Avamere Rehabilitation of Clackamas

On 9/29/25 through 10/1/25 from 8:00 AM to 4:00 PM, resident rooms one, two and four in the West Hall were observed to be used for storage of new furniture and past resident belongings. Observations of the three rooms included: -Five mattresses stacked on top of an unoccupied bed. The right side of the room was used for storage of a metal rack, two floor mats, a knee wedge, hangers, bath basin, gown, a bag of tortillas and four side tables. On the floor, a drawer from unknown origin was left on the floor and a yellow bath basin was placed on top. -Six mattresses stacked on top of an unoccupied bed. On top of the mattress, several blue blankets were placed on top of the mattresses. A sign above an unoccupied bed stated, ""emergency overflow bed only."" -Three floor mats on top of an empty bed. A blue blanket was placed on top of the floor mats. Two bed frames and two side tables were placed in random places on the left side of the room.-á On 9/29/25 at 1:32 PM, Resident 48 stated her/his room was an overflow room for staff to store furniture.-á On 9/29/25 at 1:44 PM, Resident 17 stated the extra furniture in her/his room was there since admission.-á On 10/1/25 at 8:59 AM, Resident 10 stated the furniture in her/his room bugged her/him but the facility didn't have enough storage. Staff told her/him they tried to move the furniture, but they were short staffed. Resident 10 stated she/he kept the curtain closed to avoid seeing the mess.-á On 10/1/25 at 9:23 AM, Staff 9 (CNA) stated the resident rooms were used for extra furniture. On 10/1/25 at 11:08 AM, Staff 8 (CNA) stated unoccupied areas in resident rooms were used for extra furniture. Staff 8 stated the facility stored extra equipment including furniture in a trailer next to the facility.-á On 10/1/25 at 12:58 PM, Staff 1 (Administrator) stated unoccupied resident rooms were used for temporary storage of new furniture. Staff 1 stated he was unaware new furniture was stored in occupied resident rooms. Staff 1 stated one of the rooms was previously unoccupied, but they had a last-minute admission, and he was unaware the resident wanted the furniture removed. Staff 1 stated the shed was not ready for storage. Staff 1 acknowledged storing furniture in occupied resident rooms was not a homelike environment. -á -á

1.  Stored furniture and items were removed from the identified resident rooms on West Hall, and the rooms were returned to a clean and homelike condition. 2.  Resident rooms throughout the facility were reviewed to identify additional rooms being used for storage. 3.  Staff were inserviced by the Administrator or designee regarding their role in maintaining resident rooms in a clean and homelike condition and the expectation that resident rooms are not to be used for storage. 4.  The Administrator or designee will audit environmental rounds weekly for 4 weeks, then monthly, with results reported at monthly QAPI until substantial compliance has been achieved.

Resident 5 was admitted to the facility in 8/2025 with diagnoses including stroke and dysphagia (difficulty swallowing). Resident 5GÇÖs Quarterly MDS dated 9/22/25 indicated the resident was dependent on staff for personal hygiene and grooming. Resident 5's care plan dated 8/28/25 indicated the resident required total assistance with personal hygiene.-á Resident 5 was observed on 9/29/25 at 1:11 PM, 9/30/25 at 12:59 PM and on 12/4/25 at 11:53 AM with a significant amount of visible facial hair. On 9/30/25 at 1:10 PM Resident 5 stated she/he did not want to have facial hair and wanted staff to take care of her/his facial hair. Resident 5 stated she/he relied on staff to shave unwanted facial hair. On 10/1/25 at 12:07, Staff 10 (CNA) stated she noticed Resident 5GÇÖs facial hair, which was very visible. Staff 10 indicated Resident 5 was dependent on staff to shave her/him. On 10/1/25 at 12:20 PM, Staff 11 (CNA) stated she obtained information to care for resident 5 from the care plan and acknowledged Resident 5 had a noticeable amount of facial hair. On 10/1/25 at 12:26 PM, Staff 2 (DNS) stated it was her expectation for Resident 5 to have her/his shaving preferences followed and confirmed the resident was dependent on staff for ADL care.-á

1.  Resident #5 unwanted facial hair was removed on 12/8/25. 2.  Residents identified as requiring assistance with grooming were re-reviewed to ensure preferred grooming standards were identified and care was provided as appropriate. 3.  Education was provided to nursing staff regarding ADL needs related to grooming preferences and removal of unwanted facial hair. 4.  DNS or designee will audit a sample of five residents per week x4 weeks, then monthly x1 to ensure grooming care is offered and provided in accordance with the individualized plan of care. Findings will be reported at the QA meeting x2 or until substantial compliance has been achieved.

Resident 60 admitted to the facility in 5/2025 with diagnoses including stroke with left sided weakness. A review of Resident 60GÇÖs care plan dated 4/29/25 revealed she/he required assistance from two staff members for all transfers and toileting due to high fall risk and multiple falls since admission. A facility investigation created and signed by Staff 2 (DNS) on 5/13/25 indicated Staff 7 (Former NA) transferred Resident 60 to the toilet. Staff 7 attempted to change Resident 60GÇÖs brief while the resident was seated on the toilet and the resident jerked suddenly which caused the resident to hit her/his head on the mobility bar along the wall, resulting in a large bump on the side of the resident's head. On 12/4/25 at 11:47 AM Staff 2 confirmed Staff 7 did not follow Resident 60GÇÖs care plan to have two staff assist with toileting Resident 60.-á

1.  Resident #60 has been discharged from the facility. 2.  Residents identified as requiring two-person assistance for safety were reviewed, and care plan interventions were updated as indicated. 3.  Floor staff were educated regarding following transfer and toileting interventions outlined in the care plan. 4.  DON or designee will visually audit a sample of five residents who require two-person assistance to ensure staff are following the care plan. Audits will be completed weekly x3, then monthly x2, with results reported at the QA meeting x2 or until substantial compliance has been achieved.

The Center for Disease Control's (CDC) 4/3/24 website, section titled, Transmission Based Precautions, specified Contact Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The facilityGÇÖs Transmission-Based Precautions policy dated 8/2019 stated: 3. When Transmission-Based Precautions are implemented, the Infection Preventionist:-á -á -Clearly identifies the type of precautions, the anticipated duration and the personal equipment (PPE) that must be used; -Determines the appropriate notification on the room entrance door and on the front of the residentGÇÖs chart so that personnel and visitors are aware of the need for and the type of precautions; - The signage informs staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Resident 24 was admitted to the facility in 6/2025 with diagnoses including type 2 diabetes and MRSA (a bacterial infection resistant to several antibiotics). a. On 9/29/25 at 9:57 AM, 12/2/25 at 12:40 PM and on 12/3/25 at 9:22 AM Room 8 was observed to have a full trash bag laying on the floor behind the door, an open bag of incontinence briefs laying on the floor and multiple sterile treatments supplies were opened and in a box on the floor. No staff were present in the room or hallway at the time of the observations. On 12/3/25 at 9:30 AM, Staff 8 (CNA) confirmed the trash bag was on the floor and verified opened sterile wound treatment supplies were being stored on the floor. On 12/3/25 at 9:58 AM, Staff 16 (RN) verified sterile treatment supplies were stored in a box on the floor in Room 8. On 12/3/25 at 11:20 AM, Staff 5 (IP) and Staff 4 (RNCM) stated it was their expectation for sterile wound care supplies be stored appropriately and off the floor. On 12/3/25 at 11:31 AM, Staff 2 (DNS) stated the storage of sterile supplies on the floor was not consistent with facility practice and should have been addressed immediately by staff. b. On 9/29/25 at 9:57 AM, 12/2/25 at 12:40 PM and on 12/3/25 at 9:22 AM Resident 24 was observed to have scabs and wound dressings on her/his feet and bilateral ankles. Resident 24GÇÖs room was not identified to require contact precautions. On 12/3/25 at 9:30 AM Staff 8 (CNA) stated Resident 24 was not on contact precautions and she did not wear PPE while providing care for the resident. On 12/3/25 at 9:58 AM Staff 16 (RN) stated Resident 24 was previously on contact precautions but was not any longer, and she wore gloves only when performing dressing changes. On 12/3/25 at 11:20 AM Staff 5 and Staff 4 observed Resident 24GÇÖs feet and identified an open wound. Both stated the open wound was not reported to them and the resident should have been on contact precautions based on the presence of the wound. On 12/3/25 at 11:31 AM Staff 2 stated it was her expectation open wounds were reported promptly and contact precautions implemented as required. Staff 2 confirmed Resident 24 should have been on contact precautions once the open wound was identified. -á -á -á -á -á -á -á -á -á -á

1.   DNS or designee completed a room audit on 12/4/25 to ensure wound care supplies were not stored on the floor and that appropriate precautions were in place as indicated. 2.  Resident rooms were reviewed to identify additional instances of wound care supplies being stored on the floor or precautions not being implemented as indicated. 3.  Nursing staff were educated regarding proper storage of wound care supplies and infection control precautions related to wounds. 4.  DNS or designee will audit a sample of resident rooms weekly x4, then monthly x2 to ensure wound care supplies are stored appropriately and precautions are followed as indicated. Results will be reported at the QA meeting x2 or until substantial compliance has been achieved.

A review of the Direct Care Staff Daily Reports from 8/31/25 through 9/29/25 revealed the facility had insufficient CNA staff for one or more shifts on the following dates: -8/31/25 -8/30/25 -9/2/25 -9/3/25 -9/6/25 -9/20/25 -9/26/25 -9/27/25 On 12/4/25 at 11:40 AM Staff 1 (Administrator) acknowledged the facility did not meet minimum CNA staffing requirements for the identified dates.

1.  Staffing schedules were adjusted to meet minimum CNA staffing requirements using overtime and supplemental staffing as needed. 2.  Staffing records for the cited dates were reviewed to identify shifts that did not meet minimum staffing requirements. 3.  Staffing Coordinator has been inserviced by the Administrator regarding review of staffing levels to ensure compliance with state requirements. 4.  The Administrator or designee will audit staffing levels weekly for 4 weeks, then monthly, with results reported at monthly QAPI until substantial compliance has been achieved.

Based on observation, interview and record review it was determined the facility failed to follow care plan interventions related to elopement for 1 of 1 sampled resident (#32) reviewed for elopement. This failure, determined to be an Immediate Jeopardy situation, placed all residents at risk for an unsafe elopement and injury. Findings include: The facility's revised 3/2019 Wandering and Elopement policy states the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The facility's revised 7/18/24 Avamere Living-Code Pink Guidelines, an Elopement, Exit seeking, Wandering Assessment, stated the facility will complete the Code Pink Documentation tool when the resident is identified as at risk for elopement, exit seeking or wandering. Resident 32 admitted to the facility in 3/2024, with diagnoses including dementia and congestive heart failure. Resident 32's 6/19/24 Care Plan indicated Resident 32 may leave facility premises only if accompanied by a responsible party for therapeutic leave. Resident 32's 8/15/24 AvaElopement Risk Evaluation indicated the resident was disoriented, cognitively impaired with poor decision-making skills, known history of elopement, able to self-propel wheelchair independently and a moderate risk for wandering. On 8/19/24 at 12:41 PM, a complaint was received by the State Survey Agency (SSA), which alleged Resident 32 arrived on 8/16/24 via a medical transport bus to a brand-new appointment with a new practitioner, unattended and disoriented. Paperwork received from the nursing facility stated the resident had dementia and was an elopement risk. The receiving clinic recognized the residents' risk for elopement and assigned a staff member to monitor the resident. On 9/16/24 at 10:59 AM Resident 32 stated she/he was unable to recall the recent clinic visit. On 9/16/24 at 11:05 AM Staff 4 (CNA) stated she arranged for Resident 32's transportation to the new clinic and ordered Hand To Hand: Specific instructions when the resident arrived to the clinic she/he was not to be left alone. Staff 4 stated the facility did not send staff with the resident. On 9/16/24 at 11:52 AM Staff 2 (DNS) stated medical transport takes residents to their appointments and then picks them back up. Staff 2 stated the facility did not send staff with Resident 32 for the clinic appointment and acknowledged Resident 32 was not able to communicate and was an elopement risk. Staff 2 stated the expectation was for Resident 32 to be accompanied by a responsible party. On 9/17/24 at 12:05 PM Staff 3 (RNCM) stated she had received a phone call from the clinic stating Resident 32 was confused and could not give them any information. Staff 3 stated she knew Resident 32 was an elopement risk but assumed the driver from the medical transport would escort the resident in to the clinic. On 9/18/24 at 10:27 AM Staff 5 (RN Charge Nurse) stated Resident 32 needed redirection due to being forgetful and acknowledged Resident 32 was an elopement risk. Staff 5 stated she did not know if the resident could leave the facility by her/himself. On 9/18/24 at 10:52 AM Witness 2 (Medical Transport Driver) stated she did not know what the term Hand To Hand meant when transporting residents. On 9/20/24 at 3:00 PM Staff 1 (Administrator) and Staff 2 were notified of the immediate jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to follow Resident 32's care plan to have a responsible party accompany the resident to an outside appointment. On 9/20/24 at 4:51 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: 1. The care plan for Resident 32 has been reviewed and revised to include an escort for all appointments. The resident will continue to receive 15-minute checks. 2. All staff on evening shift on 9/20/24, have been educated on the facility's elopement policy, with a special emphasis on transportation for appointments. 3. All remaining staff will be educated on the facility's elopement policy before the start of their shift, with a special emphasis on transportation for appointments. All staff with no scheduled shift within the week will have been educated by 9/26/24. 4. All residents in the facility have been reassessed for elopement risk, and care plans have been updated as necessary. 5. To ensure ongoing compliance the DNS/designee will audit and assess all new admissions for risk of elopement for one week, weekly for three weeks, and then monthly until substantial compliance is achieved. 6. All findings to be reported to the Quality Assurance and Performance Improvement Committee. On 9/23/24 at 2:20 PM, the IJ was removed as confirmed by onsite verification.

1. The care plan for resident 32 has been reviewed and revised to include an escort for all appointments. The resident will continue to receive 15-minute checks. 2. All staff on evening shift on Friday, September 20th, 2024, have been educated on the facility's elopement policy, with a special emphasis on transportation for appointments. 3. All remaining staff will be educated on the facility's elopement policy before the start of their shift, with a special emphasis on transportation for appointments. All staff with no scheduled shift within the week will have been educated by September 26th, 2024. 4. All residents in the facility have been reassessed for elopement risk, and care plans have been updated as necessary. 5. To ensure ongoing compliance the DNS/designee will audit and assess all new admissions for risk of elopement x1 week, weekly x3 weeks, and then monthly until substantial compliance is achieved. 6.All findings to be reported to the QAPI Committee.

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

Based on observation and interview the facility failed to provide a comfortable and homelike environment for 1 of 1 facility reviewed for physical environment. This placed residents at risk for a lessened quality of life. Findings include: The facility's 2021 Homelike Environment Policy revealed residents were provided with a safe, clean, comfortable and homelike environment. Comfortable and adequate lighting was provided in all areas of the facility. Resident 24 admitted to the facility in 2019 with diagnoses including hypertension (high blood pressure) and depression. Resident 24's 4/21/24 Annual MDS indication she/he was cognitively intact. On 7/16/24 at 9:24 AM Resident 24 stated she/he was going to an activity in the dining room where the lighting was bad, and her/his vision was "not so great" so she/he sat by the window or the doors to see better. On 7/16/24 at 3:40 PM Resident 24 stated the lights in the dining room could be brighter because when residents were in activities in the dining room, other residents would ask if the lights could be turned on, but the lights were already on. During the Resident Council meeting on 7/16/24 at 1:00 PM the council members stated the lights in the dining room, where they had activity groups, had light bulbs out for a while and made it difficult to see. On 7/16/24 at 1:53 PM the dining room was observed with three of the six ceiling lights to not produce light. The dining room floor had four large pieces of black tape on the light-colored floor and the flooring was buckled up near the soda machine. On 7/17/24 at 11:10 AM the shared bathroom between room one and room three was observed with brown and yellow stained caulking around the base of the toilet. The floor was stained with brown markings and appeared dirty. On 7/17/24 at 11:12 AM the shared bathroom between room two and room four was observed with brown and yellow stained caulking around the base of the toilet and appeared dirty. On 7/17/24 at 11:13 AM room four's wall under the window was observed with the paneling peeling away from the wall in several spots. On 7/19/24 at 9:58 AM Staff 11 (Maintenance Director) confirmed the lights in the dining room were not working properly and needed new bulbs. Staff 11 stated he found out about the lights on Tuesday (7/16/24) from the Resident Council meeting and was unaware prior to 7/16/24. Staff 11 confirmed the taped flooring in the dining room and the other identified areas were in disrepair. Staff 11 stated the facility did not have a plan in place to fix flooring repairs. Staff 11 acknowledged the stained caulking in the shared resident bathrooms between rooms one and three and rooms two and four. Staff 11 stated the caulking needed to be repaired. Staff 11 acknowledged the paneling pulled away from the wall in room four and stated the facility did not have a plan in place to fix the wall. On 7/19/24 at 10:10 AM Staff 1 (Administrator) confirmed the needed repairs of lights in the dining room, flooring in the dining room, shared resident bathrooms between rooms one and three and rooms two and four, and the wall in room four. Staff 1 stated he expected a plan to be in place to make the repairs.

Element 1: Corrective action for residents affected by the deficient practice. - Resident #24 identified issues with poor lighting in the dining room and stained caulking in the shared bathroom. Three of the six ceiling lights in the dining room were replaced. The stained caulking around the base of the toilets in the shared bathrooms and the flooring near the soda machine will be repaired upon receipt of the materials that have been ordered. The paneling in room four was fixed. Element 2: Identifying other residents potentially affected by the same deficient practice. - All residents have the potential to be impacted by issues related to the physical environment. Maintenance will monitor and inspect all resident areas to identify similar issues. A facility-wide inspection was conducted to identify other areas with similar issues, and immediate corrective actions were implemented as needed. Element 3: Systemic changes to ensure the deficient practice will not recur. - Maintenance will conduct weekly random audits of the facility's physical environment, inspecting lighting, flooring, and bathroom conditions in 2 rooms on each hall in the building. A weekly inspection routine for all resident areas has been established. A maintenance request log was developed to track reported issues and completion of repairs. Maintenance staff were trained on proactive identification and reporting of potential issues. Element 4: Monitoring to ensure lasting solutions. - Maintenance will conduct audits weekly x4, then monthly until substantial compliance is achieved. Weekly audits will be brought to QA meetings and reviewed monthly. Weekly inspections of resident areas will be conducted by the Maintenance Director or designee. Monthly audits will be performed by the Administrator to ensure compliance with environmental standards. Documentation of findings and actions taken will be included in QAPI meetings. Audits will continue until substantial compliance is achieved.

Based on observation, interview and record review it was determined the facility failed to ensure staff adhered to professional standards related to disinfection of common use glucometers for 1 of 2 licensed nurses (Staff #3) reviewed for infection control and medication administration. This placed residents at significant risk for bloodborne illness. Findings include: Per OAR 851-045-0040 Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall: (A) Adhere to professional practice and performance standards; Per OAR 851-045-0070 Conduct Derogatory to the Standards of Nursing Defined: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established; (3) Conduct related to the client's safety and integrity: (a) Developing, modifying or implementing policies that jeopardize client safety; The Evencare G2 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA registered wipes. The 9/2014 facility policy for Blood Sampling Capillary (Finger Sticks) indicated to follow the manufacturer's instructions. On 7/17/24 at 11:29 AM Staff 3 was observed to obtain a CBG for Resident 299. Staff 3 exited the room and cleaned the glucometer with alcohol wipes. Staff 3 stated she primarily used alcohol wipes to clean the glucometer. Staff 3 then started to proceed down the hall to complete a CBG for Resident 296 using the same glucometer. The State Surveyor intervened, and Staff 3 went back to the treatment cart and used a bleach wipe to clean the glucometer. Staff 3 then started to proceed down the hall without allowing the glucometer to dry (manufacturer instructions indicated a 3-minute contact time). The State Surveyor intervened and asked Staff 3 to review the contact time on the bleach wipes. Staff 3 then set the glucometer down and obtained another glucometer from the cart to use. On 7/17/24 at 12:11 PM Staff 3 stated she worked on all resident halls. On 7/17/24 at 1:30 PM Staff 2 (DNS) stated the expectation was for staff to use microkill bleach wipes between every glucometer use and to rotate glucometers to ensure proper dwell times were reached. Refer to F880.

Element 1: Corrective action for residents affected by the deficient practice. - Residents #13, 17, and 37 were assessed to ensure there were no adverse effects from improper glucometer disinfection. Glucometers in the facility were immediately collected and disinfected using an EPA-approved disinfectant for bloodborne pathogens prior to the next CBG checks. Staff 3 was suspended and received 1:1 education/training on blood glucose disinfecting between use, dedicating CBG equipment with residents with a diagnosis of bloodborne pathogens prior to return to work. Resident #15 was provided dedicated blood glucose monitoring equipment. Element 2: Identifying other residents potentially affected by the same deficient practice. - Other residents using glucometers were assessed to ensure there were no adverse effects from improper disinfection. Residents in the facility were audited for diagnoses of bloodborne pathogens and provided dedicated blood glucose monitoring equipment if indicated. Element 3: Systemic changes to ensure the deficient practice will not recur. - Nurses were educated on the proper disinfection process for glucometers, including timeframes and procedures. Licensed nurses, prior to the start of the shift, were educated on the proper procedure for disinfecting blood glucose monitors and completed a Blood Glucose Monitoring Competency and dedicated CBG equipment to residents with bloodborne pathogens. Element 4: Monitoring to ensure lasting solutions. - DNS or designee will observe staff weekly to ensure proper disinfection of glucometers. Audits will continue weekly x4, then monthly until substantial compliance is achieved. To ensure ongoing compliance, the DNS/designee will observe blood glucose monitor disinfection for each routine blood glucose check x1 week, weekly x3 weeks, monthly x2 months to ensure proper disinfection. All findings will be reported to the QAPI Committee. Audits will continue until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to implement resident-centered care plan interventions to ensure residents with dementia maintained their highest practicable level of well-being for 1 of 1 sampled resident (#18) reviewed for dementia. This placed residents at risk for a lack of psychosocial well-being and increased behaviors. Findings include: The facility's revised 2018 Dementia - Clinical Protocol revealed for individuals with confirmed dementia, the IDT (Inter-Disciplinary Team) would identify a resident-centered care plan to maximize their remaining function and quality of life. Resident 18 admitted to the facility in 2020 with diagnoses including dementia with agitation and depression. Resident 18's 8/21/23 Annual MDS indicated behaviors including rejection of care, combative behavior and agitation. Resident 18's 5/21/24 Quarterly MDS assessed her/him as severely cognitively impaired. Review of Resident 18's 7/18/24 behavioral care plan identified her/him as confrontational, rude, demanding, suspicious, manipulative and anxious. The care plan identified behaviors of verbal aggression, physical aggression, yelling, hitting, interference with roommate's care, and history of false accusative statements. The care planned interventions were that sometimes she/he would calm down when chocolate was given, discharge planning, separate from other residents, approach calmly and unhurriedly, notify physician if behaviors interfered with medical needs, leave the room and leave her/him alone to give space. Review of Resident 18's 7/18/24 ADL care plan revealed she/he refused ADLs and showers. The interventions were to document refusals and re-approach at a different time. No other interventions for ADLs and shower refusals were documented. On 7/19/24 at 8:43 AM Staff 10 (CNA) stated she received her information to care for residents from the care plan and shift reports from other staff members. Staff 10 stated Resident 18 had behaviors often, ate meals in her/his room due to behaviors and the staff kept her/him away from people. No other interventions were provided to prevent negative behaviors. On 5/19/24 at 9:13 AM Staff 2 (DNS) acknowledged Resident 18's care plan was not resident centered. Staff 2 acknowledged the interventions were for staff and were not specific to Resident 18 as an individual. Staff 2 reported some interventions were attempted but they were not documented or care planned in Resident 18's health record. No further information was provided.

Element 1: Corrective action for residents affected by the deficient practice. - Reviewed and updated Resident 18’s care plan with specific, resident-centered interventions. Element 2: Identifying other residents potentially affected by the same deficient practice. - Conducted a comprehensive review of care plans for all residents diagnosed with dementia. Element 3: Systemic changes to ensure the deficient practice will not recur. - Provided training for all staff on dementia care, focusing on individualized, person-centered approaches. Implemented specific interventions for managing dementia-related behaviors. Element 4: Monitoring to ensure lasting solutions. - DNS or designee will audit dementia care plans weekly x4 to ensure they are current and effective. Audits will then shift to monthly until substantial compliance is achieved. All findings will be documented and presented at QAPI meetings to ensure ongoing compliance.

Based on observation, interview and record review it was determined the facility failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident use for 1 of 1 sampled resident (# 299) reviewed during CBG checks. This failure, determined to be an Immediate Jeopardy situation, placed all residents who required CBG checks at significant risk for bloodborne illness. Findings include: The Evencare G2 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes. The 9/2014 facility policy for Blood Sampling Capillary (Finger Sticks) indicated to follow the manufacturer's instructions. On 7/17/24 at 11:29 AM Staff 3 was observed to obtain a CBG for Resident 299. Staff 3 exited the room and cleaned the glucometer with alcohol wipes. Staff 3 stated she primarily used alcohol wipes to clean the glucometer. Staff 3 then started to proceed down the hall to complete a CBG for Resident 296 using the same glucometer. The State Surveyor intervened, and Staff 3 went back to the treatment cart and used a bleach wipe to clean the glucometer. Staff 3 then started to proceed down the hall without allowing the glucometer to dry (manufacturer instructions indicated a three-minute contact time). The State Surveyor intervened and asked Staff 3 to review the contact time on the bleach wipes. Staff 3 then set the glucometer down and obtained another glucometer from the cart to use. On 7/17/24 at 11:55 AM Staff 2 (DNS) provided a list of 15 residents who required CBG checks, which included Resident 15. Resident 15's clinical record indicated she/he admitted to the facility on 6/13/24 with diagnoses including human immunodeficiency virus (HIV) and required CBG checks three times a day and used a shared glucometer. Resident 15's Diabetic Administration Record indicated Staff 3 first completed Resident 15's CBG checks twice on 6/14/24. On 7/17/24 at 12:11 PM Staff 3 stated she worked on all resident halls. On 7/17/24 at 1:30 PM Staff 2 (DNS) stated the expectation was for staff to use microkill bleach wipes between every glucometer use and to rotate glucometers to ensure proper dwell times were reached. On 7/17/24 at 2:15 PM the facility was informed that the facility's failure to improperly clean and sanitize the common use glucometer between residents constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 7/17/24 at 5:30 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: 1. Glucometers in the facility have been immediately collected and disinfected using an EPA-approved disinfectant for bloodborne pathogens prior to the next CBG checks. 2. Staff 3 was suspended, will receive 1:1 education/training on glucometer disinfection between uses, and dedicating CBG equipment for residents with diagnoses of bloodborne pathogens prior to return to work. 3. Licensed nurses, prior to start of shift, will be educated on the proper procedure for disinfecting blood glucose monitors and complete a Blood Glucose Monitoring Competency and will have dedicated CBG equipment for residents with bloodborne pathogens. 4. Resident 15 was provided with dedicated blood glucose monitoring equipment. 5. Residents in the facility will be audited for diagnoses of bloodborne pathogens and provided with dedicated blood glucose monitoring equipment if indicated. 6. The Medical Director was notified. Residents potentially exposed also notified. Testing will be offered as requested. 7. To ensure ongoing compliance, the DNS/designee will observe blood glucose monitor disinfection for routine blood glucose checks x 1 week, weekly x 3 weeks, monthly x 2 months to ensure proper disinfection. 8. All findings to be reported to the QAPI Committee. On 7/18/24 at 2:30 PM it was determined the immediacy was removed after verification of completion of the IJ removal plan.

Element 1: Corrective action for residents affected by the deficient practice. - Glucometers in the facility have been immediately collected and disinfected using an EPA-approved disinfectant for bloodborne pathogens prior to the next CBG checks. Staff 3 was suspended and received 1:1 education/training on blood glucose disinfecting between use, dedicating CBG equipment with residents with a diagnosis of bloodborne pathogens prior to return to work. Resident #15 was provided dedicated blood glucose monitoring equipment. Element 2: Identifying other residents potentially affected by the same deficient practice. - Residents in the facility were audited for diagnoses of bloodborne pathogens and provided dedicated blood glucose monitoring equipment if indicated. Element 3: Systemic changes to ensure the deficient practice will not recur. - Licensed nurses, prior to the start of the shift, were educated on the proper procedure for disinfecting blood glucose monitors and completed a Blood Glucose Monitoring Competency and dedicated CBG equipment to residents with bloodborne pathogens. Element 4: Monitoring to ensure lasting solutions. - To ensure ongoing compliance, the DNS/designee will observe blood glucose monitor disinfection for each routine blood glucose check x1 week, weekly x3 weeks, monthly x2 months to ensure proper disinfection. All findings will be reported to the QAPI Committee. Audits will continue until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to implement an active supervision program to monitor staff working on a preliminary basis for 2 of 5 staff (#s 7 and 8) reviewed for background checks. This placed residents at risk for abuse. Findings include: On 5/16/24 at 10:32 AM Staff 9 (Human Resources/Staffing) stated Staff 7 (Dietary Aide) and Staff 8 (CNA) were working in the facility on a preliminary status while they waited for clearance of their background checks. Staff 9 was aware employees on preliminary status were required to be on active supervision. Staff 9 could not identify a facility system in place to provide active supervision to employees whose background checks were pending. Staff 9 stated she did not report employees who were on preliminary status to any other department manager. According to records reviewed with Staff 9 on 5/16/24 at 10:32 AM, Staff 7 began working in the facility on 5/4/24 and was pending background clearance. Staff 8 began working on 5/4/24 and the background clearance was obtained on 5/9/24. On 7/17/24 at 10:09 AM Staff 2 (DNS) stated she was aware employees on preliminary status were required to be on active supervision while background checks were pending. Staff 2 stated the facility required staff to have a red dot on their name tag until the background check was cleared. On 7/17/24 at 10:10 AM Staff 7 was observed in the kitchen with no red dot on his name tag. On 7/17/24 at 10:12 AM Staff 3 (RN) confirmed she was the charge nurse and was accountable for the CNAs. Staff 3 stated she did not know what a red dot would indicate on an employee's name tag. On 7/19/24 at 8:38 AM Staff 1 (Administrator) acknowledged and confirmed the facility did not implement the active supervision program which required employees to be on active supervision while background checks were pending. No additional information was provided.

Element 1: Corrective action for residents affected by the deficient practice. - The Administrator and HR director on 7/20/24 have conducted a blanket audit of all employees to ensure all employee background checks have been completed and documented, finding no instances of non-compliance. Conducted immediate supervision of Staff 7 and Staff 8 until background checks were completed. Element 2: Identifying other residents potentially affected by the same deficient practice. - All residents have the potential to be affected by this alleged deficient practice. Reviewed all staff files to ensure criminal history checks are up-to-date. Element 3: Systemic changes to ensure the deficient practice will not recur. - The Administrator will conduct education for all building HR staff on completing and documenting background checks for all employees. This education will be completed prior to the alleged date of compliance of 7/28/24. Implemented a tracking system for all pending background checks. Trained HR staff on the importance of active supervision for staff with pending background checks. Element 4: Monitoring to ensure lasting solutions. - The Administrator is identified as responsible for maintaining compliance. Compliance will be maintained by the Administrator weekly x4, then monthly until substantial compliance is achieved for compliance. Weekly audits will be brought to QA meetings and will be reviewed monthly. Conduct weekly audits of employee files to ensure compliance. Report findings to QAPI monthly. Audits will continue until substantial compliance is achieved.

Based on interview and record review it was determined the facility failed to ensure state minimum staffing ratios were maintained for 10 of 30 days (14 of 90 shifts) reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the Direct Care Staff Daily Reports from 6/16/24 through 7/14/24 revealed the following days and shifts when the state minimum CNA staffing ratios were not met: 6/17/24 - evening shift. 6/23/24 - day and evening shifts. 6/27/24 - evening shift. 6/29/24 - day and evening shifts. 6/30/24 - day shift. 7/3/24 - evening shift. 7/5/24 - day and evening shifts. 7/6/24 - day and night shifts. 7/12/24 - evening shift. 7/14/24 - day shift. On 9/9/24 at 9:27 AM Staff 9 (Human Resources/Staff) confirmed the dates and shifts the facility did not meet the state minimum CNA staffing ratios. On 7/19/24 at 12:10 PM Staff 1 (Administrator) acknowledged the facility's failure to meet state minimum CNA staffing ratios. Staff 1 expected all shifts to be staffed to the minimum number of staff required. No additional information was provided.

Element 1: Corrective action for residents affected by the deficient practice. - The schedule for the upcoming weeks was reviewed and ensured that all holes had been filled. Reviewed and adjusted staffing levels to ensure compliance with state minimum CNA staffing ratios. Element 2: Identifying other residents potentially affected by the same deficient practice. - The facility has initiated in-house agency staffing to assist in meeting minimum staffing ratios. Conducted a facility-wide review to identify any residents affected by staffing shortages. Element 3: Systemic changes to ensure the deficient practice will not recur. - Administrator and Staffing Coordinator/HR have a recruitment and retention plan and committee and will continue to evaluate and update as appropriate. Ongoing recruitment and certification will continue for qualified nursing aides who meet all requirements to hire. Re-educated Staffing Coordinator on appropriate staffing levels. Implemented a staffing audit system to ensure ongoing compliance. Element 4: Monitoring to ensure lasting solutions. - The administrator/designee will complete an audit of the DHS staffing sheet weekly x4, then monthly until substantial compliance is achieved for compliance. Audits will be brought to QA meetings and will be reviewed monthly. Conduct weekly audits of staffing levels for four weeks, then monthly. Report findings to QAPI. Audits will continue until substantial compliance is achieved.

Based on observation and interview it was determined the facility failed to ensure an audible and visual call signal at the nurse station and a visible signal in the corridor intersection for 1 of 1 facility reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet needs. Findings include: Random observations from 7/15/24 through 7/17/24 revealed when residents utilized their call light, no visual signal was observed and no audible sound was heard at the nurse station. The West corridor intersection had a visual and audible system for rooms one through eleven, but there was no audio or visual signal in the other corridor intersections for rooms 12 thru 26 to alert staff a resident's call light activation. On 7/19/24 at 8:48 AM Staff 10 (CNA) stated rooms 12 thru 26 did not have an audio signal to indicate an activated resident call light. Staff 10 stated in order to see if the call lights for rooms 12 through 26 were activated, she had to walk down the halls to look above the residents' doors. On 7/19/24 at 12:10 PM Staff 1 (Administrator) acknowledged the observation that a resident's call light was activated in the hallway and the nurse station did not have an audible or visual alert to indicate a resident's call light was activated. Staff 1 confirmed there was no visual or audio signal in the hallway corridor for rooms 12 thru 26. No additional information was provided.

Element 1: Corrective action for residents affected by the deficient practice. - Quotes with outside vendors have been obtained to repair the nurse call light system, and scheduling is underway. The nurse call light system will be repaired and upgraded upon the contracted vendor's availability. Element 2: Identifying other residents potentially affected by the same deficient practice. - Conducted a facility-wide check to ensure all nurse call systems are operational. Element 3: Systemic changes to ensure the deficient practice will not recur. - Implemented regular maintenance checks for the nurse call system. Trained staff on the importance of reporting non-functional call systems immediately. Element 4: Monitoring to ensure lasting solutions. - Conduct weekly checks of the nurse call system for four weeks, then monthly. Report findings to QAPI. Audits will continue until substantial compliance is achieved.

**************************** 411-087-0100: Physical Environment: Generally Refer to F584 **************************** 411-086-0110: Nursing Services: Resident Care Refer to F658 **************************** 411-086-0240: Social Services Refer to F744 **************************** 411-086-0330: Infection Control and Universal Precautions Refer to F880 ****************************

Based on observation, interview, and record review it was determined the facility failed to re-evaluate elopement risks and revise care plan interventions to prevent repeated elopements for 1 of 1 sample residents (#1) reviewed for elopement. This placed residents at risk for an unsafe elopement and injury. Findings include: Resident 1 admitted to the facility in 3/2024, with diagnosis including dementia and Type 2 diabetes. Resident 1's 3/16/24 Elopement Assessment identified she/he was a moderate risk for elopement. Resident 1's 4/15/24 Care Plan indicated the resident presented as a high risk for wandering and elopement with interventions to implement a Code Pink protocol. Code Pink was defined as a medical emergency for residents who have wandered away from the facility and was at risk of harm and/or protecting themselves. Resident 1 was also revealed to be a significant fall risk due to cognitive impairment related to dementia. No additional interventions were identified. A 4/24/24 Facility Incident Reported revealed Resident 1 had an unwitnessed exit from the facility. Resident 1 was located according to the facility's investigation to have been found at the local market. Facility door alarms were in place but was revealed to have not alerted staff when resident exited the facility. Residents SLUMS score was revealed to be 12/30 indicating significant cognitive impairment. On 4/24/24 Resident 1's care plan interventions included working with the resident to determine reasons for wanting to leave the facility. No additional interventions were identified. A 5/31/24 Facility Incident Report revealed, Resident 1 had an unwitnessed exit from the facility. Facility indicated during internal review that staff were unaware of resident's whereabouts and unaware she/he could not leave the facility on her/his own. Facility investigation revealed care staff were not aware of Resident 1's elopement and prior interventions were determined to be unsuccessful. Resident 1 was located at the local market and returned to the facility by care staff. On 5/31/24 Resident 1's care plan interventions included placing the resident on 15 minute checks. A 6/10/24 Facility Incident Report revealed, Resident 1 had an unwitnessed exit from the facility. Resident was located at Clackamas Town Center by spouse. Resident 1 was picked up by the facility. There was no documented evidence the facility re-evaluated Resident 1's elopement risk to identify her/his risk factors and to develop targeted interventions or to determine the need for increased supervision to prevent reoccurring elopements. On 6/18/24 at 11:27 AM, Resident 1's room was observed to be located between two emergency exit doors. On 6/18/24 at 11:34 AM, Staff 3 (CNA) stated Resident 1 "consistently wanted to elope from the facility" and continued to present as an elopement risk for the facility due to Resident 1's "elusiveness" and not having staff to monitor the resident every 15 minutes. Staff 3 was unaware of any additional interventions in place for Resident 1. On 6/18/24 at 12:17 PM, Staff 7 (RNCM) stated Resident 1 was "not appropriate for a nursing facility due to residents consistent wandering behaviors and was more suitable for a memory care facility." Staff 7 indicated Resident 1 was capable of leaving the facility "without notifying anyone." Staff 7 stated no additional interventions other then fifteen minute checks were implemented in the resident's care plan. On 6/18/24 at 3:06 PM, Staff 2 (DNS) stated no additional communication, assessments, or interventions were put into place for Resident 1 outside of the fifteen minute checks due to the facility's "belief in additional interventions or assessments to be unnecessary". On 6/18/24 at 3:14 PM, (Staff 5) CNA stated Resident 1 was "smart enough" to elope from the building by waiting for care staff to "get busy then walk out through the front door or side door." Staff 5 stated only fifteen minute interventions were in place and was unaware of any additional interventions identified. On 6/20/24 at 11:04 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility failed to implement additional interventions to prevent Resident 1's elopements. Staff 2 (DNS) acknowledged the facility failed to re-evaluate Resident 1's elopement risk and failed to revise care plan interventions to prevent Resident 1's elopements.

F689 - Free of Accident Hazards/Supervision/Devices 1. How will the nursing home correct the deficiency as it relates to the resident? Resident 1 has been re-evaluated for elopement risks and care plan has been revised with interventions to prevent elopements. 2. How the nursing home will act to protect residents and staff in similar situations. The DNS/designee will audit Residents that are at a risk for elopement and have been re-evaluated for elopement and care plans revised if needed. Discrepancies found will be immediately corrected. 3. Measures the nursing home will take or systems it will alter to ensure that the problem does not occur. Staff have been educated to the elopement policy and interventions in place for elopement risk residents. 4. How the nursing home plans to monitor performance to make sure that solutions are sustained? The DNS/designee will audit residents at risk for elopement and appropriate interventions are in place weekly x4 weeks, then monthly x3 months. Discrepancies found will be immediately corrected and brought to QAPI for further evaluation. 5. Name and Title of the person responsible to ensure correction: DNS/Designee

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

Based on observation and interview it was determined the facility failed to ensure resident rooms, bathrooms and linen supplies were maintained for 2 of 2 halls reviewed for environment. This placed residents at risk for lessened quality of life. Findings include: 1. A 5/3/23 at 10:06 AM observation of Room 10 and bathroom revealed duct tape on the floor under the sink and across the toilet threshold. The grout around the toilet was uneven and patchy, there were tiles on the floor and wall in the shower stall that were cracked and broken. The dry wall leading toward the bathroom was cracked near the ceiling and the frame around the bathroom door was separated. There was a gap between the wall and ceiling along three of the bathroom walls (except the window wall). The exhaust vent did not turn on when tested. The resident in room 10 stated she/he used that bathroom. A 5/1/23 at 11:49 AM observation of the bathroom between Rooms 24 and 26 revealed the linoleum around the toilet and across the width of the bathroom floor was separated which exposed subflooring. The bathroom was used daily. A 5/1/23 at 12:24 PM observation of Room 23 and bathroom revealed the toilet riser was missing paint and visibly rusted in several spots. The linoleum was separated close to the toilet and a rust-colored ring was noted around the base of the toilet. The molding was separated from the wall under the sink, and the caulk and drywall was cracked above the sink. The floor was stained gray and brown in multiple locations, and there were several chips out of the bathroom door which exposed the wood underneath. A 5/1/23 at 12:31 PM observation of Room 21 and bathroom revealed gray stains on the floor, a commode with non-cleanable tape, caulk missing at the base of the toilet, and the base of the toilet was stained brown. The commode was rusted, and the floor had several dark nicks and scratches. A 5/1/23 at 12:43 PM observation of Room 17 and bathroom revealed a persistent urine odor, and the toilet seat did not fit the toilet (oversized). The caulk was missing from the base of the toilet and the floor surrounding the toilet was rusted and brown in color. On 5/4/23 at 11:43 AM Staff 5 (Maintenance Director) stated the Facility had discussed two of the bathroom remodels however did not plan on all of them. Staff 5 confirmed all observed concerns and acknowledged the identified findings. On 5/4/23 at 12:10 PM Staff 1 (Administrator) acknowledged the observed damage and confirmed repairs were needed. , 2. On 5/1/23 at 9:52 AM Resident 40 stated her/his shower was delayed on Sunday, 4/30/23 due to the facility not having any clean towels or linen. On 5/2/23 at 1:37 PM Staff 7 (Housekeeping Manager) stated the weekend staff did not show up to work on Saturday and Sunday. Staff 7 was not aware there was no housekeeping staff present in the facility until he was notified by the DNS on Sunday morning. On 5/2/23 at 1:59 PM Staff 2 (DNS) stated Staff 8 (CNA) called her on Sunday morning stating there was no clean linen or towels in the facility and staff were cutting up bed sheets to use as washcloths. Staff 2 called Staff 7 immediately, who came in to provide laundry and housekeeping services. On 5/5/23 at 8:48 AM Staff 8 (CNA) stated she was told by other CNA staff there was no clean towels or linen in the facility. Staff 8 called Staff 2 to inform her of the linen and towel shortage. Staff 8 stated she did not call Staff 7 because she did not have his number. On 5/5/23 9:10 AM Staff 1 (Administrator) stated she was called on Sunday regarding the linen shortage.

1) Room 10, 24, 26, 23, 21, 17 have been updated to ensure the rooms and bathrooms are maintained in a safe, clean, comfortable and homelike environment. Resident 40 has linen available to meet their needs. 2) Resident rooms and bathrooms have been reviewed to ensure they are maintained in a safe, clean, comfortable and homelike environment. Linen is readily available in the building to meet resident needs. 3) Administrator will reeducate staff to the Tels system and ensuring a clean, comfortable, home like environment. 4) Administrator/Maintenance or designee will conduct random audits weekly x4 and monthly x3 to ensure resident rooms, bathrooms and linen supplies are maintained as appropriate. Audits will be reviewed in QAPI until substantial compliance has been met x2 QAPI meetings. 5) Administrator and or designee to ensure compliance

Based on observation, interview and record review it was determined the facility failed to ensure oxygen filters were cleaned for 1 of 1 sampled resident (#4) reviewed for respiratory care. This placed residents at risk for lack of respiratory care. Findings include: The facility's 2001 policy related to respiratory support indicated washable filters were to be rinsed under running water once a week to remove dust and debris. Resident 4 admitted to the facility in 2020 with diagnoses including palliative care. A physician order dated 2/10/23 indicated Resident 4 was to have 0-2 liters of supplemental oxygen PRN to maintain saturation of more than 88 percent. A 4/24/23 hospice note indicated Resident 4 used 2 liters of oxygen continuously. Review of the 4/2023 MAR indicate Resident 4 received 2 liters of oxygen routinely. On 5/1/23 at 11:17 AM Resident 4 was observed to have oxygen in place. Resident 4 stated she/he used oxygen all the time. The oxygen filter was observed to have a thick layer of dust covering the entire filter. On 5/2/23 at 12:47 PM Staff 2 (DNS) stated night shift staff was responsible for maintaining and cleaning resident oxygen equipment, including the filters. Staff 2 acknowledged Resident 4's oxygen filter was dirty and covered in dust.

1) Resident 4’s oxygen filter has been cleaned and is on a regular cleaning schedule 2) Residents on oxygen have been reviewed to ensure their oxygen filter is being cleaned regularly 3) Licensed Nurses have been reeducated to ensure residents on oxygen have their filters cleaned per policy 4) DNS or designee will conduct random audits weekly x4 and monthly x3 to ensure residents on oxygen have their filters cleaned per policy. Results will be reviewed in QAPI until substantial compliance has been met x2 QAPI meetings. 5) DNS and or designee to ensure compliance

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 24 admitted to the facility in 2022 with diagnoses including depressive disorder. The 3/3/23 pharmacy recommendation indicated the following: -Resident 24 was taking Lexapro (antidepressant medication) 7.5 mg for depression and was due for a gradual dose reduction (GDR) assessment; The pharmacy recommendation was not signed by the provider until 4/27/23 (55 days later) and indicated no change to Resident 24's Lexapro. On 5/3/23 at 2:03 PM at Staff 2 (DNS) acknowledged the facility did not follow up with the pharmacy recommendation timely.

1) Resident 24’s pharmacy recommendations have been addressed as appropriate 2) Residents in the center have been audited to ensure pharmacy recommendations are being addressed appropriately. 3) Nurse managers have been reeducated by the DNS to ensure pharmacy recommendations are being addressed appropriately. 4) DNS or designee will conduct random weekly audits x4 and monthly x3 to validate pharmacy recommendations are being addressed appropriately. Results will be reviewed in QAPI until substantial compliance has been met x2 QAPI meetings. 5) DNS and or designee to ensure compliance

Based on interview and record review it was determined the facility failed to withhold bowel medication as indicated for 2 of 5 sampled residents (#s 3 and 24) reviewed for medication. This placed residents at risk for adverse side effects of bowel medication. Findings include: 1. Resident 3 was admitted to the facility in 2019 with diagnoses including stroke. Resident 3's 5/4/23 physician's orders included the following medications: - Miralax (laxative) BID for bowel care. - Senna (laxative) BID for bowel care. Resident 3's Bowel elimination records from 4/4/23 through 4/30/23 revealed she/he had loose stools or diarrhea documented on 17 of 30 days for a total of 24 occurrences. Resident 3's 4/2023 MAR indicated: - The resident's scheduled Miralax was administered routinely every day from 4/1/23 through 4/30/23. - The resident's scheduled senna was administered routinely every day from 4/1/23 through 4/30/23 except for the refusal of two doses. Resident 3's 4/19/23 Care Plan indicated the resident had loose stools and diarrhea with a goal of reduced episodes of diarrhea. On 5/4/23 at 11:05 AM Staff 10 (Agency RN) stated the CNAs reported loose stools to the CMA. The CMA then communicated this information to the nurse. Staff 10 reported she was not informed Resident 3 had loose stools or diarrhea. On 5/4/23 at 12:58 PM Staff 2 (DNS) acknowledged Resident 3 had loose stools or diarrhea documented in April 2023 and the scheduled bowel care medications (Miralax and senna) were administered for all but two doses. She stated if a resident had a loose stool it should be communicated so this information could be passed on to the doctor to determine if the bowel care medication should be held or discontinued. , 2. Resident 24 admitted to the facility in 2022 with diagnoses including heart failure. The 3/29/23 physician orders indicated Resident 24 was to receive the following: -polyethylene glycol powder (laxative medication) give 1 scoop in juice in the morning for bowel care; -senna 8.6 mg (laxative medication) one tab in the evening for bowel care. Hold for loose stool or more than 2 bowel movements daily; -senna-docusate sodium 8.6-50 mg (laxative medication) 2 tabs twice daily for stool softener. A review of MARs from 4/4/23 through 5/3/23 indicated the following: -Resident 24 received polyethylene glycol on 29 occasions and refused the medication four times; -Resident 24 received all doses of senna 8.6 mg in the evening as ordered; -Resident 24 received all doses of senna-docusate sodium 8.6-50 mg 2 tabs twice daily as ordered. A review of Resident 24's bowel records from 4/4/23 through 5/3/23 indicated the resident had loose stools on 17 occasions. On 5/3/23 at 1:05 PM Staff 2 (DNS) acknowledged Resident 24 had loose stools on 17 occasions between 4/4/23 and 5/3/23 and acknowledged the bowel medication was not held per the orders and not held per indication of use.

1) Resident 24 bowel medication regimen has been reviewed and is withheld appropriately. Resident 3 is no longer residing in the building. 2) Residents in the center on a bowel medication regimen have been reviewed to ensure it is withheld appropriately. 3) Licensed nurses and CNAs have been reeducated by DNS to correct bowel charting and ensuring bowel medication is withheld as appropriate. 4) DNS or designee will conduct random audits weekly x4 and monthly x3 to validate residents on bowel medications are having their meds held as appropriate. Results will be reviewed in QAPI until substantial compliance has been met x2 QAPI meetings. 5) DNS and or designee to ensure compliance

Based on observation, interview and record review it was determined the facility failed to provide palatable meals for 2 of 2 sampled residents (#s 12 and 30) reviewed for food quality. This placed residents at risk for impaired nutrition. Findings include: 1. Resident 12 was admitted to the facility in 2023 with diagnoses including pneumonia, dysphagia (difficulty swallowing) and malnutrition. Resident 12's 4/24/23 Care Plan indicated the resident had altered nutrition related to diagnoses of malnutrition and dysphagia. Resident 12's 4/26/23 ordered diet was a regular diet with minced and moist texture. A Registered Dietitian Assessment dated 4/26/23 indicated the resident had an underweight BMI (body mass index). On 5/1/23 at 1:06 PM Resident 12 reported the texture, preparation and appearance of the food was not good. The resident stated the meal served at lunch was "minced to death" and she/he was not able to identify what it was. On 5/4/23 at 12:15 PM surveyors sampled two meals (regular and minced/moist) consisting of Hawaiian-style pork, orzo (pasta), oven-roasted Brussels sprouts with garlic and fruit. The pork was observed to be overcooked, dry and flavorless. The orzo was pasty and lacked flavor. The Brussels sprouts were overcooked. The minced and moist food was not appetizing in appearance. The plate had two scoops of pale colored food (pork and orzo) and one scoop of green colored food. The food was lacking in flavor and the texture had a pureed (ground finely) consistency. On 5/3/23 at 12:24 PM Staff 14 (Corporate Nurse Consultant) sampled the food and stated the orzo was sticky and the pork was dry. When tasting the Brussels sprouts Staff 14 gagged and spat the bite out. Staff 14 acknowledged the findings identified. , 2. Resident 30 admitted to the facility in 2022 with diagnoses including anxiety. The 10/10/22 Care Plan indicated Resident 30 was independent with eating. A 3/28/23 progress note indicated Resident 30 was cognitively intact and was able to direct her/his own care. On 5/1/23 at 10:50 AM Resident 30 stated the food was not always good and kitchen staff did not know how to cook the food. On 5/4/23 at 12:15 PM surveyors sampled a regular diet meal consisting of Hawaiian-style pork, orzo (pasta), oven-roasted Brussels sprouts with garlic and fruit. The pork was overcooked, dry and flavorless. The orzo was pasty and lacked flavor. The Brussels sprouts were overcooked. On 5/3/23 at 12:24 PM Staff 14 (Corporate Nurse Consultant) sampled the food and stated the orzo was sticky and the pork was dry. When tasting the Brussels sprouts Staff 14 gagged and spat the bite out. Staff 14 acknowledeged the findings indentified.

1) Resident 30 was interviewed regarding satisfaction and quality. Any concerns were addressed as indicated. Resident 12 has discharged. 2) Residents in the center will be interviewed regarding satisfaction and quality. Any concerns will be met as indicated 3) Cooks have been reeducated by the CDM to ensure food is flavored well, texture is appropriate per diet, and has good appearance. 4) CDM or designee will conduct random audits weekly x4 and monthly x3 by resident satisfaction surveys and test trays to ensure palatability and texture is appropriate. Results will be reviewed in QAPI until substantial compliance has been met x2 QAPI meetings. 5) Administrator and or designee to ensure compliance

Based on observation and interview it was determined the facility failed to ensure garbage storage areas were maintained in a sanitary manner to prevent the presence and feeding of pests, and to ensure garbage storage area dumpsters were covered condition for 1 of 1 facility storage areas reviewed for sanitary garbage storage. This placed residents at risk for presence of pests. Findings include: On 5/1/23 at 9:09 AM during the initial kitchen tour including the outside garbage storage area Staff 9 (Cook) stated the trash compacter was broken for over a year and the facility brought in a large dumpster. A large, approximately 20 feet by 10 feet uncovered dumpster with two hinged doors at the front was observed at back side of the building. On 5/2/23 at 12:58 PM one of the dumpster doors opened was observed open; trash bags and a pair of used gloves dangled off the edge of the dumpster. On 5/3/23 at 10:12 AM one of the the dumpster doors was observed open and one garbage bag hung over the front edge; two black crows were observed by the dumpster opening. On 5/3/23 at 10:25 AM Resident 29 stated she/he saw cats and birds in the dumpster at times. On 5/4/23 at 1:55 PM Staff 6 (Dietary Manager) stated she was aware the dumpster required a cover to stop the risk of pests and rodents, but was not involved in the decision-making process for the dumpster. On 5/4/23 at 2:09 PM Staff 5 (Maintenance Director) stated the trash compactor broke almost two years ago, and the two large uncovered dumpster was in use for almost a year. Staff 5 stated one of the dumpster doors was always left open because some staff were not able to throw trash bags into the dumpster from above. On 5/5/23 at 9:07 AM Staff 1 (Administrator) acknowledged the dumpster was not covered and was not aware it had to be covered.

1) No residents identified 2) New garbage bins have been ordered to ensure garbage storage areas are maintained in a sanitary manner 3) Staff have been reeducated by administrator to ensure garbage storage area is maintained in a sanitary manner 4) Administrator and or designee will conduct audits weekly x4 and monthly x3 to validate garbage storage area is maintained in a sanitary manner. Results will be reviewed in QAPI 5) Administrator and or designee to ensure compliance

*************** OAR 411-085-0140 Nursing Services: Problem Resolution & Preventative Care Refer to F757 *************** OAR 411-086-0360 Resident Furnishing, Equiptment Refer to F584 *************** OAR 411-085-0110 Nursing Services: Resident Care Refer to F695 *************** OAR 411-086-0260 Pharmaceutical Services Refer to F756 *************** OAR 411-086-0250 Dietary Services Refer to F804 and F814 ***************

Based on observation, interview, and record review it was determined the facility failed to follow the plan of care for 1 of 3 sampled residents (#4) reviewed for falls. This failure resulted in Resident 4 experiencing a fall with a fracture. This placed residents at risk for increased falls. Findings include: Resident 4 admitted to the facility on 5/2/21 with diagnoses including dementia. Resident 4's Quarterly MDS dated 10/3/22 revealed she/he had a BIMS score of 5 (severely impaired). Resident 4's care plan dated 7/21/22 included padded fall mats on both bedsides when in bed, wider bed for comfort and a scoop mattress to prevent rolling out of bed. A 9/24/22 facility investigation revealed on 9/24/22 Resident 4 was found on the floor next to her/his bed and no fall mats were present. Staff 5 (LPN) checked Resident 4 for injuries. Staff 5 called for x-rays which revealed a broken left femur. In an interview on 11/29/22 at 2:18 PM Staff 6 (CNA) stated she did not put the fall mats next to Resident 4's bed on 9/24/22. She didn't see the mats and thought the resident no longer needed them. In an interview on 11/30/22 at 11:20 AM Staff 5 (LPN) stated he checked Resident 4 for injuries and pain on 9/24/22 after the fall. Resident 4 stated her/his knee hurt. The LN medicated the resident and call for x-rays. In an interview on 11/29/22 at 2:04 PM Staff 3 (RNCM) confirmed the care plan was not followed for Resident 4 and resulted in a fall with a fracture. In an interview on 11/29/22 at 2:06 PM Staff 2 (DNS) confirmed the care plan was not followed for Resident 4 and resulted in a fall with a fracture.

Resident #4 has returned to the facility. Falls care plan has been reviewed for appropriate interventions and verified all interventions are in place. All residents currently in house with fall care plans have been reviewed for accuracy and that all interventions are in place and being followed. This was completed 11/29/22 DNS has completed in servicing for nursing staff regarding importance of following care plans to ensure pt. safety and fall prevention. This was completed 12/2/22 DNS or designee will audit 5 residents per week to ensure that fall care plan interventions are being followed by staff and that appropriate interventions are in place. These audits will continue weekly X4 and then monthly. Results of these audits will be brought to QAPI until substance compliance has been achieved for 2 QAPIs

*********** OAR 411-086-0140 Refer to F689 ***********