report every eight hours, prior to the end of each shift for the next seven days. The would review any call light over 20 minutes and speak with the nurse about assessments and ensuring that the care needs were met for the residents. After seven days, if the call light times were below 20 minutes, the audits would go to daily for 11 weeks. * All findings would be brought through QAPI (Quality Assurance and Performance Improvement) until resolved. One to one remediation would be done for any negative findings. On 5/23/23 at 10:50 AM it was determined through observations, staff interviews and review of the facility documentation all aspects of the plan of correction were implemented and completed. . b. Review of Resident 168's call light logs revealed the following:: * 4/20/23 at 9:51 PM; 40 minutes and 26 seconds * 4/21/23 at 12:31 AM: 28 minutes and 17 seconds * 4/23/23 at 6:15 AM; 25 minutes and 40 seconds * 4/23/23 4:31 PM: 2 hours, 42 minutes and 53 seconds On 5/19/23 at 9:00 AM Staff 3 (RNCM) acknowledged the long call light wait times on 4/20/23, 4/21/23 and 4/23/23. , 2. Resident 32 was admitted to the facility in 2021 with diagnoses including paralysis. On 5/16/23 at 10:32 AM Resident 32 stated the facility did not have enough staff to answer her/his calls for assistance timely. The resident stated it took staff 30 to 45 minutes to answer her/his call light. Resident 32's call light record from 5/10/23 through 5/17/23 revealed 12 times when the resident's call light was on for more than 20 minutes. On five occasions the call light was on for more than one hour with the longest at three hours and eleven minutes. On 5/18/23 at 3:07 PM Staff 1 (Administrator) stated the expectation was for resident call lights to be answered within 20 minutes. Staff 1 stated the facility's QAPI (Quality Assurance and Performance Improvement) committee had been working on call light response times since 1/2023 and all department heads had a call light monitoring system in their offices. Staff 1 was unable to explain why the issue was not resolved. Staff 29 (Regional RN) stated the facility was having technical issues with the electronic call light system and residents received care but the call lights were not getting turned off after the care was provided. Staff 29 acknowledged administrative staff were not out on the halls observing to verify the long call light issue was actually the lights not being reset and residents had received timely care. 3. Resident 39 was admitted to the facility in 2021 with diagnoses including paralysis of the lower body. On 5/15/23 at 9:59 AM Resident 39 stated she/he had to wait up to three hours for staff to respond to her/his call for assistance, and wait times are often more than 20 minutes. Resident 39's call light record from 5/10/23 through 5/17/23 revealed six times when the resident's call light was on for more than 20 minutes. The longest was one hour and forty five minutes. On 5/18/23 at 3:07 PM Staff 1 (Administrator) stated the expectation was for resident call lights to be answered within 20 minutes. Staff 1 stated the facility's QAPI (Quality Assurance and Performance Improvement) committee had been working on call light response times since 1/2023 and all department heads had a call light monitoring system in their offices. Staff 1 was unable to explain why the issue was not resolved. Staff 29 (Regional RN) stated the facility was having technical issues with the electronic call light system and residents received care but the call lights were not getting turned off after the care was provided. Staff 29 acknowledged administrative staff were not out on the halls observing to verify the long call light issue was actually the lights not being reset and residents had received timely care. 4. Resident 41 was admitted to the facility in 2021 with diagnoses including irregular heart rhythm. On 5/15/23 at 9:59 AM Resident 41 stated she/he waited up to one and a half hours for staff to answer her/his calls for assistance four times in the last week. Resident 41's call light record from 5/10/23 through 5/17/23 revealed 27 times when the resident's call light was on for more than 20 minutes. On four occasions the call light was on for more than one hour with the longest at one hour and twenty minutes. On 5/18/23 at 3:07 PM Staff 1 (Administrator) stated the expectation was for resident call lights to be answered within 20 minutes. Staff 1 stated the facility's QAPI (Quality Assurance and Performance Improvement) committee had been working on call light response times since 1/2023 and all department heads had a call light monitoring system in their offices. Staff 1 was unable to explain why the issue was not resolved. Staff 29 (Regional RN) stated the facility was having technical issues with the electronic call light system and residents received care but the call lights were not getting turned off after the care was provided. Staff 29 acknowledged administrative staff were not out on the halls observing to verify the long call light issue was actually the lights not being reset and residents had received timely care. , 2. Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 5/15/23 the facility provided a list of residents who: -Required one or two person assistance with bathing: 25; -Were fully dependent for bathing: 43; -Required one or two person assistance for eating: 35; -Were fully dependent on staff for eating: 15; -Required one or two person assistance for toileting: 42; -Were fully dependent on staff for toileting: 24; -Required one or two person assistance with transfers: 37; -Were fully dependent on staff for transfers: 28; -Required one or two person assistance with dressing: 56; -Were fully dependent on staff for dressing: 12; -Had behavioral healthcare needs: 26; -Required suctioning: 17; -Required tube feedings: 15; -Required tracheostomy care: 16. A review of the facility Direct Care Staff Daily Reports from 4/1/23 through 5/14/23 revealed the facility had insufficient CNA staff based on state minimum staffing ratios for one or more shifts on the following dates: Skilled/Long-Term Care Units: 4/1, 4/2, 4/9, 4/10, 4/12, 4/13, 4/27 and 5/2. Ventilator Assisted Unit: 4/9, 4/15, 4/16, 4/29, 4/30 and 5/14 . Random observations revealed the following: 5/15/23: -2:17 PM A strong urine smell was noted in the hallway around rooms 204 and 205; -2:24 PM Three CNAs out of six were present for the evening shift (Shift change occurred at 2:00 PM); -2:30 PM Two day shift agency CNAs were waiting for evening shift CNAs to arrive so they could leave for the day; -2:37 PM The call light in room 401 was activated for 25 minutes; -2:40 PM There was a resident in the 200 hallway yelling for help. 5/16/23: -2:37 PM The call light in room 206 was activated for 46 minutes; 5/17/23: -8:23 AM The call light in room 405 was activated for 18 minutes; -8:35 AM The call light in room 213 was activated for 25 minutes and the call light in room 301 was activated for 22 minutes; -10:38 AM The call light in room 101 was activated for 46 minutes and the call light in room 204 was activated for 21 minutes; -12:37 PM The call light in room 210 was activated for 32 minutes; -1:11 PM The call light in room 409 was activated for 35 minutes. 5/18/23: -8:52 AM The call light in room 302 was activated for 47 minutes, the call light in room 309 was activated for 42 minutes, the call light in room 310 was activated for 37 minutes and the call light in room 207 was activated for 25 minutes; -9:29 AM The call light in room 212 was activated for 30 minutes; -11:56 AM A resident on the 200 hallway was yelling for help due to her/his hip hurting. At 12:00 PM a dietary staff member entered the room to assist the resident and was unable to provide assistance due to the resident requiring CNA help. Interviews with staff revealed the following concerns: -On 5/17/23 at 12:24 PM Staff 8 (Therapy Director) stated the rehab department was currently understaffed with OT staff so he had to prioritize residents' therapy services and reduce the amount of time spent with residents. -On 5/18/23 at 8:29 AM Staff 11 (CNA) stated CNA staff were unable to keep up with residents' turning schedules and could not meet time requirements for getting residents up and put back down. Staff 11 stated she previously spoke with management regarding staffing concerns and was told the facility was only allowed to staff to the State minimum staffing ratios. She stated it was impossible to take all of her breaks. -On 5/18/23 at 9:31 AM and 5/22/23 at 12:55 PM Staff 6 (CNA) stated all of the residents on her unit required two person assistance which made it difficult to get everything done. She stated residents' were supposed to be turned every two hours but that was "a dream." She stated there were two behavioral residents who got angry, cussed and exhibited behaviors if they had to wait too long for care. She stated there was no way for CNA staff to take all of their breaks and she often provided extra care to the residents on her own time. -On 5/18/23 at 10:08 AM Staff 26 (CNA) reported the facility was short staffed for the past two months. Staff 26 stated the facility utilized one to five agency CNAs per shift and the agency CNAs did not receive adequate orientation and were sent out on the floor without knowing the residents. Staff 26 also reported they were unable to give shift change reports because they were too busy, which impacted resident care. -On 5/18/23 at 10:58 AM Staff 16 (Staffing Coordinator) stated she staffed to the State minimum staffing ratios for CNA and licensed nursing and not to the acuity needs of the residents. Staff 16 stated any staffing needs outside of the minimum staffing ratios were determined by Staff 1 (Administrator) or Staff 2 (DNS). -On 5/18/23 at 2:30 PM Staff 1 stated in the past two months the facility utilized a lot of agency CNA and nursing staff. Staff 1 reported the facility did not check agency staff's competency to work in the nursing home setting and assumed they were competent since they were licensed. Staff 1 stated the facility staffed according to the State minimum staffing ratios. -On 5/22/23 at 8:20 AM Staff 18 (CNA) stated she was unable to adhere to the required two hour turning schedule for residents. She stated there were days when she arrived for the start of day shift (at 6:00 AM) and she was the only CNA for the entire unit until 7:30 AM, when the second CNA arrived. She stated on certain days the unit was not fully staffed with CNAs until 10:00 AM when the third CNA was scheduled to start her shift. Staff 18 stated she never got all of her breaks and often could not take her full lunch. She stated she previously told administration her concerns with staffing but nothing changed. Staff 18 stated when she asked for additional help she was told there was no help to offer. -On 5/22/23 at 12:41 PM Staff 7 (CNA) stated the unit was often short staffed and there were times she was unable to complete bathing care. She stated there was a resident who frequently asked for showers but they only provided a bed bath because the resident took a long time to shower and they did not have adequate staff. Staff 7 stated CNAs were unable to turn residents every two hours as required and if they could turn the residents more often it would help with the residents' bed sores. Staff 7 stated she had to pick and choose who got up because they did not have adequate staffing to get all of the residents up who wanted to get up. Staff 7 stated CNA staff were unable to do any stretching or exercises with residents and, due to the facility not having a restorative program, it would be helpful to the residents if the CNAs provided this service. On 5/22/23 at 1:51 PM Staff 38 (Director of Operations) was informed of staffing concerns within the facility and acknowledged the current staffing issues were not acceptable and he would present a staffing model based on acuity in the morning. This is a repeat citation previously cited on 4/19/22, 2/13/23 and 3/30/23. ,

F725- Sufficient Nursing Staff How the corrective action will be accomplished for identified affected individuals: Resident 168 no longer resides at the facility. Resident 32 was interviewed and reports that his needs have been met. Resident 39 was interviewed and reported that his needs were being met. Resident 41 was interviewed and reported this needs were being met. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be at risk of untimely and unmet care needs if call lights are not answered in a timely manner. Administrator/DON will interview current residents related to care needs and to ensure needs are being met in a timely manner. What systemic changes will ensure that the deficient practice will not recur: Administrator/Designee re-educated staff on the importance of answering call lights in a timely manner, to keep volume up on kiosks. Administrator/DNS are utilizing an Acuity tool for determining adequate staffing ratios. How the facility will monitor its corrective actions/performance: Administrator/Designee will complete daily audits for 12 weeks, then weekly audits for 2 months to ensure that the facility is meeting residents needs in a timely manner. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day seven days per week for 4 of 44 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 4/1/23 through 5/14/23 revealed on 4/1, 4/2, 4/7 and 5/14 there was no RN coverage for eight consecutive hours. On 5/18/23 at 11:34 AM Staff 16 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified days.

F727- RN 8 hrs/7 days/Wk, Full time DON How the corrective action will be accomplished for identified affected individuals: No resident has been identified. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential risk for lack of RN assessments and care by not having 8 hours of RN coverage. What systemic changes will ensure that the deficient practice will not recur: The facility continues to recruit for RN, offer bonuses, reach out to sister facility, and connect with Agency to obtain RN coverage. If the facility is unable to find RN to cover, the RN RCM will be asked to cover, then lastly RN DNS will step in to cover to maintain the 8 hours RN coverage. The Staffing Coordinator has been educated to notify the Admin/DNS if there is no RN coverage scheduled for assistance to get this covered with other resources. How the facility will monitor its corrective actions/performance: Administrator or Designee will complete daily audits for 4 weeks, then monthly audits for 3 months to ensure that the facility is 8 hours of RN coverage. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 5 sampled CNA staff (#s 19, 20, 22 and 23) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 5/17/23 indicated the following employees had not received their annual performance evaluations: -Staff 19 (CNA), hire date 4/4/18; last performance evaluation was completed on 8/26/21. -Staff 20 (CNA), hire date 6/17/17; last performance evaluation was completed on 6/11/21. -Staff 22 (CNA), hire date 3/10/21; no performance evaluation was completed. -Staff 23 (CNA), hire date 5/31/10; last performance evaluation was completed on 8/25/21. On 5/17/23 at 3:05 PM Staff 17 (Human Resource Manager) confirmed annual performance reviews for the identified staff were not completed.

F 730 Nurse Aide Perform Review- 12 hour/Year In-services How the corrective action will be accomplished for identified affected individuals: No specific residents have been identified as being affected during the survey. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected by lack of competent staff if the C.N.As do not receive adequate training. HR and DNS will complete an audit of staff who have not completed their required 12 hours of in-services and will be planning for staff to come in to complete all their required training. What systemic changes will ensure that the deficient practice will not recur: Administrator provided education to the HR Director and the DNS on the process of ensuring that the monthly trainings are completed timely for the Aides towards the 12hrs of training. DNS will hold the Aides accountable. How the facility will monitor its corrective actions/performance: Administrator/DNS will review monthly In-Services topics and verify completion of the required In-Services. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#56) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 56 was admitted to the facility in 1/2023 with diagnoses including muscular dystrophy (a genetic disorder causing progressive muscular weakness) and respiratory failure. A review of Resident 56's 4/1/23 through 5/17/23 MAR indicated an order for Senna-Ducusate Sodium (a laxative and stool softener) which was administered every morning and at bedtime for bowel health. The order indicated to hold the medication if Resident 56 had diarrhea. The MAR indicated Resident 56 was administered Senna twice daily and there were no instances when the medication was held. A review of Resident 56's Bowel Elimination Flowsheets from 4/18/23 through 5/17/23 indicated Resident 56 had loose stools/diarrhea on the following dates: 4/21, 4/22, 4/24, 4/25, 4/26, 4/28, 4/30, 5/1, 5/2, 5/3, 5/5, 5/6, 5/7, 5/8, 5/12 and 5/14. On 5/18/23 at 1:35 PM and 5/23/23 at 10:17 AM Staff 14 (RNCM) confirmed Resident 56's bowel medication should have been held on the identified dates and Staff 2 (DNS) stated she expected bowel medications to be held when residents had loose stool/diarrhea.

F 757 Drug Regimen is Free from Unnecessary Drugs. How the corrective action will be accomplished for identified affected individuals: Resident 56 was assessed for bowel management and the chart has been updated to reflect the current care needs. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents bowel care management has the potential to be affected if bowel protocol is not being monitored adequately. DNS and Designee will complete an audit of resident bowel protocol to ensure that the necessary components are being followed in a timely manner. What systemic changes will ensure that the deficient practice will not recur: DNS re-educated LN and Med-aide on bowel policy and procedures. How the facility will monitor its corrective actions/performance: DNS/Designee will complete daily audits for 4 weeks, then monthly audits for 3 months to ensure that bowel care is being monitored and followed up in a timely manner. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on observation and interview it was determined the facility failed to store treatment supplies and medications in locked compartments for 1 of 2 treatment carts randomly observed. This placed residents at risk for medication diversion and accidents. Findings include: The facility's 11/2020 Storage of Medications Policy noted: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts were not to be left unattended. On 5/15/23 at 12:58 PM an unlocked treatment cart was observed near the nurse's station on Hall 100. Staff were observed to walk by the cart but did not lock the cart. There were no residents in the area. On 5/15/23 at 1:00 PM Staff 4 (LPN) stated the treatment cart contained different items used for treatments including insulin and resident prescription medications including Coumadin (drug used to prevent blood clots), lanthanum carbonate (drug used to lower high blood phosphate levels for individuals on dialysis), sevelamer (a drug used to lower high blood pressure in patients who are on dialysis). Staff 4 stated she forgot to lock the cart when she walked away. On 5/15/23 at 1:47 PM Staff 2 (DNS) stated the cart contained treatment supplies and medications and should have been locked.

F 761 Label/Store Drugs & Biologicals How the corrective action will be accomplished for identified affected individuals: No residents have been identified as being affected during the survey. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected by medication diversion and accidents if Medication is not being locked. See on-going audits. What systemic changes will ensure that the deficient practice will not recur: DNS re-educated Med aides and LNs to ensure that Medication is stored properly. How the facility will monitor its corrective actions/performance: DNS/Designee will complete daily audits for 4 weeks, then weekly audits for 3 months to ensure that Medication/Treatment Cart is always locked. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to ensure residents received specialized rehabilitative services (OT services) at the frequency needed for donning/doffing splints for 1 of 2 sampled residents (#2) reviewed for therapy. Findings include: Resident 2 was admitted to the facility in 6/2022 with diagnoses including multiple sclerosis (progressive neurological diseases affecting the brain and spinal cord) and functional quadriplegia (complete immobility). A 6/2/22 physician order requested an OT evaluation and treatment. Resident 2's 3/12/23 Quarterly MDS indicated the resident had limited functional mobility due to impairments on both sides of her/his upper and lower extremities. Resident 2's 3/13/23 through 6/10/23 OT Recertification, Progress Report (most recent progress report dated 4/21/23) and Updated Therapy Plan indicated the following: -Caregivers will demonstrate good understanding of orthotic wearing schedule and donning/doffing protocol in order to reduce long term risk for contractures/skin breakdown. Caregivers not yet trained. -Resident 2 wore and tolerated her/his left elbow extension splint for five to six hours a day. -Resident 2 was to wear bilateral hand splints at all times other than bathing in order to reduce the risk for contractures/skin breakdown. [Resident 2] exhibited good tolerance and compliance with bilateral hand splints. On 5/15/23 at 10:30 AM an instructional sign was observed posted on the wall above Resident 2's bed which indicated bilateral blue air hand splints were to be on at all times except during bathing and the resident's left arm elbow splint was to be on every day for four to six hours as tolerated. Multiple random observations from 5/15/23 through 5/17/23 between the hours of 8:00 AM and 4:00 PM revealed Resident 2's left elbow was flexed and her/his left hand exhibited contractures. A small stuffed animal was sometimes observed in or near her/his left hand. Resident 2's right arm was extended and her/his hand was clenched. No device was observed in Resident 2's right hand. Resident 2 was not wearing bilateral hand splints or a left elbow extension splint. On 5/17/23 at 11:55 AM and 1:20 PM Staff 6 (CNA) stated Resident 2 had hand splints and an elbow splint that was supposed to be worn everyday. Staff 6 stated therapy was supposed to put Resident 2's splints on but she did not see the splints on everyday, including today (5/17/23) or yesterday (5/16/23). Staff 6 stated she did not put Resident 2's splints on because she was not yet trained to do so but she sometimes removed the splints. On 5/17/23 at 12:17 PM Staff 7 (CNA) stated Resident 2 had splints that were supposed to be put on daily but were not consistently being put on. Staff 7 stated therapy put Resident 2's splints on and took them off because staff were not trained yet. On 5/17/23 at 12:23 PM Staff 37 (OT) stated she did not know anything about Resident 2's splints because she had never seen Resident 2. On 5/17/23 at 12:24 PM Staff 8 (Rehab Director) stated Resident 2 should have bilateral hand splints on at all times and a left elbow extension splint on for four to six hours a day. Staff 8 stated therapy was "fully responsible" for putting Resident 2's splints on and taking them off. Staff 8 stated Resident 2 was scheduled with OT therapy two to three times a week and on the days Resident 2 was not scheduled, the resident's splints were "most likely" not being put on. Staff 8 reported Resident 2's hand splints were special, custom splints so staff were not able to put them on because they were not trained yet. Staff 8 stated the rehab department was currently understaffed with OT staff so he had to prioritize residents' therapy services and reduce the amount of time spent with residents. On 5/17/23 at 12:48 PM Staff 9 (Certified Occupational Therapist) stated Resident 2 should have hand splints on at all times and Resident 2 was tolerating the hand splints well so "you should see them on." Staff 9 stated she put Resident 2's splints on two to three times a week when she was assigned Resident 2 and was unsure how Resident 2's splints were put on when the resident was not scheduled with her. On 5/17/23 at 2:02 PM Staff 15 (LPN) stated he spoke with Staff 9 and verified Resident 2's bilateral hand and elbow splints were supposed to be put on by OT staff. On 5/23/23 at 10:17 AM Staff 2 (DNS) acknowledged Resident 2's splints should be put on as instructed.

F 825 Provide/Obtain Specialized Rehab Services How the corrective action will be accomplished for identified affected individuals: Resident 2 had OT services reviewed and the treatment plan has been updated to reflect the residents clinical needs. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected if the facility fails to provide OT services as ordered. The Rehab Director will audit the current resident who are on OT case load to ensure that splinting tasks are being completed per care plan or treatment plan. What systemic changes will ensure that the deficient practice will not recur: The Rehab director re-educated the therapy team and nursing team to ensure that resident OT services and recommendation are being followed. How the facility will monitor its corrective actions/performance: Rehab Director/Designee will complete weekly audits for 4 weeks, then monthly audits for 3 months to ensure that OT services are provided related to splinting services. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to accurately document in the medical record for 2 of 5 sampled residents (#'s 27 and 168) reviewed for pressure ulcers. This placed residents at risk for inaccurate medical records and unmet treatment needs. Findings include: 1. Resident 168 admitted to the facility on 4/19/23 with diagnoses including chronic respiratory failure. The resident discharged on 4/23/23. a. The 4/19/23 Admission Nurse Database (nursing assessment) indicated Resident 168 had a right iliac crest blister. The 4/19/23 Skin and Wound Assessment revealed an "undiagnosed" wound which measured 8.29 cm by 4.55 cm. The assessment indicated current treatment included wound cleanser and a foam dressing. The accompanied picture of Resident 168's buttocks revealed two Stage II (partial thickness skin loss) pressure ulcers with red skin surrounding and between the two wounds. A review of the 4/2023 TARs revealed no scheduled treatments for the two wounds. A PRN order for house barrier cream at least BID and initiate preventive measures (offloading) for any reddened areas of skin until healed was not administered. On 5/18/23 at 11:49 AM and 5/22/23 at 11:43 AM Staff 3 (RNCM) verified the 4/19/23 Admission Database documented a single blister for Resident 168's admission skin issues and the 4/19/23 Wound and Skin Assessment picture revealed two Stage II pressure ulcers. Staff 3 verified the Admission Database incorrectly documented the number and type of skin issues Resident 168 admitted with and acknowledged no wound treatments were in place as documented on the Skin and wound evaluation. b. The Point of Care (POC) documentation indicated Resident 168 was turned and repositioned on the 4/25/23 evening shift and was up in a chair for dinner on 4/25/23. On 5/18/23 at 11:49 AM Staff 3 (RNCM) verified the 4/25/23 POC documentation was inaccurate as the resident was no longer in the facility. , 2. Resident 27 admitted to the facility in 2021 with diagnoses including Parkinson's disease. A 3/15/23 Annual MDS reported Resident 27 was at risk for developing pressure ulcers. A 3/30/23 Skin and Wound Evaluation reported Resident 27 developed a newly identified sacral (tailbone) pressure ulcer documented to be at a Stage I (red, blue or purple skin discoloration). Skin and Wound Evaluations completed 4/18/23, 4/25/23 and 5/2/23 reported Resident 27's sacral pressure ulcer were Stage I. Resident 27's Care Plan from 4/30/23 included pressure ulcer care and monitoring including "weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth and type of tissue." On 5/18/23 at 11:28 AM Wound Evaluation records from 5/2/23 were reviewed with Staff 5 (RNCM). Staff 5 confirmed Resident 27's sacral pressure ulcer was incorrectly documented at Stage I and should have been recorded at a Stage II (partial thickness skin loss) due to the presence of a visible open sore.

F 842 Resident Records- Identifiable Information How the corrective action will be accomplished for identified affected individuals: Resident 27 is no longer residing at the facility. Resident 168 no longer residing at the facility. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential risk for inaccurate medical records and unmet treatment needs If the facility fails to document accurately in the medical record. DNS or Designee audited current residents wounds for accurate documentations and assessments. What systemic changes will ensure that the deficient practice will not recur: DNS re-educated RCMs and LNs on accurate wound documentation. How the facility will monitor its corrective actions/performance: DNS/Designee will complete weekly audits for 4 weeks, then monthly audits for 3 months to ensure that wound documentation is accurate. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to address QAPI (Quality Assurance and Performance Improvement) identified concerns regarding sufficient staff for 1 of 1 QA (Quality Assurance) committees reviewed for QAPI. This resulted in the failure to provide timely care and assistance to residents. Findings include: The 4/19/22 Annual Survey identified nurse staffing as an area requiring correction in order to provide adequate care to residents. A 2/12/23 complaint investigation identified nurse staffing as an area requiring continued correction with deficient practice identified from 8/2022 through 12/2022. Review of QAPI Meeting Minutes from 1/2023 identified nurse staffing as an area to address and review in future QAPI meetings. Review of QAPI Meeting Minutes from 2/2023, 3/2023 and 4/2023 included minimal information regarding an approach and attempt to resolve the ongoing identified area of nurse staffing. During the current 5/15/23 to 5/23/23 Annual Survey staffing was reviewed and identified as a continued deficient practice which impacted quality of care for residents. On 5/23/23 at 10:34 AM Staff 1 (Administrator) was informed nurse staffing and call light response timeliness were previously identified as an area of deficient practice and has continued to occur. Staff 1 confirmed nurse staffing was an on-going issue which had not been resolved by QAPI since it was identified as an issue in 4/2022. See F725.

F 865 QAPI Program/plan, Disclose/Good Faith Attempt How the corrective action will be accomplished for identified affected individuals: No resident was identified. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected by not having an effective QAPI program that identifies root cause analysis and system improvements related to sufficient staffing. What systemic changes will ensure that the deficient practice will not recur: Regional Nurse consultant/RDO re-educated Administrator and Director of Nursing on having an effective QAPI program with timely interventions and revisions as necessary. How the facility will monitor its corrective actions/performance: RDO will be reviewing facility QAPI program weekly times 4 weeks and monthly times 2 month to ensure that all components of an effective QAPI program are functioning properly.

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 4 of 44 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident care and services. Findings include: Review of the Direct Care Staff Daily Reports from 4/1/23 through 5/14/23 revealed on 4/1, 4/2, 4/7 and 5/14 there was no RN coverage for eight consecutive hours from the start of day shift and the end of evening shift. On 5/18/23 at 11:34 AM Staff 16 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified days. This is a repeat citation previously cited on 4/19/22.

M182 OAR Nursing Services: Minimum Licensed Nurse Staff How the corrective action will be accomplished for identified affected individuals: No residents were identified as being affected during the survey. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential risk for lack of RN oversight including resident care and services. What systemic changes will ensure that the deficient practice will not recur: The administrator educated the DNS and the Staffing Coordinator that the 8hr of RN coverage will need to be between daytime hours of 6am-10pm. That the staffing coordinator will notify the Administrator or DNS if the RN hours are outside of those hours so that additional resources can be arranged. How the facility will monitor its corrective actions/performance: The Administrator will audit the scheduled weekly x4 weeks, then monthly x3 months to ensure the RN coverage is meeting the regulation. 1:1 remediation will be done for any negative findings. All findings will be brought through QAPI monthly until resolved.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 8 of 44 sampled days reviewed for sufficient staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the facility Direct Care Staff Reports from 4/1/23 through 5/14/23 revealed the facility had insufficient CNA staff for one or more shifts on the following dates: 4/1, 4/2, 4/9, 4/10, 4/12, 4/13, 4/27 and 5/2. On 5/18/23 at 11:34 AM Staff 16 (Staffing Coordinator) acknowledged the lack of CNA coverage on the identified days.

M183 OAR Nursing Services: Minimum CNA Staffing How the corrective action will be accomplished for identified affected individuals: No residents were identified as being affected during the survey. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential risk for delayed care and unmet needs if the facility doesnt meet the state minimum requirements. What systemic changes will ensure that the deficient practice will not recur: The Administrator provided education to the Staffing Coordinator to report any shortages on the schedule to the Administrator and DNS so that they can assist with coverage and to use other resources as needed to meet the needs of the residents. How the facility will monitor its corrective actions/performance: The administrator will review the DHS sheets daily x12 weeks to ensure that the staffing minimums are met across the 3 shifts. 1:1 remediation will be done as needed. All findings will be brought through QAPI monthly until resolved.

******************** 411-085-0310 Residents' Rights: Generally Refer to F550 and F578 ******************** 411-085-0320 Residents' Rights: Charges and Rates Refer to F582 ******************** 411-0086-0110 Nursing Services: Resident Care Refer to F677, F684, F687 and F698 ******************** 411-0086-0230 Activity Services Refer to F679 ******************** 411-0086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686, F689, F690 and F757 ******************** 411-0086-0100 Nursing Services: Staffing Refer to F725 and F727 ******************** 411-0086-0310 Employee Orientation and In-Service Training Refer to F730 ******************** 411-0086-0260 Pharmaceutical Services Refer to F761 ******************** 411-0086-0220 Rehabilitative Services Refer to F825 ******************** 411-0085-0220 Quality Assurance Refer to F865 ********************

1.

Based on interview and record review it was determined the facility failed to ensure a registered nurse was on duty for at least 16 hours a day for 10 of 44 days reviewed for sufficient staffing on the ventilator assisted unit. This placed residents at risk for lack of comprehensive assessments and unmet needs. Findings include: Review of the Ventilator Assisted Program (VAP) unit's Direct Care Staff Daily Reports from 4/1/23 through 5/14/23 revealed the facility did not have a registered nurse on duty daily for 16 hours on the following dates: 4/4, 4/5, 4/13, 4/16, 4/20, 4/27, 4/30, 5/3, 5/6 and 5/11. On 5/18/23 at 11:34 AM Staff 16 (Staffing Coordinator) acknowledged the VAP unit did not have 16 hours of RN coverage on the identified dates. 2. Based on interview and record review it was determined the facility failed to ensure state minimum Ventilator Assisted Trained CNA staff were maintained for 6 of 44 days reviewed for sufficient staffing on the ventilator assisted unit. This placed residents at risk for lack of care. Findings include: Review of the Ventilator Assisted Program (VAP) unit's Direct Care Staff Daily Reports from 4/1/23 through 5/14/23 revealed the facility had insufficient CNA staff for one or more shifts on the following dates: 4/9, 4/15, 4/16, 4/29, 4/30 and 5/14. On 5/18/23 at 11:34 AM Staff 16 (Staffing Coordinator) acknowledged the facility lacked CNA coverage on the identified days. This is a repeat citation previously cited on 4/19/22, 2/13/23 and 3/30/23.

V 160 OAR Staffing How the corrective action will be accomplished for identified affected individuals: No resident potential to be affected identified. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected by lack of comprehensive assessments and unmet care needs if the facility does not provide 16 hours of RN coverage. What systemic changes will ensure that the deficient practice will not recur: The facility continues to recruit for RNs, offer bonuses, reach out to sister facility and connected with Agency to obtain RN coverage. If the facility is unable to find RN to cover, the RN RCM will be asked to cover, then lastly RN DNS will step in to cover to maintain the 16 hours RN coverage. The Staffing Coordinator has been educated by the Administrator to notify the Administrator and DNS if the 16hrs of RN coverage is not met with the scheduled nurses to assist with the set up of alternate resources. How the facility will monitor its corrective actions/performance: Administrator or designee will complete daily audits for 4 weeks, then monthly audits for 3 months to ensure that the facility is 16 hours of RN coverage. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to ensure the administrator completed six hours of continuing education requirements related to the care of residents dependent on an invasive mechanical ventilation as a means of life support. This placed residents at risk for lack of knowledgeable supervision. Findings include: On 5/16/23 at 3:35 PM Staff 1 (Administrator) was asked to provide documentation of her annual six hours of continuing education related to the ventilator unit. Staff 1 provided continuing education for 2021. She was requested to provide current continuing education and stated she would provide the information in the morning. On 5/17/23 at 8:17 AM Staff 1 stated she was not aware she needed to complete six hours of continuing education annually and acknowledged she did not complete six hours of continuing education related to the ventilator unit as required.

V 170 OAR Staff Training How the corrective action will be accomplished for identified affected individuals: Administrator completed the 6 hours training on 5/17/2023 How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected if the Administrator is not fully trained annually in working with residents who are dependent on an invasive mechanical ventilation. What systemic changes will ensure that the deficient practice will not recur: RDO re-educated Administrator on completing the required annual 6 hours training per year. How the facility will monitor its corrective actions/performance: Administrator will complete the required training annually. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review, it was determined the facility failed to replace missing items for 1 of 3 (#100) sampled residents reviewed for resident rights/grievances. This placed residents at risk for loss of personal items. Findings include: Resident 100 admitted to the facility in 12/2022 with diagnoses including hip fracture and hypertension. Resident 100's 12/2022 5 Day MDS revealed a BIMS score of 12, indicating moderate cognitive impairment. Resident 100's care plan dated 12/8/22 revealed she/he was a one person limited assist for most ADL's including dressing. On 2/6/23 at 6:54 PM, Witness 1 (Complainant) reported several items that belonged to Resident 100 were missing from her/his room. Witness 1 stated some of the items were replaced by the facility but the clothing item was not. A grievance form dated 12/28/22 was reviewed and one item of clothing was identified as missing and not found. There was no evidence the facility reimbursed Witness 1 for the item. On 2/13/23 at 1:30 PM, Staff 1 (Administrator) was notified of the findings of this investigation and provided no further information.

1.How the corrective action will be accomplished for identified affected individuals Resident #100; Pink night gown was replaced on 2/22/2023. Resident #100 is an active resident residing at the facility. No other concerns for missing items. 2. How will other individuals with the potential to be affected or in similar situations be identified and protected Other residents are at risk for potential missing items and loss of personal items if the facility fails to follow up on the grievance process in a timely manner. 3. What systemic changes will ensure that the deficient practice will not recur 1) Grievances for missing items will be brought up in stand up so IDT can review the next step 2) social services and housekeeping manager will check resident room when items are identified missing. 3) SSD or designee will contact family for reimbursement or replacement items. 4) Administrator or Designee will provide education to the facility staff on the process of filling out a grievance form and will provide education to the Social Service Director on the process of timely follow-up. 4. How the facility will monitor its corrective actions/performance Administrator or designee will audit grievances weekly x 4 weeks, then monthly x 2 months to ensure compliance with grievance process. 5. When will corrective action be accomplished All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review, it was determined the facility failed to provide the necessary care and services for 2 of 3 (#s 100 and 200) sampled residents reviewed for bowel care. This placed residents at risk for bowel care complications. Findings include: The facility's Bowel Management policy, dated 9/2021 stated the facility would follow standing physican orders unless other direction/orders were provided. Standing orders consisted of recording bowel movements daily and resident records were reviewed by the licensed nurse (LN). If residents had no bowel movements for 6 shifts or within their routine bowel pattern, the bowel program was initiated, the LN would assess the resident and if the bowel program was ineffective the LN notified the physician for further orders. 1. Resident 100 admitted to the facility in 12/2022 with diagnoses including hip fracture and hypertension. Resident 100's 12/2022 5 Day MDS revealed a BIMS score of 12, indicating moderate cognitive impairment. Resident 100's care plan dated 12/8/22 revealed she/he was a one person limited assist for most ADLs including bowel care. At the time of her/his admission, Resident 100 was continent of bowel and required assistance to toilet. Resident 100's 12/8/22 admission orders instructed staff "if no BM (bowel movement) in 72 hours, Licensed Nurse to perform abdominal assessment and offer 17 g of Miralax in 8 oz of liquid. Notify provider for orders if no result in 12 hours. Okay to use on top of exiting Miralax order, if it exists. For any patient on narcotics, ask for order for scheduled and PRN stool softners or Miralax." Bowel records for 12/2022 revealed Resident 100 did not have a bowel movement from 12/8/22 through 12/14/22. Resident 100's 12/2022 MAR revealed no PRN bowel medication was administered until 12/13/22. On 2/10/23 at 11:35 AM, Staff 4 (RNCM) confirmed there was no bowel assessment completed as ordered and no bowel medications were administered as ordered. On 2/13/23 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were advised of the findings of this investigation and provided no additional information. 2. Resident 200 admitted to the facility in 4/2021 with diagnoses including Chronic Obstructive Pulmonary Disease and Chronic kidney disease. Resident 200's 12/2022 5 Day MDS revealed a BIMS score of 15, indicating no cognitive impairment. Resident 200's care plan dated 11/15/22 revealed she/he was incontinent of bowel, was frequently constipated and interventions were to follow the facility bowel protocol. Resident 200's physician orders dated 7/6/22 instructed staff "Give 1 (Sennosides) tablet by mouth as needed for constipation may have once per day." Bowel records for 1/2023 and 2/2023 revealed Resident 200 did not have a bowel movement from 1/14/23 through 1/18/23 and from 2/4/23 through 2/9/23. Resident 200's 1/2023 and 2/2023 MAR revealed no PRN bowel medication was administered. On 2/9/23 at 12:39 PM, Staff 3 (RNCM) confirmed no PRN bowel medications were administered as ordered. On 2/13/23 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were advised of the findings of this investigation and provided no additional information.

1.How the corrective action will be accomplished for identified affected individuals Resident #100 is an active resident in the facility. Resident was assessed by the nurse during the Survey, bowel care treatment plan was reviewed and the treatment plan and Care Plan have been revised. Resident #200 has discharged from the facility. 2. How will other individuals with the potential to be affected or in similar situations be identified and protected Other residents have the potential risk of bowel care complications if the facility does not follow the standard bowel protocol. DNS has audited the resident records to ensure resident bowel protocol is in place for each resident. 3. What systemic changes will ensure that the deficient practice will not recur DNS/RCM will review daily bowel results and address bowel care as needed to ensure that facility is following bowel protocol. DNS or Designee provided education to the Licensed Nurses regarding the clinical alert review, following the bowel protocol and documenting results. 4. How the facility will monitor its corrective actions/performance DNS or Designee will audit bowel reports weekly x 4 weeks, and monthly x 2 months to ensure bowel protocol is being followed and addressed timely. 5. When will corrective action be accomplished All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on observation, interview and record review it was determined the facility failed to provide sufficient staffing to ensure residents maintained their highest practicable quality of life for 3 of 4 halls (100, 300 and 400 halls) reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet needs. Findings include: 1. Resident 200 admitted to the facility in 4/2021 with diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. Resident 200's 12/2022 5 Day MDS revealed a BIMS score of 15, indicating no cognitive impairment. On 8/25/22 a public complaint was received which alleged Resident 200 was not receiving assistance timely due to long call light wait times. Witness 5 (Complainant) reported the resident routinely waited over an hour and as long as five hours for call lights to be responded to. On 2/6/23 at 4:06 PM, Resident 200 confirmed that call light time reponses had been long in 8/2022. Call lights logs for Resident 200 from 8/21/22 through 8/25/22 revealed the following response/reset times: 8/21/22 at 1:47 PM: 1 hour, 41 minutes 8/21/22 at 3:38 PM: 53 minutes 8/21/22 at 4:53 PM: 3 hours, 50 minutes 8/21/22 at 9:42 PM: 1 hour, 24 minutes 8/23/22 at 5:20 PM: 1 hour, 4 minutes 8/23/22 at 7:15 PM: 2 hours, 11 minutes 8/24/22 at 8:52 AM: 43 minutes 8/24/22 at 3:31 PM: 52 minutes 8/25/22 at 7:49 AM: 41 minutes 8/25/22 at 10:16 AM: 43 minutes On 2/8/23 at 4:47 PM, Staff 1 (Administrator) stated the expected response time for call lights was 30 to 40 minutes or as soon as possible. Staff 1 was unable to provide a written policy regarding call light response times. On 2/13/23 at 1:30 PM Staff 1 and Staff 2 (DNS) were informed of the findings of this investigation and provided no further information. 2. Resident 800 was admitted to the facility in 1/2023 with diagnoses including leg and foot fractures and diabetes mellitus. Resident 800's 1/2023 MDS 5 Day assessment revealed a BIMS score of 13, indicating no cognitive impairment. Resident 800's care plan dated 1/16/23 revealed she/he had occasional bowel incontinence and required assistance with bathing, bed mobility and toileting. On 2/7/23 at 2:08 PM, the call light monitor was observed activated for Resident 800's room. At 2:52 PM, Staff 6 (CNA) was observed entering Resident 800's room and left the room a few minutes later. Resident 800 was immediately interviewed and confirmed Staff 6 was the only staff who responded to her/his call light since it had been activated 44 minutes ago and she/he was the only resident in the room. Resident 800 stated staff were "lax" about responding to call lights and wait times could be up to an hour and a half. On 2/8/23 at 4:47 PM, Staff 1 (Administrator) stated the expected response time for call lights was 30 to 40 minutes or as soon as possible. Staff 1 was unable to provide a written policy regarding call light response times. On 2/13/23 at 1:30 PM Staff 1 and Staff 2 (DNS) were informed of the findings of this investigation and provided no further information. 3. Resident Council meeting notes were reviewed for 11/2022, 12/2022 and 1/2023 with the following comments: 11/29/22: "Constant excuses to long call light wait times...the call lights over shift change are the worst, 5:00 AM - 7:00 AM, 2:00 PM - 4:00 PM and 9:00 PM - 12:00 AM"; 12/28/22: "Call lights-CNA's come in, turn off call lights claiming to come back, only to have to wait all over again"; 1/30/23: "Call lights turned off without care performed - staff say they'll come back and don't." A review of the SNF/ICF units Direct Care Staff Daily Reports from 12/1/22 through 12/31/22 revealed the following shifts did not have sufficient CNA staff in relation to the facility census: 12/2/22: evening shift; 12/7/22: evening shift; 12/11/22: day shift; 12/18/22: day shift; 12/20/22: day shift; 12/22/22: day shift; 12/23/22: day shift; 12/25/22: day shift. A review of the ventilator unit's Direct Care Staff Daily Reports from 12/1/22 through 12/31/22 revealed the facility did not have a registered nurse on duty daily for 16 hours on the following dates: 12/1/22, 12/2/22, 12/4/22, 12/5/22, 12/6/22, 12/7/22, no report provided for 12/8/22, 12/12/22, 12/13/22, 12/15/22, 12/18/22, 12/19/22, 12/20/22, 12/21/22, 12/23/22, 12/24/22, 12/25/22, 12/26/22, 12/27/22, 12/28/22 and 12/29/22. On 2/10/23 at 1:50 PM, Staff 7 (Staffing Coordinator) confirmed there was a CNA staffing shortage in December 2022. On 2/13/23 at 1:30 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings of this investigation and provided no further information.

1.How the corrective action will be accomplished for identified affected individuals Residents #200 and #800 are no longer residents at the facility. Residents on 100, 300 and 400 halls have been interviewed to ensure needs are met timely. No negative outcomes noted related to untimely call light times. 2. How will other individuals with the potential to be affected or in similar situations be identified and protected Residents on all 4 halls that are reliant on staff assistance are at risk for unmet care needs if call lights are not answered timely. Residents will be interviewed to ensure care needs are being met. 3. What systemic changes will ensure that the deficient practice will not recur 1) Nursing staff educated by the DNS on timely call light response and reporting barriers to effective time management. 2)Review of the iAlert system by Maintenance/DNS/Admin to review efficiency, accuracy and inventory of accessories. Education will be provided to facility staff for any findings or new interventions put into place by the DNS or Designee 4. How the facility will monitor its corrective actions/performance 1) 5 Random resident interviews to ensure care needs are met weekly x 4 weeks, then monthly x2 months by SSD or designee. 2) Call light audits will be done weekly x 12 weeks by the Administrator or Designee 5. When will corrective action be accomplished All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to accurately document the DCSDR (Direct Care Staff Daily Report) for 24 out of 31 days reviewed for staffing for 2 of 2 units. This placed residents and visitors at risk for being uninformed of available staff and hours worked by facility staff. Findings include: The December 2022 DCSDR reports contained forms not filled out for entire shifts and days, inaccurately listed dates, missing resident census and staff hours worked on the following days: SNF/ICF Unit: 12/3/22: Report missing; 12/4/22: No day shift and census information completed; 12/6/22: No day shift information completed; 12/7/22: No night shift and census information completed; 12/8/22: No evening and night shift information completed; 12/9/22: No night shift and census information completed; 12/10/22: No day shift and census information completed; 12/12/22: No night shift and census information completed; 12/14/22: No night shift and census information completed; 12/15/22: No evening, night shift and census information completed; 12/17/22: Report missing; 12/18/22: No night shift and census information completed; 12/19/22: No night shift and census information completed; 12/20/22: No CNA information completed for night shift; 12/21/22: No CNA information completed for all shifts and no licensed or registered nurses information completed for evening and night shift; 12/22/22: No CNA and census information completed for night shift; 12/23/22 No night shift and census information completed; 12/24/22: Report missing 12/25/22: No night shift and census information completed; 12/27/22 through 12/29/22: Reports missing; 12/30/22: No night shift and census information completed; 12/31/22: Report missing VENT Unit: 12/3/22: No CNA information completed for night shift; 12/4/22 No CNA information completed for all shifts; 12/8/22: Report missing; 12/10/22: No CNA information completed for day shift; 12/11/22: Report missing; 12/18/22: No day shift information completed; 12/21/22: No shift and census information completed; 12/23/22: Date was listed as "02/23/2002"; 12/24/22: No day and evening shift and census information completed; 12/25/22: No day and evening shift information completed and census information for all shifts not completed; 12/27/22: No day and evening shift information completed and census information for all shifts not completed; 12/28/22: No night shift and census information completed. On 2/13/23 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings of this investigation and provided no additional information.

1.How the corrective action will be accomplished for identified affected individuals No specific residents were identified as being affected during the survey. 2. How will other individuals with the potential to be affected or in similar situations be identified and protected. Residents and Visitors are at risk for being uninformed of available staff and hours worked by facility staff if the facility doesnt have accurate and complete staffing information posted. See on-going audits. 3. What systemic changes will ensure that the deficient practice will not recur Administrator re-educated staffing coordinator and nurses on ensuring that DHS posting is completed and accurate daily. 4. How the facility will monitor its corrective actions/performance Administrator or Designee will audit DHS staffing posting weekly x12 weeks to ensure compliance. 5. When will corrective action be accomplished All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

*********************************** 411-085-0310 Resident's Rights: Generally Refer to F550 *********************************** 411-086-0110 Nursing Services: Resident Care Refer to F684 *********************************** 411-086-0110 Nursing Services: Staffing Refer to F725 *********************************** 411-086-0110 Nursing Services: Staffing Refer to F732

Based on interview and record review it was determined the facility failed to ensure a registered nurse was on duty for at least 16 hours a day for 21 of 31 days reviewed for staffing on the ventilator unit. This placed residents at risk for lack of comprehensive assessments and unmet needs. Findings include: Review of the ventilator unit's Direct Care Staff Daily Reports from 12/1/22 through 12/31/22 revealed the facility did not have a registered nurse on duty daily for 16 hours on the following dates: 12/1/22, 12/2/22, 12/4/22, 12/5/22, 12/6/22, 12/7/22, no report provided for 12/8/22, 12/12/22, 12/13/22, 12/15/22, 12/18/22, 12/19/22, 12/20/22, 12/21/22, 12/23/22, 12/24/22, 12/25/22, 12/26/22, 12/27/22, 12/28/22 and 12/29/22. On 2/13/23 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings of this investigation and provided no additional information.

1.How the corrective action will be accomplished for identified affected individuals No specific residents were identified as being affected during the survey. 2. How will other individuals with the potential to be affected or in similar situations be identified and protected. Residents have the potential risk for lack of comprehensive assessments and unmet needs if the required 16hrs of RN coverage is not met daily. See on-going audits. 3. What systemic changes will ensure that the deficient practice will not recur Administrator and DNS reviewed the scheduling practices to ensure that 16hrs of RN coverage will be scheduled in the Vent Unit per the requirement. If the RCM hours are needed, she will be on the floor available to the nursing staff, residents and will be listed as the RN on the schedule, assignment sheet and DHS posting. Will continue efforts with RN recruitment and retention. Education provided to the Scheduling Coordinator by the Administrator to notify the Admin/DNS if the schedule has less than 16hrs of RN coverage so that arrangements can be made to meet the requirement. 4. How the facility will monitor its corrective actions/performance Administrator or Designee will audit DHS staffing posting weekly x12 weeks to ensure compliance. 5. When will corrective action be accomplished All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on observation and interview it was determined the facility failed to provide residents with pull strings for over bed lights for two of four halls (100 and 200 halls). This placed residents at risk for accidents and lack of independence. Findings include: Random observations on 4/12/2022 revealed resident rooms 103, 105, 111, 201 and 206 did not have pull strings for the over bed lights. This prevented residents from independently accessing their over bed lights. On 4/12/22 at 6:33 PM Witness 4 (Complainant) stated the over bed light in room 111 did not have a pull string. The only way to turn a light on in the room was to get out of the bed and ambulate to the light switch by the door. Witness 4 stated this was not safe and did not give residents maximal independence. On 4/14/2022 at 10:53 AM Staff 9 (Maintenance Manager) confirmed there were missing over-bed pull strings. On 4/19/2022 at 10:17 AM Staff 1 (Administrator) agreed the pull strings were missing and needed to be replaced.

F 558 Reasonable Accommodations Needs/Preferences How the corrective action will be accomplished for identified affected individuals: Room 103, 105, 111, 201, and 206 pull strings for over bed lights have been replaced. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents have the potential risk of accidents or lack of independence if their overhead light pull string is not in place or functioning. Administrator/Designee completed an audit of whole building to ensure that resident rooms have functional overhead light pull strings. What systemic changes will ensure that the deficient practice will not recur: Administrator re-educated maintenance directors regarding the need to ensure all resident rooms have functional pull strings. Administrator or DNS provided education to the facility staff regarding the importance of reporting any overhead light pull strings that are missing or not working properly. How the facility will monitor its corrective actions/performance: Administrator/Designee will complete a weekly audit for 4 weeks, then monthly audits for 2 months of resident rooms on all the halls to ensure that we functional pulls strings. If Pull strings are missing when audits completed, maintenance will be notified to replace it. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to provide a completed Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice of Non-coverage (ABN) two days prior to discharge as required, failed to provide Quality Improvement Organization (QIO) contact information on the NOMNC, and failed to provide a NOMNC for 3 of 3 sampled residents (#s 20, 33, and 407) reviewed for beneficiary protection notification. This placed residents at risk of unforeseen financial responsibilities and not being fully informed for whom to contact to appeal non-coverage. Findings include: 1. Resident 407 was admitted with Medicare Part A services in 10/2021. She/he discharged home on 10/28/21. No NOMNC was found in the resident's clinical record. On 4/18/22 at 4:32 PM Staff 1 (Administrator) stated the discharge for Resident 407 was planned and voluntary. Staff 1 acknowledged the resident should have been provided with a NOMNC but was unable to verify one was provided. 2. Resident 20 admitted with Medicare Part A services in 11/2021 and discharged on 12/3/21. The 12/16/21 NOMNC did not contain the name or contact information of the QIO for her/him to file an appeal. Both the NOMNC and ABN were dated 12/16/21 (13 days after the resident's discharge). On 4/18/22 at 4:32 PM Staff 1 stated the facility attempted to have Resident 20 sign her/his NOMNC and ABN in a timely manner but she/he was unavailable until 12/16/21. Staff 1 acknowledged the NOMNC was incomplete because of the omitted QIO information. 3. Resident 33 admitted with Medicare Part A services in 2/2022 and discharged on 3/9/22. Both the NOMNC and ABN were dated 3/8/22. These letters were not provided to or reviewed with Resident 33 two days prior to discharge as required. On 4/18/22 at 4:32 PM Staff 1 confirmed Resident 33's last covered day under Medicare Part A was 3/9/22 and the resident signed the NOMNC and ABN on 3/8/22.

F 582 Medicaid/Medicare Coverage/Liability Notice How the corrective action will be accomplished for identified affected individuals: Resident 407- discharged from the facility. Resident 20, was made aware of the late NOMNC and ABN. Resident 33 was made of the delaying in issuing the NOMNC and ABN. No negative outcomes noted. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents at the facility for a skilled stay under Medicare A have the potential risk of not being informed of unforeseen financial responsibilities and not being informed of whom to contact to appeal non-coverage when the discharge is prior to the 100th day. Administrator will complete an audit of Medicare A residents to ensure that NOMNC and ABN were issued according to CMS guidelines. What systemic changes will ensure that the deficient practice will not recur: Administrator re-educated Social Services Director regarding NOMNC and ABN policy and guidelines. How the facility will monitor its corrective actions/performance: Administrator/Designee will complete a weekly audit for 4 weeks, then monthly audits for 2 to ensure that NOMNC and ABN are issued completely and accurately. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to maintain a safe, clean, comfortable and homelike environment for four of four halls (100, 200, 300 and 400 halls) reviewed for environment. This placed residents at risk for health and safety concerns, and discomfort. Findings include: Random observations of resident rooms on 4/12/22, 4/14/22 and 4/19/22 revealed the following: Room 111's windows did not lock, there was an open gap between the window and the wall to the outside and there were no screens. The windows in rooms 204 and 206 did not have latches to lock the windows. The windows in rooms 104, 212, 302, 404, 407, 411 and 412 did not have screens. The windows in room 309 did not have latches to lock and did not have screens. An entry on the facility's maintenance log dated 11/30/21 revealed the window in room 111 was drafty and the windows in 412 did not lock. On 4/12/22 at 11:00 AM Staff 16 (LPN) stated many resident rooms did not have screens. During interviews from 4/12/22 through 4/15/22 Witness 2 (Complainant), Witness 3 (Complainant) and Witness 4 (Complainant) all stated the windows in room 111 did not lock. On 4/14/22 at 11:00 AM Staff 9 (Maintenance Manager) agreed the window in room 111 did not lock, did not have screens and had an open gap to the outside. He also confirmed other resident rooms had windows that did not lock and windows without screens. On 4/18/22 at 8:43 AM Staff 20 (Receptionist/Central Supply) stated there have been complaints over the years of windows in residents' rooms not locking. On 4/19/22 at 10:17 AM Staff 1 (Administrator) agreed there were many resident rooms with windows that did not lock and did not have screens.

F 584 Safe/Clean/Comfortable/Homelike Environment How the corrective action will be accomplished for identified affected individuals: Resident rooms 111, 204, 206, 309, maintenance installed new locks. Resident rooms 104, 212, 302, 404, 407, 411, and 412 screens have been replaced. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents on the 4 hallways have the potential risk for health and safety concerns, and discomfort if windows arent functioning properly, are missing screens or have gaps allowing a draft. Also, if the identified maintenance log items are not addressed timely. Administrator/Designee completed a house audit of resident rooms to ensure that any issues pertaining to the windows has been identified so that corrections can be made. Administrator reviewed the last 30days of maintenance log items with the maintenance director to ensure adequate follow-up. What systemic changes will ensure that the deficient practice will not recur: Administrator re-educated Maintenance Director to ensure that resident rooms need to have locks and screens. Education included daily review of the Maintenance Log and timely follow-though on items identified. How the facility will monitor its corrective actions/performance: Administrator/Designee will complete a weekly audit of 5 resident rooms for 4 weeks, then monthly audits for 2 months to ensure that resident rooms have locks and screens. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary. Administrator or designee will review the Maintenance log weekly x12 weeks to ensure timely follow-through on identified items.

Based on interview and record review the facility failed to obtain a physician order for 1 of 3 sampled residents (#54) reviewed for physical therapy. This placed residents at risk for unmet needs. Findings include: Resident 54 was admitted to the facility in 11/2021 with diagnoses including a knee replacement. A Resident Inventory dated 11/4/21 revealed Resident 54 was admitted with a cryo cuff cooler (a device used to provide cold therapy to knees). A Pain Assessment dated 11/4/21 indicated Resident 54 was to receive ice to her/his knee but did not specify a particular device or how to complete the treatment. An admission progress note dated 11/4/21 indicated Resident 54 had "an ice cooler pack/wrap to right knee." A progress note dated 11/4/21 indicated ice was changed twice for Resident 54's "ice-cooler" and did not provide any additional information. A progress note dated 11/9/21 indicated a CNA filled the resident's ice bucket. There was no physician order for a cryo cuff cooler found in Resident's 54's clinical records. Instructions for the use of the cryo cuff cooler were not on the resident's 11/2021 TAR. On 4/14/22 at 12:00 PM Staff 21 (Rehab Director) stated Resident 54 had a knee replacement and he believed CNAs put ice into the device. On 4/18/22 at 9:30 AM Staff 17 (RN) stated Resident 54 had an ice cooler device for her/his knee and confirmed the use of the device was not in the resident's clinical record. On 4/18/22 at 12:19 PM Staff 2 (DNS) stated there was no physician order for the cryo cuff cooler in the resident's chart. She stated staff should have asked the physician for an order and then ensured the order instructions were on the resident's TAR.

F 635 Admission physician orders for immediate care: How the corrective action will be accomplished for identified affected individuals: Resident 54 has been discharged from the facility; care needs were met despite no physician order for the cryotherapy. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other newly admitted residents are at risk for unmet needs if orders arent clarified when unclear or missing at time of admission. DNS/Designee will complete audits of current residents admitted within the last 30 days to ensure that physicians orders are reviewed and to review the progress notes and obtain orders as needed. What systemic changes will ensure that the deficient practice will not recur: DNS/Designee re-educated Licensed Nurses and RCMs on obtaining physicians order for any immediate care needs upon admissions. How the facility will monitor its corrective actions/performance: DNS/Designee will complete a weekly audit for 4 weeks, then monthly audits for 2 months to ensure that facility will obtain physicians order for resident immediate needs. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to ensure professional standards for medication administration and medication errors were upheld for 1 of 7 nursing staff (#24) reviewed for medication administration. This placed residents at risk for adverse side effects of medication. Findings include: Resident 48 admitted to the facility in 12/2021 with diagnoses including hypertension. A 12/22/21 physician order indicated to provide carvedilol (a blood pressure lowering medication) two times a day. The medication was to be held "for SBP [systolic blood pressure, the first/greater number in a blood pressure measurement] less than 100 and pulse less than 55 and notify MD." A review of the 2/2022 MAR indicated Resident 48's blood pressure was 92/69 on 2/17/22 and Staff 24 (CMA) administered carvedilol to the resident. A review of the 3/2022 MAR indicated ten instances when Resident 48's SBP was less than 100. On 3/29/22, 3/30/22, and 3/31/22 Staff 24 administered carvedilol to Resident 48 when the resident's SBP measured lower than 100. There were no occasions when Staff 24 withheld carvedilol from Resident 48. A review of the 4/2022 MAR indicated Resident 48's blood pressure was 80/46 on 4/6/22 when Staff 24 administered carvedilol to the resident. No evidence was found in Resident 48's clinical record to indicate the resident was monitored for a medication error on any of the identified dates. During interviews on 4/18/22 at 1:38 PM and 4/19/22 at 10:06 AM Staff 24 stated she normally withheld blood pressure medication for a SBP less than 100. Staff 24 stated she did not withhold the medication for Resident 48 because she interpreted the parameters to mean it was only to be withheld if the resident's SBP was less than 100 and the resident's heart rate was less than 55. Staff 24 stated she discussed the parameters with a nurse in the past and was told to provide the medication even though the resident's SBP was less than 100 since the pulse was not less than 55. Staff 24 was not able to state which nurse she spoke to or when the conversation occurred. Staff 24 stated she clarified the order with Staff 5 (RNCM) after administering the medication on 4/6/22 and was told to withhold the medication if either criteria was met. When asked if she informed Staff 5 or any other staff member of the 4/6/22 medication error, she said she was unable to recall if she told anyone about the specific situation. Staff 24 stated she monitored the resident after the medication error on 4/6/22 but did not document the activity. Staff 24 stated in her training as a CMA she was trained to not provide a blood pressure reducing medication if the SBP was less than 100. On 4/18/22 at 3:52 PM Staff 12 (LPN) indicated she was the charge nurse on Resident 48's hall on 4/6/22. Staff 12 stated she was not aware of the medication error on 4/6/22. Staff 12 stated if Staff 24 would have told her about Resident 48's low blood pressure then she would have told Staff 24 to withhold the medication. During interviews with Staff 2 (DNS) and Staff 5 on 4/18/22 both staff indicated they were not aware of the 4/6/22 medication error. The staff indicated facility protocol was to hold blood pressure reducing medication if the SBP was less than 100. Staff 5 indicated if she had known the medication error occurred she would have placed Resident 48 on alert and monitored the resident for a medication error.

F 658 Services Provided Meet Professional Standards How the corrective action will be accomplished for identified affected individuals: Resident #48 is a current resident and was reassessed by the nurse. There were no adverse side effects noted from the medication error. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents have the potential risk for adverse side effects of medications if professional standards for medication administration is not upheld. DNS/Designee will complete audits of current resident who is on high blood pressure medications and to ensure that physicians orders is being followed. What systemic changes will ensure that the deficient practice will not recur: DNS/Designee re-educated Licensed Nurses and Medication Aides on reading the physicians order correctly and following professional standards for Medication Administration guidelines. How the facility will monitor its corrective actions/performance: DNS/Designee will complete a weekly audit for 4 weeks, then monthly audits for 2 months to ensure that blood pressure medication is given within parameters. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review the facility failed to ensure residents were transported safely for 1 of 2 sampled residents (#51) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 51 was admitted to the facility in 3/2022 with diagnoses including fracture of right humerus (upper arm). The 3/27/22 care plan indicated Resident 51 required two-person assistance with transfers using a mechanical lift. A 4/7/22 Supervisor Coaching and Counseling report indicated Staff 13 (CNA) transported a resident in an unsafe manner. Staff 13 was educated not to transport residents in a mechanical lift. On 4/13/22 at 11:31 AM Staff 20 (Receptionist/Central Supply) stated she observed Staff 13 and Staff 14 (Personal Care Assistant) transport Resident 51 in a mechanical lift to the shower room and was concerned for Resident 51's safety. On 4/13/22 at 4:10 PM Staff 12 (LPN) stated she observed Staff 13 and Staff 14 transport Resident 51 to the shower room in a mechanical lift on 4/7/22 and was concerned for Resident 51's safety. Staff 12 stated she educated Staff 13 and Staff 14 on transport safety, issues a disciplinary warning to the staf members and reported the incident to Staff 3 (LPN Resident Care Manager). No evidence was found to indicate the facility conducted an assessment to identify if any other residents were transported in an unsafe manner. On 4/15/22 at 11:27 AM and 1:25 PM Staff 13 and Staff 14 both acknowledged they transported Resident 51 to the shower room in a mechanical lift on 4/7/22. Staff 13 acknowledged the mechanical lift was not intended to transport residents. On 4/15/22 at 12:15 PM Resident 51 acknowledged she/he was transported in a mechanical lift to the shower room on 4/7/22. On 4/18/22 at 11:44 AM Staff 3 confirmed using a mechanical lift to transport residents was an unsafe practice.

F 689 Free of Accident Hazards/Supervision/Devices How the corrective action will be accomplished for identified affected individuals: Resident #51 is a current resident and was assessed at the time of the incident, no physical or psychosocial concerns noted. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents have the potential risk for accidents if not safely transported. See on-going audits. What systemic changes will ensure that the deficient practice will not recur: DNS/Designee re-educated C.N.As on safe transfers process. How the facility will monitor its corrective actions/performance: DNS/Designee will complete a weekly observation of 10 transfers for 4 weeks, then monthly audits for 2 months to ensure that staff is safely transferring resident. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to provide sufficient staffing to ensure residents maintained their highest practicable quality of life for 2 of 4 halls (100 and 300 halls) reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet needs. Findings include: 1. On 4/14/22 at 10:10 AM a call light monitor indicated Resident 49's call light in the 300 hall was activated. On 4/14/22 at 11:12 AM a staff member was observed to answer Resident 49's call light after the resident waited 66 minutes for nursing assistance. During an interview on 4/14/22 at 11:15 AM Resident 49 stated she/he waited for assistance from nursing staff for toileting assistance since 10:10 AM. Resident 49 stated waiting for more than 45 minutes for nursing assistance was typical. Resident 49 stated she/he decided to bang a cane against her/his furniture to get nursing staff's attention after waiting 45 minutes. On 4/14/22 at 11:31 AM Staff 12 (LPN) confirmed Resident 49 waited 66 minutes for assistance. Staff 12 stated delays in call light response occurred on the majority of shifts she worked in the facility. 2. On 4/14/22 at 10:28 AM a call light monitor indicated Resident 48's call light in the 300 hall was activated. On 4/14/22 at 11:31 AM Staff 12 (LPN) was observed using a two way radio to request a response to Resident 48's call light, stating the call light had been on for an hour. On 4/14/22 at 11:31 AM Staff 12 (LPN) confirmed Resident 48's call light was on since 10:28 AM with no response. Staff 12 stated a delay in call light response occurred on the majority of shifts she worked in the facility. On 4/14/22 at 11:32 AM a CNA was observed entering Resident 48's room 64 minutes after the resident requested assistance. During an interview on 4/14/22 at 11:34 AM Resident 48 confirmed she/he waited for assistance since 10:28 AM. Resident 48 stated waiting extended periods for staff to respond to call lights was not unusual. , 3. On 4/12/22 at 6:13 PM a call light monitor at the nurses station indicated Resident 48's call light on the 100 hall was active and was activated 21 minutes prior. On 4/12/22 at 6:14 PM Resident 48 stated she/he was waiting for assistance and the call light was activated "a while ago." On 4/12/22 at 6:18 PM (26 minutes after the call light was activated) Staff 25 (CNA) was observed to enter Resident 48's room, speak to Resident 48 and then leave the room. On 4/12/22 at 6:20 PM Staff 25 stated the resident asked for a PRN medication. Staff 25 stated he was not sure how long the resident's call light was on prior to entering the room. Staff 25 stated he answered call lights as quickly as he could and tried to answer them within five minutes. 4. On 4/13/22 at 11:38 AM a call light monitor at the nurses station indicated Resident 405's call light on the 100 hall was active and was activated 25 minutes prior. On 4/13/22 at 11:46 AM Staff 8 (Social Services Coordinator) was observed to enter Resident 405's room and speak with the resident. On 4/13/22 at 11:47 AM Staff 8 stated she answered call lights if she saw one activated for more than five minutes. Staff 8 stated Resident 405's call light was active for about 35 minutes prior to staff providing assistance. , 5. On 4/14/22 at 10:09 AM Witness 7 (Family Member) stated she pushed Resident 304's call light (on the 200 hall) for ADL care at 8:18 AM. Witness 7 stated after a 30 minute wait a CNA came into the room, turned the call light off and said they would be back. Witness 7 stated, "now it's been an hour later and I'm out here in the hallway asking for help." Observation of the call light monitor was consistent with the witness's statement. 6. A 2/28/22 resident council meeting log revealed residents reported a call light wait time average of 45 minutes. Residents reported having forgotten reasons for requests of care due to delayed call light responses. A 3/31/22 resident council meeting log revealed continued concerns of extended call light wait periods. 7. On 4/19/22 at 1:22 PM Staff 1 (Administrator) confirmed delayed call light response times was an ongoing issue at the facility.

F725- Sufficient Nursing Staff How the corrective action will be accomplished for identified affected individuals: Review of care needs for resident 49, 405, and 48 no negative outcomes noted related to long call light times. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents will have the potential risk for lack of timely assistance and unmet needs if call lights are not addressed timely. Social Services Director/Designee will interview current residents in the facility related to care needs and to ensure all needs are being met in a timely manner. What systemic changes will ensure that the deficient practice will not recur: Administrator/Designee re-educated staff on the importance of answering call lights in a timely manner. Administrator will continue to educate staff as iAlert upgrades are added to remove steps to clear the call lights. DNS or Designee will educate LN’s and Med Aides about assisting with call light answering. How the facility will monitor its corrective actions/performance: DNS/Designee will complete weekly audits of the call lights for 4 weeks, then monthly audits for 2 months to ensure that the facility is meeting resident’s needs in a timely manner. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to use the services of a registered nurse for 8 consecutive hours per day for 22 of 45 days reviewed for RN coverage. This placed residents at risk for lack of comprehensive assessments and unmet needs. Findings include: Review of the Direct Care Staff Daily Reports from 3/1/22 through 4/14/22 revealed no RN was working in the 100, 200 or 300 halls on the identified dates: 3/3, 3/4, 3/10, 3/11, 3/12, 3/17, 3/24, 3/25, 3/31, 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, 4/10, 4/11, 4/12, and 4/13. During an interview on 4/19/22 at 12:15 PM, Staff 6 (Staffing/Payroll) confirmed there was no RN coverage in the 100, 200 and 300 halls on the identified dates. On 4/19/22 at 12:47 PM, Staff 1 (Administrator) confirmed the facility did not have RN coverage in the 100, 200 and 300 halls on the identified dates.

F727- RN 8 hrs/7 days/Wk, Full time DON How the corrective action will be accomplished for identified affected individuals: No specific Resident negative outcomes identified. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents on the 100, 200 and 300 halls have the potential to be affected by not having 8 hours of RN coverage. See on-going audits. What systemic changes will ensure that the deficient practice will not recur: The facility continues to recruit for RN, offer bonus, reach out to our sister facilities and are connected with Staffing Agencys to obtain RN coverage. If the facility is unable to find RN to cover, the RN RCM will be asked to cover, then lastly RN DNS will step in to cover to maintain the 8 hours RN coverage. Administrator or designee will educate the staffing coordinator to alert the Administrator and DNS if there is an RN shortage for the upcoming schedule for added assistance to acquire coverage. How the facility will monitor its corrective actions/performance: Administrator will complete daily audits for 4 weeks, then monthly audits for 2 months to ensure that the 100, 200 and 300 are in compliance with 8 hours of RN coverage. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on interview and record review it was determined the facility failed to withhold blood pressure medication when contraindicated for 1 of 5 sampled residents (#48) reviewed for unnecessary medication. This placed residents at risk for adverse side effects of medication. Findings include: Resident 48 admitted to the facility in 12/2021 with diagnoses including hypertension. A 12/22/21 physician order indicated to provide carvedilol (a blood pressure lowering medication) two times a day. The medication was to be held "for SBP [systolic blood pressure, the first/greater number in a blood pressure measurement] less than 100 and pulse less than 55 and notify MD." A review of the 2/2022 MAR indicated Resident 48's blood pressure was 92/69 on 2/17/22 and Staff 24 (CMA) administered carvedilol to the resident. A review of the 3/2022 MAR indicated on 3/29/22, 3/30/22, and 3/31/22 Staff 24 administered carvedilol to Resident 48 when the resident's SBP measured lower than 100. A review of the 4/2022 MAR indicated Resident 48's blood pressure was 80/46 on 4/6/22 when Staff 24 administered carvedilol to the resident. During interviews on 4/18/22 at 1:38 PM and 4/19/22 at 10:06 AM Staff 24 acknowledged she provided blood pressure lowering medication to Resident 48 despite the resident's low blood pressure measurements. Staff 24 stated she provided the medication due to confusion about the wording of the parameters. During interviews with Staff 2 (DNS) and Staff 5 (RNCM) on 4/18/22 both staff indicated the facility protocol was to hold blood pressure reducing medication if the SBP was less than 100. See F-658.

F757- Drug Regimen is Free from Unnecessary Drugs How the corrective action will be accomplished for identified affected individuals: Resident 48 has been reassessed by the nurse. No adverse effect noted from the medication error. How will other individuals with the potential to be affected or in similar situations be identified and protected: Other residents with blood pressure medication have the potential to be affected by failure to follow the physicians order. What systemic changes will ensure that the deficient practice will not recur: DNS re-educated LNs and Medication Aides on the importance of following physicians order for administering blood pressure medications. How the facility will monitor its corrective actions/performance: DNS will complete weekly audits for 4 weeks, then monthly audits for 2 months to ensure that the staff is following physicians order for Blood Pressure Medications. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on observation and interview it was determined the facility failed to ensure waste was properly contained in dumpsters and garbage storage areas were maintained in a sanitary condition for 1 of 1 garbage area reviewed for kitchen sanitation. This placed residents at risk for exposure to pathogens related to the harborage and feeding of pests. Findings include: On 4/12/22 at 10:42 AM procedure gloves, a blood glucose strip, and three garbage bags containing food waste were observed scattered behind, around, and under the main dumpster located outside of the kitchen. The kitchen door leading to the dumpster area was propped open. On 4/12/22 at 10:44 AM Staff 19 (Dietary Services Manager) stated the kitchen door leading to the dumpster should not be left open. On 4/15/22 at 8:06 AM the dumpster area was not clean and contained the same items as noted from 4/12/22. Staff 9 (Maintenance Manager) reported he was in charge of keeping the garbage dumpster area free of debris. He stated he did not check or clean the garbage area. On 4/18/22 at 8:34 AM the same bag of garbage initially observed on 4/12/22 was still behind and partially under the dumpster outside of the kitchen. Orange peels were also observed discarded on the ground behind the dumpster. On 4/18/22 at 1:18 PM Staff 19 was informed of the unsanitary conditions at the garbaga area. No further information was provided.

F814- Dispose Garbage and Refuse Properly How the corrective action will be accomplished for identified affected individuals: No resident identified to be affected. How will other individuals with the potential to be affected or in similar situations be identified and protected: All residents have the potential to be affected by waste that was not properly contained in the dumpsters area. What systemic changes will ensure that the deficient practice will not recur: Administrator re-educated Dietary and Maintenance Director to complete daily rounds to ensure the dumpster area is kept in sanitary conditions. How the facility will monitor its corrective actions/performance: Administrator will complete weekly audits for 4 weeks, then monthly audits for 2 months to ensure that dumpster area is maintained. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to provide for resident privacy for 3 of 4 halls (100, 200 and 300) reviewed for environment. This placed residents at risk for lack of visual privacy. Findings include: Random observations of rooms on 4/12/22, 4/14/22 and 4/19/22 revealed resident rooms 105, 111, 202, 206 and 210 had blinds with missing or broken slats which prevented residents from obtaining privacy. On 4/12/22 at 11:00 AM Staff 16 (LPN) stated many resident rooms had broken blinds. On 4/14/22 at 10:53 AM Staff 9 (Maintenance Manager) agreed some of the resident rooms lacked functional window blinds. An entry on the Maintenance Log dated 9/8/21 indicated resident room 202's blinds were "completely broken." On 4/19/22 at 10:17 AM Staff 1 (Administrator) agreed some of the resident rooms did not have complete and functioning blinds to ensure resident privacy.

F914- Bedrooms Assure Full Visual Privacy How the corrective action will be accomplished for identified affected individuals: Rooms 105, 111, 202, 206, and 210 window slats were replaced. SSD interviewed the affected residents, no negative outcomes noted. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents have the potential to be affected by lack of privacy if windows are missing slats. What systemic changes will ensure that the deficient practice will not recur: Administrator re-educated Housekeeping and Maintenance Director to complete daily rounds to ensure to replace window blinds/slats that is missing from resident room. Administrator or Designee educated nursing and therapy staff to report any missing blinds/slats or if privacy can’t be maintained. How the facility will monitor its corrective actions/performance: Administrator will complete weekly audits for 4 weeks, then monthly audits for 2 months to ensure resident room do not having missing slats and replacement are in process to ensure resident have full privacy. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

,

Based on interview and record review it was determined the facility failed to ensure a RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 38 of 45 days reviewed for RN coverage. This placed residents at risk for lack of comprehensive assessments and unmet needs. Findings include: Review of the Direct Care Staff Daily Reports from 3/1/22 through 4/14/22 revealed no designated RN charge nurse worked for eight hours in the 100, 200 or 300 halls of the facility between the start of day shift and the end of evening shift on the following dates: 3/1, 3/2, 3/3, 3/4, 3/6, 3/7, 3/8, 3/9, 3/10, 3/11, 3/12, 3/13, 3/14, 3/15, 3/16, 3/17, 3/18, 3/19, 3/20, 3/21, 3/24, 3/25, 3/28, 3/29, 3/31, 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, 4/10, 4/11, 4/12, and 4/13. During an interview on 4/19/22 at 12:15 PM Staff 6 (Staffing/Payroll) confirmed no designated RN charge nurse worked in the 100, 200 and 300 halls of the facility during day or evening shifts on the identified dates. During an interview on 4/19/22 at 12:47 PM Staff 1 (Administrator) confirmed the facility did not have a RN charge nurse working in the 100, 200 and 300 halls during day or evening shifts on the identified dates.

M182- OAR Nursing Services: Minimum Licensed Nurse Staff How the corrective action will be accomplished for identified affected individuals: No specific resident negative outcomes identified. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents on the 100, 200 and 300 halls have the potential to be affected by not having 8 hours of RN coverage between the start of day shift and the end of evening shift. What systemic changes will ensure that the deficient practice will not recur: The facility continues to recruit for RN, offer bonus, reach out to our sister facilities and are connected with Staffing Agencys to obtain RN coverage. If the facility is unable to find RN to cover, the RN RCM will be asked to cover then lastly RN DNS will step in to cover to maintain the 8 hours RN coverage. Administrator or designee will educate the staffing coordinator to alert the Administrator and DNS if there is an RN shortage for the upcoming schedule for added assistance to acquire coverage. How the facility will monitor its corrective actions/performance: Administrator will complete daily audits for 4 weeks, then monthly audits for 2 months to ensure that the facility has 8 hours of RN coverage. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

******************** 411-0086-0360 Resident Furnishings, Equipment Refer to F-558 ******************** 411-085-0320 Residents' Rights: Charges and Rates Refer to F-582 ******************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F-584, F-689, F-757 ******************** 411-086-0040 Admission of Residents Refer to F-635 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F-658 ******************** 411-086-0100 Nursing Services: Staffing Refer to F-725 and F-727 ******************** 411-086-0250 Dietary Services Refer to F-814 ******************** 411-087-0130 Resident Care Unit Refer to F-914 ********************

Based on observation, interview and record review it was determined the facility failed to ensure a registered nurse was on duty for at least 16 hours a day for 30 of 44 days reviewed for staffing on the ventilator unit. This placed residents at risk for lack of comprehensive assessments and unmet needs. Findings include: Observations of the ventilator unit staff were conducted 4/12/22 through 4/18/22 between the hours of 7:30 AM and 6:00 PM. During these observations, no RN was observed on duty on 4/12/22 and 4/13/22. Review of the ventilator unit's Direct Care Staff Daily Reports from 3/1/22 through 4/13/22 revealed the facility did not have a registered nurse on duty daily for 16 hours on the following dates: 3/2/22, 3/3/22, 3/4/22, 3/7/22, 3/9/22, 3/10/22, 3/11/22, 3/14/22, 3/15/22, 3/16/22, 3/17/22, 3/18/22, 3/20/22, 3/22/22, 3/23/22, 3/24/22, 3/25/22, 3/30/22, 3/31/22, 4/1/22, 4/2/22, 4/5/22, 4/6/22, 4/7/22, 4/8/22, 4/9/22, 4/10/22, 4/11/22, 4/12/22 and 4/13/22. On 4/14/22 at 4:34 PM Staff 6 (Staffing/Payroll) reviewed the ventilator unit Direct Care Staff Daily Reports for the above listed dates and confirmed there was not a registered nurse on duty daily for 16 hours. On 4/15/22 at 1:06 PM Staff 1 (Administrator) was notified of the findings of this investigation and acknowledged the lack of registered nurse coverage in the ventilator unit.

V 160 OAR Staffing How the corrective action will be accomplished for identified affected individuals: No specific resident negative outcomes identified. How will other individuals with the potential to be affected or in similar situations be identified and protected: Residents on 400 hall have the potential to be affected by not having 16 hours of RN coverage. What systemic changes will ensure that the deficient practice will not recur: The facility continues to recruit for RN, offer bonus, reach out to our sister facilities and are connected with Staffing Agency to obtain RN coverage. If the facility is unable to find RN to cover, the RN RCM will be asked to cover then lastly RN DNS will step in to cover to maintain 16 hours RN coverage. Administrator or designee will educate the staffing coordinator to alert the Administrator and DNS if there is an RN shortage for the upcoming schedule for added assistance to acquire coverage. How the facility will monitor its corrective actions/performance: Administrator will complete daily audits for 4 weeks, then monthly audits for 2 months to ensure that the facility has 16 hours of RN coverage. Any issues identified through the audits will be brought to QAPI and a process improvements plan will be developed as necessary.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/29/2021 and 12/05/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to ensure a resident was treated with dignity for 1 of 4 sampled residents (#7) reviewed for incontinence care. This placed residents at risk for impaired dignity. Findings include: Resident 7 was admitted to the facility in 2020 with diagnoses including pressure ulcer and neurogenic bladder (lack of bladder control due to a nervous system issue). A Progress Note dated 1/15/21 at 4:15 AM indicated Witness 7 (Complainant) called the facility and gave instructions to send a clean change of clothes, briefs, wheelchair footrest and pad when the resident went to her/his wound clinic appointment. A Progress Note dated 1/15/21 at 2:39 PM revealed Resident 7 went from the facility to a routine wound clinic appointment with no dressing applied to the resident's pressure ulcer and the resident was soaked with urine. The note indicated the "medical professionals" at the clinic were "extremely upset". On 10/19/21 at 9:56 AM Witness 9 (Certified Physician Assistant) confirmed Resident 7 arrived for a wound treatment appointment soaked in urine. Witness 9 stated the resident did not have spare briefs or additional clean clothing with her/him for the resident to change into. On 10/18/21 at 1:46 PM Staff 8 (LPN/Resident Care Manager) confirmed the incident occurred and staff were provided education to make sure Resident 7 went to appointments with a clean change of clothes, briefs and a dressing applied.

1. Resident #7 no longer resides at the facility, discharging 3/11/21. 2. Other residents that require assistance with incontinence care and/or dressing changes have the potential risk of dignity not being maintained if cares are not provided per care plan or physician orders prior to leaving for outings or appointments. See Audit section for on-going audits 3. Education provided to nursing staff (LNs and Aides) by the DNS for ensuring continence cares are provided to maintain dignity, ensuring continence supplies are available for outings, that dressings are applied per MD order prior to residents going out for outings or appointments and that communication of family requests or instructions are clear during shift, to shift change over. 4. Audits to ensure dignity regarding continence care, dressing changes and family requests being honored will be done weekly x4 weeks, then monthly x2 months by the RCM or designee to ensure on-going compliance. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to notify the family when a resident was transferred to the hospital for 1 of 3 sampled residents (#6) who was reviewed for notification. This placed residents and responsible parties at risk for not being informed of significant changes of condition and making informed decisions. Findings include: Resident 6 was admitted to the facility in 2021 with diagnoses including failure to thrive. Resident 6 no longer resided in the facility. On 2/8/21 at 2:37 PM Witness 6 (Complainant) stated the resident's family was not notified by the facility the resident was transferred to the hospital until the hospital contacted them. A Progress Note dated 2/3/21 indicated Resident 6 was sent to the hospital by provider order related to high potassium levels. The note did not indicate the resident's family was notified. On 10/14/21 at 11:33 AM Staff 27 (RN), who was the nurse on duty when Resident 6 was sent to the hospital, stated she normally documented in the Progress Notes when family is contacted due to a significant change in resident condition. Staff 27 could not recall if she notified Resident 6's family and stated she must have forgotten.

1. Resident #6 no longer resides at the facility, discharging 2/3/21. 2. Other residents and their responsible parties have the potential risk of not being informed of a significant change of condition or the ability to make informed decisions if the resident or their responsible party is not notified of a resident being transferred to the hospital. See Audit section for on-going audits. 3. Education provided to the LNs by the DNS regarding notification to the resident or their responsible party of a resident being transferred to the hospital and documenting the notification in the record. 4. Audits to ensure notification is made to resident or their responsible party and then documented in the records will be done weekly x4 weeks, then monthly x2 months by the RCM or Designee to ensure on-going compliance. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interviews and record review it was determined the facility failed to protect residents from abuse for 3 of 6 sampled residents (#s 17, 10 and 2) reviewed for abuse. This placed residents at increased risk for physical or psychosocial harm. Findings include: 1. Resident 17 was admitted to the facility 9/2020 with diagnoses including chronic obstructive pulmonary disease (lung disease making it difficult to breathe). A 10/20/21 FRI report indicated Resident 5 exposed her/his genitals to Resident 17 and attempted to grab her/his breast and run her/his hand up her/his leg. Resident 5's behavior monitor dated 3/19/21 indicated Resident 5 had target behaviors which included: inappropriate sexual comments, touching to female staff and residents, entering wrong rooms without permission, invading personal and private space of others. Facility interventions for Resident 5's behaviors included: intervene as necessary to protect the rights and safety of others, explain/reinforce why behavior is inappropriate or unacceptable to the resident, and monitor Resident 5's whereabouts at all times when up ambulating in the facility. The following incident reports revealed past allegations of inappropriate behavior involving Resident 5: -A 4/18/21 FRI report indicated Resident 5 stood in a female resident's doorway and made a sexually oriented statement to her, which made her feel uncomfortable. -A 8/1/21 facility incident report indicated Resident 5 entered a female resident's room and tried to get in her bed. On 10/25/21 at 2:57 PM, Resident 27 stated she/he had to keep an eye on Resident 5. Resident 27 stated Resident 5 came into her/his room and made inappropriate comments, "I love you; I want to hold you." Resident 27 stated she/he did not feel safe. On 10/26/21 at 11:36 AM, Staff 45 (CNA) stated Resident 17 did not want to come out of her/his room to see people because Resident 5 made her/him uncomfortable. On 10/26/21 at 1:10 PM, Resident 17 stated she/he stayed behind her/his curtain to stay safe from Resident 5. On 10/26/21 at 3:30 PM, Staff 46 (LPN) stated Resident 5 would stand next to her at the medication cart and put his hand on her back. Staff 46 stated Resident 5 made inappropriate comments, "You sure look pretty." "I sure like standing here looking at you." On 11/1/21 at 5:56 PM, Staff 29 (LPN) stated the facility did not have enough staff available for 1:1 supervision for Resident 5 and because of this the facility could not ensure the safety of female residents. On 11/2/21 at 12:46 PM, Staff 8 (LPN/Resident Care Manager) stated female residents were at risk with Resident 5 due to lack of staff to provide 1:1 supervision for Resident 5. On 11/3/21 at 12:53, Staff 2 (DNS) stated if Resident 5 was not monitored by staff, female residents were at risk. , 2. Resident 10 was admitted to the facility in 2016 with diagnoses including hemiplegia (lack of control of one side of the body) and traumatic brain injury. Review of Resident 10's care plan dated 3/25/20 indicated the resident may exhibit behavior such as hitting staff, kicking staff, and yelling at staff and staff were to reapproach the resident when care was refused. According to a facility investigation dated 4/9/20, Staff 37 (CNA) observed Staff 36 (former CNA) striking Resident 10 while stating, "you're a piece of shit," when Resident 10 became aggressive and combative towards Staff 36 during care. On 10/18/21 at 10:18 AM an interview with Resident 10 was attempted. Resident 10 was alert but was not physically or verbally responsive. On 10/25/21 at 10:14 AM Staff 37 recalled on 4/9/20 observing Staff 36 directing verbal and physical abuse towards Resident 10 while assisting Resident 10. Staff 37 stated she was shocked that Staff 36 struck Resident 10. On 10/25/21 at 10:21 AM Staff 36 confirmed she made verbally abusive statements and physically struck Resident 10 when Resident 10 was resistant to care. On 10/29/21 at 2:43 PM the findings were discussed with Staff 1 (Administrator). Staff 1 confirmed abuse occurred. 3. Resident 2 was admitted to the facility in 6/2021. According to a MDS from 9/27/21, Resident 2 had a BIMS score of 15 which indicated normal cognitive function. According to the facility investigation dated 9/17/21 Witness 10 (Former RN) stated, "go screw yourself" in response to a comment from Resident 2. In the investigation, Witness 10 confirmed this statement was made and that it was directed towards Resident 2. Multiple attempts to reach Witness 10 for interview were unsuccessful. On 10/13/21 at 12:50 PM Resident 2 confirmed the statement made by Witness 10 occurred and considered what Witness 10 said verbal abuse. On 10/29/21 at 2:43 PM Staff 1 (Administrator) confirmed staff to resident verbal abuse occurred on 9/17/21.

1. Residents #17, #10 and #2 all reside at the facility and have been assessed for physical and/or psychosocial harm. There are no unaddressed concerns at this time, care plans reflect current needs. 2. Other residents have a potential risk of abuse or psychosocial harm if abuse policies are not followed and/or effective interventions are not put into place to protect residents from identified target behaviors. Residents that have identified target behaviors have had interventions evaluated to ensure effectiveness, revisions made as necessary to reflect current needs. Residents have been interviewed to ensure there are no unidentified concerns. 3. Education has been provided to facility staff by the Administrator or DNS on current Abuse Policies, reporting ineffective interventions or limitations/barriers to being able to implement an intervention. 4. Audits to ensure residents feel safe (by the SSD or designee), abuse policy is being followed (by the Administrator or Designee), interventions are being followed and are currently effective (by the RCMs or Designee) will be done weekly x8 weeks, then monthly x1 month to ensure on-going compliance. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interviews and record review it was determined the facility failed to ensure residents were free from misappropriation of financial resources of 1 of 6 sampled residents (#11) reviewed for abuse. This placed residents at risk for financial abuse. Findings include: On 2/3/20 Resident 11 was admitted to the facility with diagnoses including left lower leg fracture, Parkinson's disease (nervous system disorder that affects movement), and cognitive impairment. On 4/3/20 Witness 15 (complainant) reported to the facility Resident 11's credit card was used unauthorized at various locations in the metro area while Resident 11 resided at the facility. According to the facility investigation dated 4/3/20, Resident 11's credit card was used without her/his authorization on multiple occasions from 2/29/20 through 3/12/20 both in the facility and out in the community. The resident did not leave the facility during this time. The facility reported the incident to the police department. Resident 11's credit card was never located. On 4/3/20 Resident 11's care plan was updated to address private property monitoring and storage. Resident 11's care plan included having received education and recommendations to have valuable personal property including credit cards locked in a private location to prevent unauthorized purchases. On 4/8/20 Resident 11's wallet with remaining bank cards was placed in the Administrator's office after Resident 11 refused to have her/his wallet locked in a safe. On 10/20/21 at 1:42 PM Witness 17 (Police Officer) stated Resident 11's credit card was determined stolen and used at restaurants and gas stations in the metro area requiring use of a physical card. On 10/22/21 at 2:02 PM Witness 15 stated Resident 11's credit card was missing from Resident 11's property and used at multiple locations in the metro area as well as at the facility vending machine while the resident resided at the facility. On 10/29/21 at 2:43 PM the findings were discussed with Staff 1 (Administrator) and she provided no additional information.

1. Resident #11 no longer resides at the facility, discharging 4/14/2020. 2. Other residents have the potential risk for financial abuse if abuse/misappropriation policies are not followed. Resident interviews have been conducted to ensure there are no unknown cases of financial abuse. 3. Education provided to facility staff on 11/22/2021 regarding investigation processes related to misappropriation of financial resources. 4. Grievances regarding misappropriation of financial resources will be reviewed and investigated by Administrator/DNS or SSD weekly x 4 weeks then monthly x 2 months to ensure ongoing compliance. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interviews and record review, it was determined staff failed to immediately report an allegation of sexual abuse for 1 of 3 sampled residents (#17) reviewed for abuse. This placed residents at risk for sexual abuse. Findings include: The facility's abuse investigation and reporting policy dated June 2018 indicated: All staff members and agents of the facility are mandatory reporters of abuse. Mandated Reporters are to immediately report to their supervisor when they have reasonable cause to believe abuse has occurred, or when they have reason to suspect an incident is sexual or physical assault. An alleged violation of abuse will be reported immediately, but no later than two (2) hours if the alleged violation involves abuse. Resident 5 was admitted to the facility 2/2021 with diagnoses including dementia. Resident 17 was admitted to the facility 9/2020 with diagnoses including chronic obstructive pulmonary disease (a lung disease that makes if difficult to breathe). On 10/25/21 at 4:41 PM, Staff 41 (Activities Director) stated on 10/19/21 around 10:00 PM she received a text message from Resident 21 which read: "Hey guess what Resident 5 did to Resident 17 this evening?" "Resident 5 went over to Resident 17 exposed herself/himself and said, "Come on let's go do it." Staff 41 stated she should have called administration, but it was late. Staff 41 stated on 10/20/21 around 10:00 AM she reported the incident to Staff 16 (Social Service Director). On 10/26/21 at 12:51 PM, Resident 21 stated on 10/19/21 at 7:00 PM Resident 17 came out for a smoke break with her/him. Resident 17 reported to Resident 21 that Resident 5 exposed herself/himself to her/him and said, "Let's go do it." Resident 21 stated she/he thought about it for some time as she/he wasn't sure what to do. Resident 21 stated she/he sent a text message on 10/19/21 around 11:00 PM to Staff 41 because they were friends. Resident 21 stated Staff 41 called her/him and said you need to report this incident and Staff 41 was going to do the same. Resident 21 stated on 10/20/21 around 11:00 AM, she/he reported the incident to Staff 16. On 10/26/21 at 3:51 PM, Staff 16 stated Staff 41 reported the incident to her the morning of 10/20/21 but could not recall the time. Staff 16 stated she immediately reported the incident to Staff 2 (DNS). Review of a FRI form revealed the 10/19/21 resident to resident sexual abuse incident was reported to the State Survey Agency on 10/20/21 at 4:25 PM, which was twelve hours beyond the appropriate reporting time. In an interview on 11/3/21 at 12:53 PM, Staff 2 stated the expectation was for staff to report abuse within two hours. Refer to F600

1. Resident #17 resides at the facility and has been assessed for physical and/or psychosocial harm. There are no unaddressed concerns at this time, care plans reflect current needs. 2. Other residents have the potential risk of abuse if mandatory reporting policies are not followed. See F600 for resident interviews to ensure there are no unidentified abuse concerns. 3. Facility staff were educated by the DNS on 11/22/21 regarding reporting alleged violations, being a mandatory reporter. Education included to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. 4. Audits of abuse allegations for timely reporting will be done weekly x 12 weeks by the Administrator to ensure Mandatory Reporter reporting was done per policy. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to provide bathing, toileting and incontinence care for 2 of 9 sampled residents (#s 6 and 13) reviewed for bathing, toileting and incontinence care. This placed residents at risk for poor hygiene. Findings include: 1. Resident 6 was admitted to the facility in 2021 with diagnoses including failure to thrive. Resident 6 no longer resided in the facility. On 2/8/21 at 2:37 PM Witness 6 (Complainant) stated the resident was not showered or shaved when she visited. A review of Resident 6's January and February 2021 bathing record indicated the resident did not receive, or refuse, bathing during her/his six day stay in the facility. A review of Resident 6's Activities of Daily Living care plan initiated on 1/28/21 indicated the resident was scheduled for bathing on Tuesdays and Fridays. A review of Resident 6's Progress Notes from 1/28/21 through 2/3/21 revealed no indication the resident was unavailable or refused bathing on Friday 1/29/21 or Tuesday 2/2/21. On 10/12/21 at 2:28 PM Staff 2 (DNS) verified there was no indication Resident 6 received bathing and residents were scheduled for two baths per week. , 2. Resident 13 was admitted to the facility in 11/2020 with diagnoses including urinary tract infection and sepsis (infection of the bloodstream). According to a 12/11/20 intake interview for a public complaint to the State Survey Agency, Resident 13 did not consistently receive timely toileting assistance or bathing as scheduled. Resident 13's 11/26/20 toileting and bathing care plan indicated Resident 13 required one-person extensive assistance for toileting and bathing and the resident was scheduled for bathing on Sundays and Wednesdays. An 11/27/20 Progress Note completed by Witness 11 (Former RN) revealed Resident 13 notified Witness 11 she/he was incontinent because nobody answered the call light. A review of Resident 13's December 2020 bathing record indicated the resident did not receive bathing from 12/2/20 until 12/9/20. On 12/6/20, Resident 13 was marked as unavailable. A review of Resident 13's Progress Notes from 12/2/20 through 12/9/20 revealed no documentation indicating Resident 13 was provided additional bathing opportunities prior to 12/9/20. On 10/13/21 through 10/16/21, Witness 11 (Former RN), Staff 4 (CNA), Staff 7 (CNA) and Staff 20 (CNA) all reported during November and December 2020, they were unable to provide timely toileting assistance and showers as scheduled due to staffing shortages. Refer to F725

1. Resident #6 discharged from facility on 2/3/21 and resident # 13 discharged 12/18/20. 2. Other residents that require staff assistance for ADL's have potential risk for poor hygiene if bathing, toileting and incontinence care is not provided per care plan. See F725 for resident interviews to ensure care needs are met. 3. In service provided to nursing staff on 11/22/21 regarding providing care based on Care Planned needs, reporting to nurse any barriers in providing care per Care Plan. 4. DNS or designee to audit 5 residents weekly x 4 weeks and then 5 residents monthly x 2 months to ensure bathing, toileting and incontinence care is being provided per care plan. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to follow physician's orders for medication administration for 1 of 3 sampled residents (#2) reviewed for medication administration. This placed residents at risk for adverse medication consequences. Findings include: On 6/2021 Resident 2 was admitted to the facility with diagnoses including congestive heart failure, respiratory failure and end stage renal disease. According to the 9/27/21 MDS, Resident 2 had a BIMS score of 15 which indicated normal cognitive function. Physician Orders indicated that metoprolol succinate (blood pressure medication) was not to be administered when Resident 2's systolic (top number in a blood pressure reading) blood pressure was below 110. Resident 2's MAR revealed metoprolol succinate was administered on 8/1/21 when Resident 2's systolic blood pressure was 105, on 8/13/21 when Resident 2's systolic blood pressure was 105, and on 8/31/21 when Resident 2's systolic blood pressure was 103. On 10/13/21 at 12:50 PM, Resident 2 stated she/he received metoprolol succinate in error during August 2021 which resulted in her/him feeling nauseous, sweaty, and clammy for entire days. On 10/15/21 at 11:04 AM, Staff 19 (CMA) stated blood pressure checks were performed immediately before administering metoprolol succinate to determine a resident's need for this medication. Staff 19 stated the usual orders for metoprolol succinate included instructions to not administer metoprolol succinate when a resident's systolic blood pressure was below 100. Staff 19 confirmed she gave metoprolol succinate to Resident 2 when her/his blood pressure was below 110. Staff 19 did not provide a rational why physician's orders were not followed for holding Resident 2's metoprolol succinate medication. On 10/15/21 at 11:47 AM, Staff 2 (DNS) confirmed the medication administration errors.

1. Resident #2 currently resides in facility. Medication reconciliation has been completed to ensure physicians orders are being followed with no further findings. 2. Other residents requiring medications to be given within parameters have potential risk for adverse medication consequences if physician orders for medication administration are not followed. Completed facility audit on MAR with no further findings. 3. In service provided by DNS to LNs and CMAs on 11/22/21 regarding following physician orders. 4. DNS or designee will audit 5 residents MARS weekly for accuracy of administration x 4 weeks and then 5 residents monthly x 2 months to ensure physician orders are being followed. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to accurately and comprehensively assess a pressure ulcer, implement a comprehensive pressure ulcer care plan, ensure wound care treatment was provided and follow physician's orders for wound care for 1 of 3 sampled residents (#7) reviewed for skin impairment. This placed residents at risk for pressure ulcers and delayed healing. Findings include: Resident 7 was admitted to the facility in 2020 with diagnoses including pressure ulcer. CMS Appendix PP defined a Stage 3 pressure ulcer as "Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI." CMS Appendix PP defined a Stage 4 pressure ulcer as "Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI." Resident 7's hospital History and Physical dated 9/17/20 indicated the resident had a Stage 4 pressure ulcer on the left buttock with exposed bone which measured 4.2 cm by 8.6 cm and 5.2 cm deep. There was tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) near the top left of the wound which measured 5.2 cm in depth. A review of Resident 7's comprehensive care plan initiated 10/2/20 revealed there was no comprehensive pressure ulcer care plan in place. A review of Resident 7's October, November and December 2020 TARs revealed treatment orders for staff to document the number of pieces of foam that were packed into the resident's Stage 4 pressure ulcer when wound care was provided. No documentation was found in the resident's clinical record that indicated the number of pieces of foam used when wound care was provided. A provider's Progress Note dated 10/4/20 indicated the resident had a Stage 4 pressure ulcer to the left buttock. A review of the twenty weekly Skin & Wound Evaluations from 10/7/20 through 3/8/21 for Resident 7 revealed: - The wound was consistently, and incorrectly, assessed as a Stage 3 pressure ulcer instead of a Stage 4. - Three assessments failed to include a depth measurement. - Eleven assessments failed to include tunneling measurements. - Fourteen assessments failed to describe the wound bed. - Thirteen assessments failed to indicate if the wound had drainage. - Thirteen assessments failed to describe the condition of the tissue surrounding the wound. - Twelve assessments failed to describe the current treatment that was provided. - The assessments alternated between indicating the wound was "stalled", "stable" and "improving" without a clear rationale for the progress determination that was provided. A Progress Note dated 1/15/21 revealed Resident 7 went from the facility to a routine wound clinic appointment with no dressing applied to the resident's Stage 4 pressure ulcer and the resident was soaked with urine. The note indicated the "medical professionals" at the clinic were "extremely upset". On 10/19/21 at 9:56 AM Witness 9 (Certified Physician Assistant) confirmed Resident 7 arrived for a wound treatment appointment with no dressing applied to the Stage 4 pressure ulcer and the resident was soaked in urine. Witness 9 stated she/he was not happy with the care Resident 7 received at the facility. On 10/18/21 at 1:46 PM and 10/20/21 at 1:54 PM Staff 8 (LPN/Resident Care Manager) acknowledged the weekly wound assessments were not comprehensive and accurate, verified there was no comprehensive pressure ulcer care plan, verified there was no documentation that indicated the number of pieces of foam used during wound care and verified the resident was sent to a wound clinic appointment with no dressing in place.

1. Resident #7 no longer resides in facility. Discharged on 3/11/21. 2. Other residents with pressure ulcers have potential risk for worsening pressure ulcers and delayed healing if pressure ulcers are not comprehensively assessed, comprehensive care plan developed and wound care is not completed per MD order. Facility audit completed regarding care plans for residents who currently have pressure injuries. Wound assessments reviewed for accuracy. Care plans reflect current risks/needs/treatments to avoid pressure injuries and promote healing. 3. In service provided to LNs by the DNS regarding comprehensive wound assessments, developing a care plan for pressure injuries and following treatments per MD order. 4. DNS or designee to audit weekly x4 weeks, then monthly x2 months wound assessments for accuracy, care plans for comprehensiveness and appropriate treatments to heal or prevent pressure injuries. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs in a timely manner for 2 of 3 sampled residents (#s 1 and 13) who were reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 13 was admitted to the facility in 11/2020 with diagnoses including urinary tract infection and sepsis (infection of the bloodstream). According to a 12/11/20 intake interview for a public complaint to the State Survey Agency, on 11/27/21, Resident 13 used the call light for assistance during the night and staff did not respond. Later that night, Resident 13 needed assistance with toileting, the resident again used her/his call light and staff did not respond for over 45 minutes and staff reported they were frequently short staffed. Resident 13's 11/27/20 toileting care plan indicated the resident required one-person extensive assistance for toileting and the resident "has two stimulators [bladder] and urgency. Please check and offer toileting *frequently* please. Difficulty getting off toilet-please follow up with [her/him] while ON TOILET. Assist back to bed [her/his] legs fall asleep quickly while on toilet!" An 11/27/20 Progress Note completed by Witness 11 (Former RN) revealed Resident 13 notified Witness 11 she/he was incontinent because nobody answered the call light. Later, Witness 11 heard Resident 13 calling for help and rushed into the room and found Resident 13 on the toilet and the call light had been on for a "very long" time. A Review of Resident 13's iAlert Page Report (call light response logs) from 11/26/20 through 11/27/20 and 12/5/20 through 12/15/20 revealed the following: -the resident's call light was triggered 47 times; -26 of the 47 times, Resident 1 waited greater than 20 minutes for staff to answer her/his call light request; -10 of the 26 times, the resident waited greater than one hour for her/his call light to be answered with call light response times as follows: one hour, one hour 11 minutes (x2), one hour 26 minutes, one hour 32 minutes, one hour 34 minutes (x3), one hour 36 minutes and one hour 48 minutes; -2 of the 26 times, the resident waited greater than two hours for her/his call light to be answered with call light response times as follows: two hours and 36 minutes and two hours and 47 minutes; -3 of the 26 times, the resident waited greater than three hours for her/his call light to be answered with call light response times as follows: three hours and five minutes, three hours and eight minutes and three hours and 20 minutes; -1 of the 26 times, the resident waited greater than four hours for her/his call light to be answered with call light response time as follows: four hours and 21 minutes. On 10/13/21 at 10:36 AM, Witness 3 (Complainant) reported around the first day Resident 13 was at the facility, Resident 13 called for assistance to use the bathroom and it took a long time for the staff to respond and then it took over two hours for staff to return to assist her/him from the toilet. Witness 3 stated facility staff told them they were short staffed and Witness 3 spoke to the facility administration who denied this. On 10/13/21 at 2:11 PM, Witness 11 stated during 11/2020 and 12/2020, staffing ratios were not safe for the level of acuity of the residents which posed an unsafe working environment. On 10/14/21 at 4:36 PM, Staff 14 (CNA) stated during 11/2020 and 12/2020 the facility was so short staffed the CNAs were unable to provide care such as showers and call light response times were often one hour to one and one-half hours long. On 10/15/21 at 1:29 PM and 10/16/21 at 1:08 PM, Staff 7 (CNA) and Staff 20 (CNA) stated during 11/2020 and 12/2020 the facility was short staffed which impacted the CNAs ability to provide showers and toilet residents in a timely manner. Both staff stated residents that were typically continent were often incontinent because staff could not respond to them timely. Staff 20 stated call light times were easily over one hour and staffing was so bad they were concerned for the resident's safety. , 2. Resident 1 was admitted to the facility in 5/2021 with diagnoses including Parkinson's Disease (disorder of the central nervous system that affects movement) . According to 5/6/21 and 7/12/21 intakes for public complaints to the State Survey Agency, Resident 1 used the call light for assistance with toileting and/or brief change. The resident experienced call light wait times of 40 minutes or more before staff responded. The resident was left in urine and feces soaked briefs due to long periods of waiting for staff and experienced skin breakdown in her/his groin area as a result. Resident 1's 5/12/21 toileting care plan indicated Resident 1 required two person extensive assist for toileting tasks and personal hygiene care. Resident 1's 5/20/21 care plan indicated Resident 1 was prone to redness to the groin related to moisture. Progress Notes dated 5/16/21 and 7/12/21 indicated Resident 1 had redness in her/his groin area. A review of Resident 1's iAlert Page Report (call light response logs) from 5/6/21 through 5/31/21 revealed the following: -the resident's call light was triggered 173 times; -94 of the 173 times, Resident 1 waited greater than 20 minutes for staff to answer her/his call light request; -35 of the 94 times, the resident waited greater than one hour for her/his call light to be answered; -8 of the 94 times, the resident waited greater than two hours for her/his call light to be answered; -1 of the 94 times, the resident waited greater than three hours for her/his call light to be answered; -1 of the 94 times, the resident waited greater than four hours for her/his call light to be answered. A review of Resident 1's iAlert Page Report (call light response logs) from 7/12/21 through 7/31/21 revealed the following: -the resident's call light was triggered 185 times; -38 of the 185 times, Resident 1 waited greater than 20 minutes for staff to answer her/his call light request; -7 of the 38 times, the resident waited greater than one hour for her/his call light to be answered; -3 of the 38 times, the resident waited greater than two hours for her/his call light to be answered; -1 of the 38 times, the resident waited greater than four hours for her/his call light to be answered. On 10/14/21 at 8:08 AM, Witness 13 (Complainant) reported while at the facility in July 2021, he reviewed call records for Resident 1 and found wait times of 45 minutes or more. Witness 13 spoke directly to the Social Services Director (Staff 16) who acknowledged the facility was short on staff and there were delays in care. On 10/15/21 at 11:35 AM and 12:15 PM, Staff 7 (CNA) and Staff 14 (CNA) both stated staff were very busy on the floor and there were not enough staff available which made it difficult to respond to toileting, brief changes and residents needs/care. On 10/25/21 at 3:43 PM, Resident 1 stated she/he would press the call light for toileting and/or brief change, and would often wait for an hour, then yelled for help. Resident 1 reported staff told her there were delays in care because the facility was short on staff. Resident 1 stated she/he was concerned for skin breakdown in her/his groin area related to being left in a soaked brief for an extended period of time and due to the facility extremely short staffed.

1. Resident #1 no longer resides at the facility, discharging 10/13/21. Resident #13 no longer resides at the facility, discharging 12/18/20. 2. Other residents that are reliant on staff assistance are at risk for unmet care needs if staffing levels are not sufficient. Residents will be interviewed to ensure care needs are being met. See Section 4 for on-going audits. 3. Education provided to Staffing Coordinator by the DNS on staffing ratios and reporting to Admin/DNS if unable to meet ratios. Nursing Staff educated by the DNS on timely call light response and reporting barriers to effective time management. 4. Audits to ensure care needs are met weekly x4 weeks, then monthly x2 months by the SSD or Designee. Call Light audit will be done weekly x12 weeks by the DNS or designee. Audits for Staffing Ratios will be done weekly x12 weeks by the Administrator or Designee. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to ensure sufficient staffing levels were maintained to assure resident safety and well-being for 2 of 3 sampled residents (#s 103 and 109) reviewed for sufficient staffing. This placed residents at risk for delayed and unmet care needs. Findings include: 1. On 1/11/22 at 4:10 PM Resident 109 stated she/he had to wait a half hour or longer for her/his call light to be answered. The resident also stated she/he had to wait a half hour or longer to receive assistance with toileting. On 1/12/22 at 1:30 PM Staff 4 (CNA) stated there was not always sufficient facility staff. He stated he was not able to complete his daily assignments most days. On 1/12/22 at 1:36PM Staff 5 (CNA) stated the facility was struggling with staffing. She also stated she was not able to complete resident scheduled showers or weights in a timely manner or at all some days. On 1/12/22 at 2:08 PM Staff 7 (CNA) stated there were shifts where they fell behind and often the resident's needs were not met. On 1/12/22 at 2:48 PM Staff 8 (CNA) stated it was very hard for her to complete her daily assignments. She stated she felt rushed to get her assignments completed and was not able to get to resident showers most days. Review of the call light log for Resident 109 from 12/16/21 through 1/12/22 revealed the following wait times for call light response: - 1/12/22 at 11:43 AM 1 hour and 57 minutes - 1/12/22 at 6:08 AM 1 hour and 10 minutes - 1/11/22 at 7:38 PM 47 minutes - 1/11/22 at 1:37 PM 1 hour and six minutes - 1/11/22 at 8:13 AM 25 minutes - 1/7/22 at 8:19 PM 36 minutes - 1/7/22 at 7:13 AM 1 hour and 24 minutes - 1/6/22 at 8:23 PM 54 minutes - 1/6/22 at 2:41 PM 40 minutes - 1/6/22 at 5:38 AM 25 minutes - 1/5/22 at 11:14 PM 50 minutes - 1/5/22 at 5:22 PM 1 hour and 18 minutes - 1/5/22 at 5:33 AM 25 minutes - 1/4/22 at 9:45 AM 21 minutes - 1/3/22 at 7:28 PM 21 minutes - 12/23/21 at 5:08 AM 24 minutes - 12/16/21 at 10:25 AM 24 minutes On 1/13/22 at 11:02 AM Staff 1 (Administrator) acknowledged the long call light wait times indicated on Resident 109s logs. Staff 1 stated she reviewed call light logs each day and investigated long call lights to determine what occurred. Staff 1 stated she had no information about the long waits indicated on Resident 109's call light logs. , 2. On 1/11/22 at 4:03 PM Resident 103 indicated she/he waited too long for assistance from staff members. Resident 103 indicated she/he did not believe staffing levels were improved since the facility was previously cited for insufficient staffing. A review of Resident 103's call light monitor log revealed 13 instances between 12/16/21 and 1/11/22 when staff took from 26 to 84 minutes to respond to the resident's call light. On 1/13/22 at 11:02 AM Staff 1 (Administrator) acknowledged the long call light wait times indicated on Resident 103's logs. Staff 1 stated she reviewed call light logs each day and investigated long call lights to determine what occurred. Staff 1 stated she had no information about the long waits indicated on Resident 103's call light logs. 3. A review of the facility's Direct Care Staff Daily Reports from 12/16/21 through 1/12/22 revealed eleven days when state minimum staffing ratios were not met on one or more shifts. During interviews with Staff 1 (Administrator) and Staff 12 (Staffing Coordinator) on 1/13/22 the staff acknowledged the facility did not meet the current minimum CNA staffing requirements. Refer to M-183. , ,

1. Resident #103 is a current resident at the facility, assessed by an RN and no negative outcomes noted. Care Plan reflects current care needs. Resident #109 is a current resident at the facility, assessed by an RN and no negative outcomes noted. Care Plan reflects current care needs. 2. Other residents that are reliant on staff assistance are at risk for unmet care needs if staffing levels are not sufficient and call lights are not answered timely. Residents will be interviewed to ensure care needs are being met. See Section 4 for on-going audits. 3. 1) Education provided to Staffing Coordinator by the DNS on staffing ratios and reporting to Admin/DNS if unable to meet ratios. 2) Nursing Staff educated by the DNS on timely call light response and reporting barriers to effective time management. 3) Review of the iAlert system by Maintenance/DNS/Admin to review efficiency, accuracy and inventory of accessories. Education will be provided to facility staff for any findings or new interventions put into place by the DNS or designee. 4) Review of Shower and Weights schedule system, education to nursing staff by the DNS for any changes in the system. 4. 1) 5 Random resident interviews to ensure care needs are met weekly x4 weeks, then monthly x2 months by the SSD or Designee. 2) Call Light audit will be done weekly x12 weeks by the DNS or designee. 3) Audits for Staffing Ratios will be done weekly x12 weeks by the Administrator or Designee. 4) Shower/Weight audit weekly x12 weeks by the DNS or designee. 5) Will continue to work with the Oregon Staffing Coordinator under the Staffing Waiver through DHS. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to provide PT and OT services according to physician orders for 3 of 3 sampled residents (#s 13, 14 and 15) reviewed for therapy services. This placed residents at risk for a decline in strength, mobility and ADL functioning. Findings include: 1. Resident 13 was admitted to the facility in 11/2020 with diagnoses including urinary tract infection and sepsis (infection of the bloodstream). An 11/26/20 physician order revealed PT and OT were to evaluate and treat Resident 13. Resident 13's 11/26/20 OT Evaluation and Treatment Plan stated the resident was referred to OT due to new onset of decreased strength, functional mobility, ability to transfer and ability to ambulate safely. The plan indicated the resident was to receive OT treatment five times a week for 99 days. Resident 13's 12/1/20 PT Evaluation and Treatment Plan stated the resident was referred to PT due to new onset of decreased strength and functional mobility, reduced ability to safely ambulate, reduced functional activity tolerance and an increased need for assistance from others. The plan indicated the resident was to receive PT treatment five days a week for seven weeks. According to a 12/11/20 intake interview for a public complaint to the State Survey Agency, Resident 13 was supposed to receive therapy twice a day but did not receive therapy according to physician's orders. The 12/1/20 through 12/31/20 Patient Encounters Report indicated Resident 13 did not receive therapy services after 12/4/20. Resident 13 was at the facility from 11/26/20 to 12/18/20. 2. Resident 14 was admitted to the facility in 11/2020 with diagnoses including sepsis (infection of the bloodstream) secondary to an epidural abscess (an infection inside the skull near the spine). An 11/12/20 physician order revealed PT and OT were to evaluate and treat Resident 14. Resident 14's 11/13/20 OT Evaluation and Treatment Plan stated the resident was referred to OT due to new onset of reduced ADL participation, decreased strength and functional mobility, decreased transfers and ability to ambulate, reduced balance and an increased need for assistance from others. The plan indicated the resident was to receive OT treatment five times a week for 99 days. Resident 14's 11/13/20 PT Evaluation and Treatment Plan stated the resident was referred to PT due to a new onset of decreased strength, transfers and functional mobility, reduced ability to safely ambulate, pain, paresis/paralysis (the loss of ability to move part or most of the body) and increased need for assistance from others. The plan indicated the resident was to receive PT treatment five times a week for 60 days. The 11/13/20 through 12/23/20 Patient Encounters Report indicated Resident 14 did not receive rehab services from 12/5/20 through 12/17/20. Resident 14 was at the facility from 11/11/20 through 12/24/20. 3. Resident 15 was admitted to the facility in 10/2020 with diagnoses including diabetes and end-stage renal disease. A 10/26/20 physician order revealed PT and OT were to evaluate and treat Resident 15. Resident 15's 10/27/20 OT Evaluation and Treatment Plan stated the resident was referred to OT due to new onset of reduced ADL participation, decreased strength and functional mobility, decreased transfers, and ability to safely ambulate and reduced balance. The plan indicated the resident was to receive OT treatment three times a week for 99 days. Resident 15's 10/27/20 PT Evaluation and Treatment Plan stated the resident was referred to PT due to new onset of reduced ability to safely ambulate and reduced functional tolerance. The plan indicated the resident was to receive PT treatment two times a week for 46 days. The 12/1/20 through 12/31/20 Patient Encounters Report indicated Resident 15 did not receive rehab services from 12/3/20 through 12/21/20. Resident 15's rehab services were discontinued 1/14/21 and the resident remained in the facility. On 10/12/21 at 2:35 PM and 3:09 PM and 10/26/21 at 12:24 PM, Staff 10 (Rehab Director) and Staff 11 (Rehab Area Director) stated Resident 13, Resident 14 and Resident 15 did not receive rehab services due to a lack of rehab staff. Staff 10 reported there were no physician orders placing the resident's therapies on hold and no assessments were completed for restorative therapy or other services that could have addressed strengthening, mobility or ADL functioning. On 10/13/21 at 10:36 AM, Witness 3 (Complainant) reported Resident 13 was admitted to the facility for therapy services and was told the resident would not be able to be discharged until she/he was done with therapy. Witness 3 stated Resident 13 never got any therapy services so the family requested Resident 13 be discharged home. On 10/28/21 at 10:12 AM, Staff 2 (DNS) stated she expected rehab services to be provided according to physician's orders and if there were no rehab staff to provide services, residents should have been considered for transfer to other facilities where rehab services were available.

1. Resident #13 no longer resides at the facility, discharging 12/18/20. Resident #14 no longer resides at the facility, discharging 12/24/20. Resident #15 no longer resides at the facility, discharging 11/2/21. 2. Other residents that require PT or OT have the potential risk for decline in strength, mobility and ADL function if PT and/or OT services are not provided per MD order. Current residents w/ MD orders in place for PT and OT have been reviewed to ensure services are provided to meet the MD order. 3. Education has been provided to the Therapy Director by the DNS to ensure that collaboration with MD and Nursing occurs when MD orders are not able to be followed for PT or OT to ensure alternative care can be set up. 4. Audits to ensure Therapy Services have been provided per MD order will be done by the Director of Therapy weekly x4 weeks, then monthly x2 months. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on observations, interviews and record review it was determined the facility failed to maintain appropriate infection control practices to prevent the potential spread of the COVID-19 virus and other infectious diseases for 2 of 3 hallways, 1 of 1 breakrooms and 2 of 2 screening stations reviewed for infection prevention. This placed residents at risk for exposure and contraction of the COVID-19 virus and other infectious diseases. Findings include: 1. The Center for Disease Control (CDC), "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", last revised 9/10/21, instructed healthcare workers to perform hand hygiene before and after all patient contact, before and after removing PPE (Personal Protective Equipment) which included gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. The Lippincott Manual of Nursing Practice, 10th edition, "Fundamentals of Standard Precautions for Hand Hygiene" indicated hand hygiene is the single most recommended measure to reduce the risk of transmitting micro-organisms. Hand hygiene should be performed between patient contacts; after contact with blood, body fluids, secretions and excretions, and contaminated equipment or articles; before donning and after removing gloves is vital for infection control. The facility Personal Protective Equipment (PPE) Policy, dated 7/12/21, indicated if eye protection or face shields were touched or repositioned then staff must immediately perform hand hygiene. Observations were conducted from 10/16/21 through 10/29/21 between the hours of 10:00 AM and 4:00 PM. During these observations, staff were observed to not perform hand hygiene appropriately to prevent the spread of the COVID-19 virus. Examples included: -On 10/18/21 at 10:53 AM, Staff 38 (Housekeeping) adjusted and touched her face coverings, entered a resident's room and began cleaning without completing hand hygiene. Staff 38 confirmed hand hygiene was necessary after touching face coverings. -On 10/18/21 at 10:57 AM, Staff 40 (LPN) exited a resident's room and went to a treatment cart without completing hand hygiene. Staff 40 stated hand hygiene was necessary before entering and after exiting a resident's room. -On 10/18/21 at 12:10 PM, Staff 44 (CNA) donned gloves, adjusted her face shield, picked up a tray, delivered it to a resident, removed her gloves and donned a clean isolation gown without completing hand hygiene. Staff 44 stated she was unaware that she did not complete hand hygiene after touching her face shield and after removing her gloves but hand hygiene should be completed before/after gloving and after touching anything dirty. -On 10/19/21 at 11:30 AM and 12:33 PM, Staff 24 (Medical Records) was observed in her office doffing and donning her face coverings and not performing hand hygiene immediately afterwards. Staff 24 stated she did not usually complete hand hygiene while in her office. 2. The CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", revised 9/10/21, instructed facilities to ensure environmental cleaning and disinfection procedures were followed consistently and correctly and any reusable Personal Protective Equipment (PPE) must be properly cleaned, decontaminiated and maintained after and between use. The Facility PPE Policy, dated 7/12/21, indicated if staff were not required to wear eye protection, the eye protection must be removed, cleaned with an EPA registered disinfectant and stored in a plastic bag or bin between uses and staff will store all facility issued PPE at the facility. -EPA N Disinfectant Results Table indicated the contact time for AF3 Germicidal, EPA number 9480-9, was three minutes. -EPA N Disinfectant Results Table indicated the contact time for Sani-Cloth wipes, EPA number 9480-4, was one minute. Observations were conducted from 10/16/21 through 10/29/21 between the hours of 10:00 AM and 4:00 PM. During these observations staff were observed to not adhere to or have knowledge of proper storage of PPE, appropriate disinfection processes for shared equipment or PPE or have knowledge of dwell/contact times to ensure proper disinfecting to kill the COVID-19 virus. Examples included: -On 10/16/21 at 2:00 PM, Staff 29 (LPN) was observed overseeing the evening staff screening process as staff entered through the side door near station one. Staff self-screened by writing responses to a staff questionnaire located in a notebook and then took their own temperatures. Staff shared the same pen and thermometer without disinfecting between uses. Staff 29 stated he was unaware staff were required to disinfect shared equipment between use during the screening process. -On 10/16/21 at 2:00 PM, Staff 37 (CNA) arrived for their shift carrying a face shield, entered the facility and donned the face shield. Staff 37 reported they used the face shield the previous day and stored it in their car for the next shift. -On 10/18/21 at 10:58, Staff 40 (LPN) exited a resident's room with vital sign equipment, placed the equipment in the hallway and did not disinfect the equipment. Staff 40 stated they typically disinfected shared equipment after each resident's use, utilizing the purple top wipes (Sani-Wipes) but they did not do so this time. Staff 40 stated they were unsure of the contact time for the Sani-Wipes. -On 10/18/21 at 11:01 AM, Staff 38 (Housekeeping) was observed training another housekeeper using wipes from a container labeled AF3 with EPA number 9480-9. Staff 38 did not know the contact time necessary to kill the COVID-19 virus. -On 10/18/21 at 1:38 PM, Staff 32 (CMA) reported she utilized purple top wipes (Sani-Wipes) to disinfect shared equipment and the product had a contact time of 90 seconds. -On 10/18/21 at 2:01 PM, Staff 15 (Staffing/HR) was observed screening oncoming staff into the main door of the facility. Staff 15 utilized a hand-held thermometer and did not disinfect the thermometer between staff usages. Staff 15 reported she was aware the thermometer needed to be disinfected between staff but did not consistently do so. -On 10/19/21 at 10:30 AM, 12:33 PM and 12:58 PM, Staff 24 (Medical Records) was observed with her face mask and shield sitting on her desk without a barrier. Upon Surveyor entering room, Staff 24 donned her face coverings without completing hand hygiene. Staff 24 stated she typically put her face coverings on her desk and did not complete hand hygiene unless she exited her office. Staff 24 stated she was unsure of any protocol to store and disinfect face coverings unless she was leaving for the day. -On 10/19/21 at 12:59 PM face masks were observed to be unattended on two separate tables in the staff break room. There were empty small and large brown paper bags scattered on a shelf and table; some labeled with names and others not. There were no items observed in the bags. Staff 26 reported the unattended face coverings did not belong to them and the small brown paper bags were for storing face masks and large brown paper bags were for storing face shields. Staff 26 reported there were no clean brown paper bags or supplies available for storing or disinfecting face coverings while in the breakroom, and facility staff were not consistently following infection control practices. -On 10/19/21 at 1:51 PM, Staff 23 (CMA) arrived for her shift carrying a plastic bag, reached into the bag and pulled out her face shield. Staff 23 stated at the end of the day she placed her face shield in the plastic bag and stored it in the trunk of her car. -On 10/22/21 at 11:15 AM, Staff 5 (CNA), Staff 19 (CMA) and Staff 21 (CMA) were observed in the breakroom. There were three face shields left unattended on tables and the staff reported the unattended face shields did not belong to them. Staff 5, Staff 19 and Staff 21 were either holding their face coverings or had them placed on the table next to them. Staff 5 stated face shields were supposed to be disinfected and stored in brown paper bags but the breakroom did not have disinfecting supplies and there were no clean brown paper bags for storage. -On 10/29/21 at 11:42 AM, an unattended mask and face shield was sitting on a table in the breakroom. Staff 4 (Housekeeping) returned from the staff smoking area and donned the mask and face shield sitting on the table. Staff 4 reported she was unclear on the procedure to disinfect and store face coverings while on break and she had been unable to find necessary supplies. During an interview on 10/29/21 at 11:51 AM, Staff 15 (Staffing/HR) reported the facility used to have a good infection control system in place but with the administration and staff turn-over they were trying to play catch-up and get operating procedures for infection control back in line. On 11/3/21 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings. No additional information was provided.

1. No specific residents were identified as being affected during the survey. All 3 hallways, breakroom and screening stations have been assessed and revised to ensure proper infection control practices. See Section 4 for on-going audits. 2. Residents and Staff have the potential risk of contracting or spreading COVID-19 or other infectious diseases if appropriate infection control practices are not maintained per policy. See Section 4 for on-going audits. 3. Education provided to Facility Staff by the DNS regarding EPA dwell times, Hand Hygiene, PPE etiquette w/ hand hygiene, proper PPE storage, donning/doffing PPE and shared equipment cleaning. 4. Audits of infection control practices will be done by the DNS or Designee weekly x12 weeks to ensure on-going compliance w/ proper infection control. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to ensure residents' care was managed by a registered nurse for all residents currently residing in the facility. The facility had a census of 43 residents. This placed residents at risk for inadequate care management, assessments and care planning. Findings include: A review of the facility's staff list on 10/12/21 revealed Staff 3 (LPN) and Staff 8 (LPN) with the position description of "RCM" (resident care manager). On 10/20/21 at 10:19 AM Staff 2 (DNS) stated the facility did not have any RN care managers on staff and the facility's care managers were all LPNs. Refer to F686

1. No specific residents were identified as being negatively affected for this citation. See Section 2. 2. Residents have the potential risk of inadequate care management, assessments and care planning if not provided with an RN Care Manager. Residents have been assessed by an RN to ensure care needs are being met and that the Care Plans are current for care needs. 3. Education to DNS, LPN Care Managers and Administrator by the Regional Nurse Consultant on the State OAR guidance for RN Resident Care Managers, assignments, delegation and documentation. 4. Audit will be completed by the DNS or designee for each resident to ensure an RN is assigned as an RN Care Manager in the record, Care Plan and Comprehensive Assessments are signed by an RN and will continue with weekly audits x4 weeks, then monthly x2 months to ensure new admissions are assigned an RN Care Manager. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 36 of 127 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: 1. A review of the Direct Care Staff Daily Reports (DCSDRs) from 11/26/20 through 12/15/20 revealed the following days when state minimum CNA staffing ratios were not met. 11/26/20-night shift was short one CNA; 11/28/20-night shift was short one CNA; 12/1/20-day and night shifts were short one CNA; 12/2/20-day, evening and night shifts were short one CNA; 12/4/20-day shift was short one CNA; 12/5/20-day shift was short one CNA; 12/6/20- day shift was short two CNAs; 12/7/20-day and evening shifts were short one CNA; 12/11/20-evening shift was short one CNA; 12/13/20-day shift was short one CNA; 12/14/20-day shift was short one CNA. 2. A review of the DCSDRs from 9/1/21 through 10/16/21 revealed the following days when state minimum CNA staffing ratios were not met. As of 8/24/21, Per Oregon Administrative Rule (OAR) 411-086-0100 (temporary rule), the facility was required to have one CNA for every 8.5 residents during day shift, one CNA for every 12 residents during evening shift, and one CNA for every 18 residents during night shift. 9/5/21-day shift was short two CNAs and evening shift was short one CNA; 9/12/21-day shift was short one CNA; 9/18/21-day shift was short one CNA; 9/25/21-days shift was short four CNAs; 9/26/21-days shift was short one CNA; 10/9/21-days shift was short one CNA; 10/10/21-day shift was short two CNAs; 10/16/21-days shift was short three CNAs. On 10/29/21 at 12:10 PM and 1:09 PM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 15 (Staffing/HR) acknowledged the failure to meet state minimum CNA staffing ratios. , 3. A review of the DCSDRs from 5/1/21 through 5/31/21 revealed the following days when state minimum CNA staffing ratios were not met. 5/1/21-evening shift was short one CNA; 5/2/21-day shift was short one CNA, evening shift was short two CNAs; 5/6/21-evening shift was short one CNA; 5/7/21-day and evening shifts were short one CNA; 5/8/21-day shift was short one CNA, evening shift was short 2 CNAs; 5/12/21-evening shift was short one CNA; 5/13/21-evening shift was short one CNA; 5/15/21-day shift was short one CNA; 5/17/21- night shift was short one CNA; 5/25/21-evening shift was short one CNA; 5/30/21-day shift was short one CNA. 4. A review of the DCSDRs from 7/1/21 through 7/31/21 revealed the following days when state minimum CNA staffing ratios were not met. 7/4/21-evening shift was short one CNA; 7/9/21-day shift was short one CNA; 7/11/21-day and evening shifts were short two CNAs; 7/12/21-day and evening shifts were short one CNA; 7/18/21-day shift was short one CNA; 7/24/21-evening shift was short one CNA. On 10/29/21 at 1:09 PM, Staff 15 stated the DCSDRs for May 2021 and July 2021 were accurate and acknowledged the failure to meet state minimum CNA staffing ratios.

1. No specific residents were identified as being negatively affected for this citation. See section 2. 2. Residents have the potential risk for delayed treatment, cares and unmet care needs if staffing ratios are not followed per the OAR. See F725 for resident interviews ensuring care needs are met. 3. Education to Staffing Coordinator by the Administrator on OAR staffing ratios and to report barriers or challenges to meeting the requirement to the Administrator or DNS for collaboration to meet the ratio requirement. 4. Audits will be done by the Administrator weekly x12 weeks to ensure staffing ratios are being met. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were met for 11 of 28 days reviewed for staffing. This failure placed residents at risk for delayed and unmet care needs. Findings include: A review of the facility's Direct Care Staff Daily Reports from 12/16/21 through 1/12/22 revealed the following dates when state minimum staffing ratios were not met: - 12/19/21: day shift short one CNA - 12/24/21: day shift short one CNA - 12/25/21: day shift short one CNA - 1/3/22: day shift short one CNA - 1/5/22: day shift short one CNA - 1/6/22: day shift short one CNA - 1/7/22: day shift short one CNA - 1/8/22: day shift short two CNAs - 1/10/22: day shift short one CNA - 1/11/22: day and evening shifts both short one CNA - 1/12/22: day shift short one CNA During interviews with Staff 1 (Administrator) and Staff 12 (Staffing Coordinator) on 1/13/22 the staff acknowledged the facility did not meet the current minimum CNA staffing requirements. ,

1. No specific residents were identified as being negatively affected for this citation. See section 2. 2. Residents have the potential risk for delayed treatment, cares and unmet care needs if staffing ratios are not followed per the OAR. See F725 for resident interviews ensuring care needs are met. 3. Education to Staffing Coordinator by the Administrator on OAR staffing ratios and to report barriers or challenges to meeting the requirement to the Administrator or DNS for collaboration to meet the ratio requirement or to ensure a plan is in place to meet resident needs. Will continue to work w/ the Oregon Staffing Coordinator under the DHS Staffing Waiver. 4. Audits will be done by the Administrator weekly x12 weeks to ensure staffing ratios are being met. 5. All findings will be brought through QAPI until resolved. 1:1 remediation will be done for any negative findings.

******************** 411-085-0310 Residents ' Rights: Generally Refer to F-550 ******************** 411-086-0130 Nursing Services: Notification Refer to F-580 ******************** 411-085-0360 Abuse Refer to F-600, F-602 and F-609 ******************** 411-086-0100 Nursing Services: Resident Care Refer to F-677 ******************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F-686 ******************** 411-086-0100 Nursing Services: Staffing Refer to F-725 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F-684 ******************** 411-086-0220 Rehabilitative Services Refer to F-825 ******************** 411-086-0330 Infection Control and Universal Precautions Refer to F-880 ********************

******************** 411-086-0100 Nursing Services: Staffing Refer to F-725 ********************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/06/2021 and 09/12/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/30/2021 and 09/05/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/23/2021 and 08/29/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/19/2021 and 07/25/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/12/2021 and 07/18/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.