Dallas Retirement Village Health Center

Resident 8 was admitted to the facility in 4/2025 with a diagnosis of a stroke.-á -á Resident 8's 10/24/25 Quarterly MDS revealed she/he was moderately cognitively impaired. -á Resident 8's Progress Notes revealed on 11/28/25 she/he was admitted to the hospital. -á Resident 8's clinical record did not reveal she/he or her/his representative was provided bed hold information.-á-á -á On 4/6/26 at 11:21 AM Witness 3 (Family) stated in 11/2025 when Resident 8 was admitted to the hospital, she was not provided information related to a bed hold. -á On 4/8/26 at 10:10 AM Staff 14 (LPN) stated when residents were transferred to the hospital, bed hold information was placed in a packet, and provided to the transportation team to deliver to the hospital staff. Staff 14 stated she did not follow up with a resident or resident's representative to ensure they received the bed hold information.-á On 4/9/26 at 11:45 AM Staff 2 (DNS) stated when a resident was transferred to the hospital, a transfer packet, including the bed hold policy, was sent with the resident. Staff 2 stated Staff 13 (Admissions Director) reviewed the bed hold policy with the resident or resident's representative if a resident was admitted to the hospital. -á On 4/9/26 at 11:50 PM Staff 13 stated she followed up with residents or residents' representatives when they were admitted to the hospital, and then she made a note in a resident's clinical record. Staff 13 stated she did not recall if she/he followed up with Resident 8 or her/his family.-á-á On 4/10/26 at 10:41 AM Staff 1 (Administrator) stated when a resident who resided on the long-term care unit was admitted to the hospital they were always allowed back to the facility. Staff 1 also stated the bed hold information was more directed toward the skilled residents.-á

1. Resident #8 returned to the facility immediately following hospitalization. All hospitalized residents are at risk related to this alleged deficient practice. 2. Administrator or designee on or before 4/13/2026 contacted all hospitalized residents and their representative to review the facility bed hold policy and procedure. 3. The policy for bed holds has been reviewed. Additionally, the Administrator or designee on or before 5/4/2026 re-educated staff to notifying residents and their representative of the facility bed hold policy. 4. Administrator or designee will complete weekly audits of hospitalized resident records for notification of the facility bed hold policy. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

The facility's Baseline Care Plan policy dated 1/2026 stated, ""a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission."" Resident 59 admitted to the facility on 3/27/26 with a diagnosis of nondisplaced fracture of right femur.-á Review of Resident 59's Baseline Care Plan revealed it was completed and reviewed with the resident on 3/30/26. On 4/10/26 at 10:02 AM Staff 20 (RNCM) stated baseline care plans for newly admitted residents were finalized within 72 hours of admission.-á On 4/10/26 at 11:38 AM Staff 2 (DNS) acknowledged Resident 59's Baseline Care Plan was not completed timely and needed to be finalized within 48 hours of her/his 3/27/26 admission.

1. Resident #59’s comprehensive care plan for transfer status was completed on 3/30/26.  All residents who admit to the facility and require a baseline care plan are at risk related to this alleged deficient practice. 2. All current newly admitted residents that required a baseline care plan were audited for timely development and completion of the care plan.  Audit was conducted of baseline care plans completed from 4/12/26 through 4/26/26. 3. The policy for baseline care plans has been reviewed. Additionally, the Director of Nursing Services or designee on or before 5/4/2026 re-educated staff to completing the baseline care plan timely. 4. Director of Nursing Services or designee will complete weekly audits of 100% of baseline care plans for timely completion. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Resident 80 was admitted to the facility in 4/2025 with diagnoses including depression and anxiety. The 10/2/25 Quarterly MDS indicated Resident 80 had a BIMS score of 13 which indicated the resident was cognitively intact. A 10/22/25 Physician Order revealed Resident 80 had erythema (abnormal redness under the skin) under her/his neck fold. Staff were to monitor the skin impairment every shift and notify the provider if the area deteriorated. A 12/3/25 Progress Note by Staff 8 (LPN) revealed Resident 80GÇÖs erythema under the neck fold showed signs of deterioration including increased size and was tender to the touch. Staff 8 notified the provider and waited for a response. A review of Resident 80GÇÖs Provider Progress Notes on 12/3/25, 12/5/25, and 12/7/25 revealed no response from Staff 8GÇÖs notification related to the deterioration of erythema under Resident 80GÇÖs neck fold. A review of Resident 80GÇÖs progress notes revealed no follow-up notes related to a response from the provider or any further follow up calls placed to the provider to obtain further directions. A review of Resident 80's 12/2025 TAR revealed no new treatments for the deterioration of erythema under Resident 80's neck fold.-á On 4/10/26 at 11:15 AM Staff 8 stated he did not recall the 12/3/25 progress note or if the provider ever responded. On 4/10/26 at 11:45 AM Staff 2 (DNS) stated she expected staff to follow up with the provider the next day if a response was not received. Staff 2 confirmed there was no follow up to the provider completed for Resident 80GÇÖs deterioration of erythema under her/his neck fold.

1. Resident 80’s skin impairment resolved on 01/02/2026. All residents with skin impairment are at risk related to this alleged deficient practice. 2. All current residents with skin impairments from 4/12/2026 through 4/26/2026 were audited for a deterioration in a skin impairment without a notification to the provider.  A notification was made if there was a deterioration noted and a request for treatment change, if indicated, at time of audit was made. 3. The policy for Change in Condition has been reviewed. Additionally, the Director of Nursing Services or designee on or before 5/4/2026 re-educated staff to notifying the physician upon change in skin condition. 4. Director of Nursing Services or designee will complete weekly audits of 100% of skin impairments for timely physician notification and implementation of new orders as applicable. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Resident 59 admitted to the facility on 3/27/26 with a diagnosis of nondisplaced fracture of right femur.-á Review of Resident 59's Care Plan initiated 3/30/26 revealed nursing staff were to use a ceiling lift for transfers. Resident 59's Care Plan initiated 4/1/26 also revealed the resident was only to ambulate with therapy staff.-á A 3/31/26 Functional Abilities Evaluation revealed Resident 59 was dependent on facility staff for transfers.-á A 3/31/26 Incident Report indicated Resident 59 had a witnessed fall without injury in her/his room when Staff 19 (CNA) attempted to ambulate the resident with a front wheel walker and gait belt. A statement from Staff 19 revealed Resident 59 lost her/his balance during a transfer and was guided to the ground with low impact.-á A 3/31/26 Nursing Progress Note indicated Resident 59's care plan directed nursing staff to use a ceiling lift for transfers and the resident was only to ambulate with therapy staff.-á-á On 4/6/26 at 10:05 AM, Resident 59 stated she/he fell during a standing transfer with nursing staff in her/his room.-á On 4/9/26 at 12:02 PM and 4/10/26 at 10:39 AM attempts to reach Staff 19 were unsuccessful.-á On 4/9/26 at 1:39 PM Staff 18 (RN) stated Staff 19 told her he did not check Resident's 59 care plan before he attempted to transfer the resident.-á On 4/10/26 at 10:09 AM Staff 20 (RNCM) confirmed Resident 59's care plan directed nursing staff to use a ceiling lift to assist Resident 59 with transfers on 3/31/26, and the resident fell on 3/31/26 when her/his care plan was not followed by nursing staff.-á-á

1. Resident #59’s transfer intervention was originally updated on 3/30/2026 on the care plan.  Resident #59’s care plan was reviewed and updated to reflect their current transfer intervention on 04/14/2026. All residents who admit to the facility are at risk related to this alleged deficient practice. 2. All current resident transfer interventions were audited for accuracy on or before 4/30/2026. 3. The policy for care plans has been reviewed. Additionally, the Director of Nursing Services or designee on or before 5/4/2026 re-educated staff to updating transfer interventions on the care plan timely. 4. Director of Nursing Services or designee will complete weekly audits of up to 30 care plans for accurate transfer intervention. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Resident 67 was readmitted to the facility in 4/2023 with a diagnosis of chronic kidney disease. -á Resident 67's Care Plan revised on 4/2/26 revealed she/he had an ADL self-care deficit. Resident 67 was identified to be ""mostly"" incontinent of bowel and bladder, ""occasionally"" used a bedside commode for toileting, and required the use of a mechanical lift for transfers.-á -á On 4/7/26 at 12:45 PM Staff 15 (CNA) was observed to enter Resident 67's room. Resident 67 stated she/he had to go to the bathroom. Staff 15 informed Resident 67 that she/he had an incontinent brief on and he would assist with incontinent care after lunch. Staff 15 was then observed to exit Resident 67's room and was observed to distribute other residents' meal trays. Resident 67 was observed to attempt to stand and this surveyor notified Staff 15 of Resident 67's attempt to self-transfer. When Staff 15 re-entered Resident 67's room she/he was located in her/his bathroom.-á -á On 4/8/26 at 8:15 AM Staff 15 stated Resident 67 did not always like to use the bedpan, was usually incontinent, and did not walk for at least three weeks. Staff 15 also stated on 4/7/26 he had to finish distributing other residents' meal trays and informed Resident 67 he would assist her/him with incontinent care after lunch.-á On 4/9/26 at 12:08 PM Staff 2 (DNS) stated if there were two staff in the hall, one staff should assist residents with toileting upon their request.-á On 4/10/26 at 11:20 AM Staff 1 (Administrator) stated a resident should be assisted with toileting when requested.-á -á -á

1. Resident #67 was assisted with toileting. All residents requiring assistance with toileting are at risk related to this alleged deficient practice. 2. All current residents with incontinence were reviewed for appropriate toileting interventions on or before 4/30/2026. 3. The policy for Dignity has been reviewed. Additionally, the Director of Nursing Services or designee on or before 5/4/2026 re-educated staff to complete resident's toileting needs timely. 4. Director of Nursing Services or designee will complete weekly audits for toileting per care plan interventions and prompt response to requests for toileting. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

-á 3. During a breakfast dining observation on 4/6/26 at 8:12 AM Staff 23 (CNA) was observed to assist Resident 35 with drinking from a straw. Staff 23 used his hand to adjust the straw up and down and held the straw to Resident 35GÇÖs mouth. Staff 23 then, without sanitizing his hands, assisted Resident 43 with eating yogurt from a spoon and wiped her/his mouth with a napkin. Staff 23 returned to Resident 35 and assisted her/him with eating eggs from a spoon, without sanitizing his hands. On 4/6/26 at 8:48 AM, Staff 23 stated he was not expected to sanitize his hands between residents while assisting with eating unless he got up from the table. Staff 23 acknowledged he did not sanitize his hands while he assisted Resident 35 and 43. On 4/6/26 at 8:53 AM, Staff 2 (DNS) stated staff were expected to perform hand hygiene between assisting residents with eating when food, straws, or the residentGÇÖs face were touched. -á -á -á -á , 2. On 4/9/26 at 12:36 PM Staff 11 (CNA) utilized a ceiling-mounted lift device to transfer a resident in Room 215. At 12:45 PM Staff 11 put the lift onto a cart, moved it into the hallway, and left without cleaning the lift. At 12:48 PM Staff 12 (CNA) moved the same ceiling lift cart into Room 213 to use with a different resident. Staff 12 was stopped by the surveyor and notified the ceiling lift was not cleaned after it was last used. On 4/9/26 at 12:50 PM Staff 12 stated the ceiling lifts were to be cleaned after each use and he assumed the lift was clean because it was in the hallway.-á On 4/9/26 at 12:51 PM Staff 11 (CNA) confirmed she did not clean the lift before placing it in the hallway. Staff 11 stated ceiling lifts were to be cleaned after each use.-á On 4/10/26 at 10:24 AM Staff 2 (DNS) stated ceiling lift devices were to be cleaned after every use prior to placing them in the facility hallway.-á -á , 1. The facility's Disinfection of Resident Care Items and Equipment policy revised 11/2025 stated: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). On 4/6/26 at 9:39 AM Staff 7 (CNA) exited Room 166 with a mechanical lift then took the mechanical lift to Room 167 without cleaning and disinfecting it. At 9:47 AM Staff 7 left Room 167 and parked the mechanical lift in the hallway without cleaning and disinfecting it. Staff 7 stated the mechanical lift was not cleaned then but another staff member came through during the day and wiped off the lifts.-á On 4/8/26 at 3:19 PM Staff 2 (DNS) stated mechanical lifts were reusable equipment and were to be disinfected between each resident.-á -á

1. No residents were directly affected. All residents requiring the use of mechanical lifts are at risk of this alleged deficient practice. 2. An audit of easily accessible manufacturers recommended cleaning supplies was completed on 4/13/26. Manufacturers recommended cleaning supplies have been placed within easy access of the mechanical lifts. 3. The policy for Disinfection of Resident-Care Items and Equipment has been reviewed. Additionally, the Director of Nursing Services or designee on or before 5/4/2026 re-educated staff to proper cleansing of reusable durable medical equipment. 4. Director of Nursing Services or designee will complete weekly observation of up to 30 opportunities for disinfecting reusable resident equipment between residents. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance. 1. Residents #35 and 43 did not have any adverse effect. All residents that require assistance with dining are at risk of this alleged deficient practice. 2. Dining rooms were audited for availability of appropriate amounts of hand hygiene supplies, as well as gloves which may be needed for assisting with handheld food items while dining on 4/27/2026. Any additional needed supplies were placed in the dining rooms on 4/27/2026. 3. The policy for hand hygiene has been reviewed. Additionally, the Director of Nursing Services or designee on or before 5/4/2026 re-educated staff to proper hand hygiene while assisting with dining. 4. Director of Nursing Services or designee will complete weekly observation of up to 30 opportunities for hand hygiene usage in the dining room with focus on assisting a resident with a meal. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, interview, and record review it was determined the facility failed to ensure medication storage temperatures were logged and failed to ensure proper labeling of biologicals for 3 of 3 medication storage refrigerators reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: 1. On 12/4/24 at 9:15 AM, one open, undated vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) was observed in the nurses' station three medication room refrigerator. The manufacturer's instructions indicated to discard the medication 30 days after opening. On 12/4/24 at 9:15 AM, Staff 11 (LPN) acknowledged the vial of tuberculin was open and not labeled with an open date. On 12/4/24 at 12:12 PM, Staff 2 (DNS) stated the expectation was for staff to label tuberculin with an open date. 2. On 12/4/24 at 8:56 AM, the nurses' station one hall medication room refrigerator temperature logs was observed to be blank from 11/1/24 through 11/25/24. On 12/4/24 at 8:56 AM, Staff 12 (LPN) acknowledged the temperature logs were blank on the identified dates. On 12/4/24 at 12:12 PM, Staff 2 (DNS) stated the expectation was for the medication room refrigerator temperature to be checked and logged twice daily. Staff 2 acknowledged there were no temperatures documented from 11/1/24 through 11/25/24. 3. On 12/4/24 at 9:08 AM, the nurses' station two hall medication room refrigerator temperature logs was observed to be blank on 11/17/24 and 11/29/24. On 12/4/24 at 9:08 AM, Staff 13 (RNCM) acknowledged the temperature logs were blank on the identified dates. On 12/4/24 at 12:12 PM, Staff 2 (DNS) stated the expectation was for the medication room refrigerator temperature to be checked and logged twice daily. Staff 2 acknowledged there were no temperatures documented on 11/17/24 and 11/29/24.

The undated vial of tuberculin was discarded on 12/4/2024. All residents are at risk of receiving outdated medications related to this alleged deficient practice. Director of Nursing Services or designee on 12/5/2024 completed an audit of all open medications for dates. Any medications without dates were discarded. The policy for medication storage has been reviewed. Additionally, the Director of Nursing Services or designee on or before 12/20/2024 re-educated staff to proper dating of medications when opened. Director of Nursing Services or designee will complete weekly audits of opened medications to ensure they are dated properly. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance. The Director of Nursing Services or designee on 12/3/2024 began re-education of licensed nurses to the facility policy and procedure for refrigerator temperature checks. All residents that receive medications that require refrigeration are at risk of receiving medication that may not have been stored properly related to this alleged deficient practice. Director of Nursing Services or designee on 12/2/2024 completed an audit of refrigerator temperature logs. The policy for medication storage has been reviewed. Additionally, the Director of Nursing Services or designee on or before 12/5/2024 re-educated staff to twice daily documentation of medication refrigerator temperatures. Director of Nursing Services or designee will complete daily weekday audits of the medication refrigerator temperature logs. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation and interview it was determined the facility failed to serve, store, and label food in a sanitary manner for 1 of 2 dining rooms and 1 of 2 facility refrigerators observed for dining. This placed residents at risk for contamination and at risk for food borne illness. Findings include: 1. On 12/4/24 at 1:00 PM, Staff 15 (Dietary Aid) was observed serving lunch in the second floor kitchen. While Staff 15 served a meal ticket fell off the serving station into the dining room. Staff 15 walked out of the kitchen, picked up the meal ticket with her gloved hand, returned to the kitchen with the meal ticket, placed it back on the service station, and touched multiple service items while wearing the same gloves. Staff 15 confirmed the meal ticket should not have been placed back on the service station once it fell on the floor and her gloves should have been changed after she touched the floor. On 12/4/24 at 1:43 PM, Staff 16 (Dietary Manager) confirmed once the meal ticket fell it should not be placed back on the service station. , 2. On 12/2/24 at 10:25 AM, a communal refrigerator in the facility's pantry area was observed with the following: -One clear container filled with meat covered in gravy with no date. -One clear container with a red top containing left over white cake with white and chocolate frosting with no date. On 12/2/24 at 10:32 AM, Staff 1 (Administrator) stated it was her expectation food items were to be dated and labeled with the residents room number in which the item belonged to.

On 12/4/2024 staff #15 was re-educated to proper hand hygiene and glove changing practices. All current residents receiving meals from the facility are at risk for this alleged deficient practice. The Administrator or designee on or before 12/23/2024 completed competency related to when to change gloves and when/how to do hand hygiene with current servers. On 12/18/2024 a policy for dietary hand hygiene was adopted. The Administrator or designee on or before 12/23/2024 re-educated current servers to proper hand hygiene and glove changing practices. The Administrator or designee will complete weekly observations of up to 5 servers for use of proper hand hygiene. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance. On 12/2/2024 all items not properly stored were removed from the communal refrigerator. All current residents storing items in communal refrigerators are at risk for this alleged deficient practice. On 12/2/2024 the Administrator audited all communal refrigerators for proper storage, items not meeting these criteria were discarded. The policy for storage of items in communal refrigerators has been reviewed. The Administrator or designee on or before 12/20/2024 re-educated dietary staff to proper storage of items in communal refrigerators. The Administrator or designee will complete daily weekday audits of communal refrigerators to ensure proper storage of items. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, interview, and record review it was determined the facility failed to ensure community use CBG glucometers were properly cleaned and sanitized between resident use, failed to follow transmission based precautions, and failed to process laundry to produce hygienically clean laundry to prevent the spread of infection for 4 of 6 sampled residents (#s 33, 80, 83, and 84) and 1 of 1 laundry room reviewed for infection control. This placed residents at risk for bloodborne illness, exposure to infections, and contaminated laundry. Findings include: 1. The facility's 3/2024 Blood Glucose Monitoring policy indicated to follow the manufacturer instructions for cleaning and disinfection of the meter. The Even Care G3 blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes. Resident 80 admitted to the facility in 2023 with diagnoses including diabetes. On 12/2/24 at 11:34 AM, Staff 14 (LPN) was observed to obtain a CBG from Resident 80. Staff 14 exited the room and cleaned the glucometer with alcohol wipes. Staff 14 stated she used alcohol wipes on a regular basis to clean the glucometer. Staff 14 stated she was assigned rooms 130-144 and the community use glucometer was used for five different residents on the hall. On 12/2/24 at 12:28 PM and at 1:00 PM, Staff 11 (LPN) stated she already completed resident CBG checks for the day and was assigned rooms 201-216. Staff 11 stated she primarily used alcohol wipes to clean the glucometer and the community use glucometer was used for three different residents on the hall. On 12/2/24 at 12:03 PM and on 12/3/24 at 9:27 AM, Staff 2 (DNS) stated the expectation was for staff to use EPA wipes between every glucometer use and ensure proper dwell times were reached. , 2. Resident 33 admitted to the facility in 6/2020, with diagnoses including lung cancer. On 12/02/24 at 2:18 PM, Resident 33's room was observed to have a sign which indicated staff were to follow enhanced barrier precautions when providing high contact activities, there was a cart outside the door which contained gloves, masks, and gowns. On 12/3/24 at 1:16 PM, Staff 17 (CNA) entered Resident 33's room and assisted her/him in using a bedpan. Staff 17 wore gloves and a mask but did not wear an isolation gown. On 12/3/24 at 1:21 PM, Staff 17 exited Resident 33's room, confirmed she assisted her/him with toileting. Staff 17 stated she knew Resident 33 required additional precautions previously, but she was told Resident 33 no longer needed the additional precautions. On 12/4/24 at 9:50 AM, Staff 18 (CNA) entered Resident 33's room and assisted her/him in using the toilet. Staff 18 wore a mask and gloves but did not wear an isolation gown. On 12/4/24 at 10:01 AM, Staff 18 was asked about Resident 33's enhanced barrier precautions, she stated the staff were to wash their hands instead of sanitizing, but was not aware of the need to wear a gown during any care activities. On 12/4/24 at 2:20 PM, Staff 3 (Assistant Director of Nurses) stated the staff were to wear a gown, gloves and mask when they provided high contact care such as toileting for all residents on enhanced barrier precautions. Staff 3 confirmed Resident 33 was on enhanced barrier precautions and the staff should have worn gloves, gown, and a mask when they assisted her/him with toileting. , 3. Resident 83 admitted to the facility on 10/2024, with diagnoses including bilateral post-surgical femoral artery resection and repair. On 12/1/24 Resident 83 tested positive for COVID and was placed on Contact and Droplet Precautions, signage at the door and personal protective equipment (PPE) cart was placed outside of the resident's door. On 12/3/24 at 1:16 PM, observed Staff 19 (CNA) exit a resident room while wearing a face mask without completing hand hygiene and retrieved a lunch tray for Resident 83. Staff 19 donned gown and gloves and entered Resident 83's room. Staff 19 exited the room, doffed gown and gloves, kept the same face mask and went back to retrieve another lunch tray to deliver. On 12/3/24 at 1:30 PM, Staff 19 acknowledged he should have sanitized his hands before and after handling the foods trays, worn full PPE and changed his face mask. On 12/6/24 at 9:53 AM, Staff 2 (DNS) stated she expected all staff to complete hand hygiene before and after entering a resident room and wear full PPE when entering an isolation room to decrease the spread of COVID in the facility. 4. Resident 84 admitted to the facility on 11/2024, with diagnosis including clostridioides difficile (C. diff). On 11/25/24 Resident 84 tested positive for COVID and was placed on Contact and Droplet Precautions, signage was placed on the resident's door, and personal protective equipment (PPE) cart was placed outside of the resident's door. On 12/4/24 at 10:04 AM, Staff 20 (RN) was observed to place her face mask on the PPE cart without a barrier and entered the isolation room on the COVID hall. Staff 20 exited Resident 84's room and donned the same face mask she had put on the PPE cart. On 12/4/24 at 10:10 AM, Staff 20 stated she should have put on a new face mask after exiting Resident 84's room. On 12/6/24 at 9:53 AM, Staff 2 (DNS) stated she expected all staff to use and wear proper PPE at all times to decrease the spread of COVID in the facility. , 5. According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left in machines overnight. On 12/4/24 at 1:34 PM, Staff 8 (Laundry) stated his shift ended at 10:30 PM and he had the last shift of the day. Staff 8 stated when wet laundry was not completed in the washing machine at the end of his shift, he left the wet laundry in the washing machine overnight. On 12/4/24 at 1:38 PM, Staff 9 (Laundry) stated her shift started at 5:30 AM and she transferred the wet laundry to the dryer and did not rewash the laundry. On 12/5/24 at 1:24 PM, Staff 10 (Environmental Services Department Manager) stated wet laundry was left in the washing machine overnight and was placed in the dryer the next morning. The wet laundry was never rewashed as it would take too long to do so. On 12/5/24 at 1:37 PM, Staff 1 (Administrator) stated she was unaware of a laundry policy regarding damp laundry left in the washing machine overnight.

On 12/2/2024 the manufacturer recommendation for proper cleaning of blood glucose machines was reviewed and all machines were cleaned accordingly. All current residents requiring blood glucose checks are at risk for this alleged deficient practice. On 12/2/2024 the Director of Nursing Services or designee audited all current residents for the need for individual blood glucose machines, individual machines were acquired for residents identified. On 12/2/2024 the policy for checking blood glucose levels was reviewed. The Director of Nursing Services or designee on or before 12/20/2024 re-educated staff to the proper cleaning of blood glucose monitors. The Director of Nursing Services or designee will complete up to 3 observations weekly of licensed nursing staff for proper glucometer cleaning. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance. Staff #17, 18, 19 and 20 were re-educated to facility policy for utilizing personal protective equipment (PPE) per posted signage. All residents that require the use of personal protective equipment (PPE) are at risk for this alleged deficient practice. The Director of Nursing Services or designee audited current residents for need for use of personal protective equipment (PPE), ensured proper signage was posted and PPE carts were in place outside of identified resident rooms. The policy for use of personal protective equipment was reviewed. On or before 12/12/2024 the Director of Nursing Services or designee re-educated staff to the facility policy for utilizing personal protective equipment (PPE) per posted signage and began observations of the same. The Director of Nursing Services or designee will complete weekly audits using observation of at least 3 resident rooms to ensure staff members are utilizing personal protective equipment properly. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance. Resident #s 33, 80, 83, and 84 laundry was re-washed and dried. All residents are at risk for this alleged deficient practice of leaving damp laundry in the washing machine overnight. On 12/5/2024 the facility discontinued leaving damp laundry in washing machines overnight. On 12/5/2024 the facility adopted a policy for washing and drying of laundry. The Administrator or designee on or before 12/5/2024 re-educated staff to ensuring no damp laundry is left in washing machines overnight. The Administrator or designee will complete weekly audits using face-to-face interviews of up to 3 staff members to ensure damp laundry is not being left in washing machines overnight. Audits will be conducted until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

******************************** OAR 411-086-0260 Pharmaceutical Services Refer to F761 ******************************** OAR 411-086-0250 Dietary Services Refer to F812 ******************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ******************************** OAR 411-087-0230 Laundry Services Refer to F880 ********************************

Based on observation, interview, and record review it was determined the facility failed to protect a resident's right to be free from physical abuse by staff for 1 of 4 sampled resident (#1) reviewed for abuse. This placed residents at risk for physical abuse. Findings include. On 11/4/24, the State Survey Agency received a public complaint which alleged Resident 1 was treated roughly and slapped by a CNA. Resident 1 was admitted to the facility in 9/2024, with diagnoses including post-traumatic hydrocephalus (traumatic brain injury, TBI). A 9/18/24 Admission care plan indicated Resident 1 had left sided weakness, required substantial-total assist with bed mobility and spoke Spanish. A 9/19/24 Admission MDS indicated the resident had severe cognitive impairment. On 11/7/24 at 9:41 AM, Resident 1 was observed to be resting comfortably in bed with bolsters on each side of the bed, the bed was lowered, fall mats were in place, the bed was up against the wall, and the call light was within reach. The residents spouse was in the room. Resident 1 was sleeping off and on with no signs of distress. On 11/7/24 at 1:56 PM, Staff 5 (CNA) stated if he was aware a resident was being abused he would make sure the resident was safe and report it to the nurse. On 11/7/24 at 2:08 PM, Staff 7 (RN) stated if she was aware a resident was being abused she would make sure the resident was safe, alert the Administrator and file a report with the state. On 11/7/24 at 2:44 PM, Staff 8 (CNA) stated she always worked on the skilled side of the facility and enjoyed working double shifts from evenings to night shift. Staff 8 stated if residents were bed bound, she was able to turn residents by herself. Staff 8 stated she had never been rough with Resident 1, never caused physical abuse to Resident 1 and had never slapped Resident 1. On 11/8/24 at 1:17 PM, Staff 9 (CNA) assisted with Spanish translation. Staff 9 asked Resident 1 (in Spanish) if she/he felt safe at the facility. Resident 1 answered 'No' and when asked why, Resident 1 was unable to answer. Resident 1's demeanor was calm. On 11/12/24, the State Survey Agency received a public complaint. The anonymous complainant included video footage of Resident 1 and Staff 8 on 10/27/24. On 11/13/24 at 12:58 PM, Witness 3 (Client Care Surveyor, Interpreter) interviewed Resident 1 via phone with the surveyor in the room. Resident 1 stated she/he was aware there was a camera in the room. When Resident 1 was asked if any of the staff had been rough with her/him, Resident 1 started to cry and was upset. Resident 1 stated she/he did not feel safe in the facility. On 11/13/24 at 2:39 PM, Staff 8 (CNA) stated Resident 1 was a 'heavy turn' and stated most of the time she was able to turn Resident 1 in the bed by herself. Staff 8 stated she was not rough with the resident when she provided care and did not slap the resident. "God no I wouldn't slap a resident." Staff 8 was made aware Resident 1 had a camera in her/his room on the same day of her interview. On 11/13/24 at 2:39 PM, the video footage of Resident 1 taken on 10/27/24 at 2:13 AM was reviewed with Staff 8 (CNA). Staff 8 denied the CNA in the room was her. "I don't have a scrub top like that. I have never treated a patient like that. Look, that is not my hair!" The 10/27/24 staff schedule revealed Staff 8 (CNA) worked a double shift from evening shift to night shift. Staff 8 was assigned to Resident 1 in room 114. On 11/13/24 at 2:45 PM, the video was reviewed by the surveyor, Staff 1 (Administrator) and Staff 2 (DNS). Staff 1 and Staff 2 identified Resident 1 and Staff 8 (CNA) in the video. The video revealed Resident 1 in bed on 10/27/24 at 2:13 AM. Staff 8 was observed to forcefully and roughly push Resident 1's legs to the side in the bed while Staff 8 performed a linen change. Resident 1 can be heard saying, "No, no, no" and "Ai yai yai" (Spanish for "oh no" or "oh my god") while Staff 8 pushed Resident 1's legs side to side. At one point, Staff 8 used a slapping motion in the direction of Resident 1's face. The slap was heard on the audio. Staff 8 was then seen grabbing Resident 1's right hand and arm and pushing it away. On 11/13/24 at 2:49 PM, Staff 1 (Administrator), Staff 2 (DNS) and the state surveyor, reviewed facility video footage taken from the hallway on 10/27/24 between 2:00 AM and 2:30AM. Staff 8 (CNA) was observed to walk out of room 114 where Resident 1 resided. On 11/13/24 at 3:20 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Staff 8 (CNA) was rough, aggressive and made a 'slapping motion' at Resident 1. Staff 1 stated the care provided in the video by Staff 8 was not conducted according to the facility standards and expectations. Staff 8 was sent home.

1. Staff #8 was removed from the schedule on 11/13/2024. All current residents are at risk for this alleged deficient practice. 2. Administrator or designee on or before 11/19/2024 completed interviews of current residents to determine if any other residents had concerns of abuse. No additional concerns were identified. 3. The policies for abuse prevention, peri care, and repositioning were reviewed. Additionally, the Director of Nursing Services or designee on or before 11/21/2024 re-educated staff to the abuse prevention policy and procedure with emphasis on what to report, when to report and who to report to; signs of caregiver burnout and techniques for preventing burnout with emphasis on what to do when feeling frustrated; proper peri care technique with observation of care being completed and emphasis on what to do if a resident complains of pain during care and what to do if a resident refuses care; proper repositioning techniques with observation of repositioning being completed. 4. Director of Nursing Services or designee will complete weekly audits using face-to-face interviews and observations of up to 5 staff members to ensure that all staff are aware of the facility abuse prevention policy and procedure; are aware of the signs of caregiver burnout and techniques for preventing burnout; are using proper peri care technique and aware of what to do if a resident complains of pain during care and or a resident refuses care; and are using proper repositioning technique. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

**************************************************** 411-085-0360 - Abuse Refer to F600 *****************************************

Based on interview and record review it was determined the facility failed to treat a resident with dignity for 1 of 1 sampled resident (#47) reviewed for dignity. This placed residents at risk for lack of dignity and quality of life. Findings include: Resident 47 was admitted to the facility in 2023 with diagnoses including PTSD (Post-Traumatic Stress Disorder), anxiety disorder and depression. Resident 47's 6/11/23 Quarterly MDS indicated a moderately severe score for depression. Resident 47's 6/12/23 Care Plan for psychosocial well-being indicated staff were to involve the resident in all aspects of care to encourage resident empowerment. A Progress Note dated 7/18/23 indicated the resident complained of itching in her/his private genital area. A physician's order was received for the resident to be administered Diflucan (anti-fungal medication) orally one time a day for three days for the yeast infection. Resident 47's provider progress note dated 7/27/23 indicated Resident 47 continued to experience genital discomfort and itchiness. A physical exam was performed and the resident was ordered a cream for her/his genital area for symptoms of burning and itching. On 7/24/23 at 2:30 PM Resident 47 stated a couple of weeks ago Staff 16 (Social Service Director) came to her/his room and said staff reported that she/he was sexually aroused during peri-care (genital cleaning) which made the staff uncomfortable. Resident 47 reported she/he was not sexually aroused and was humiliated by this information and cried. On 7/28/23 at 9:50 AM Staff 28 (CNA) stated Resident 47 moaned during peri-care from the itching and pain. Staff 28 stated she was told by Staff 20 (LPN) the resident was changed from a one-person staff assist to a two-person staff assist due to reports about the resident being sexually aroused with cares. On 7/28/23 at 10:50 AM Staff 27 (CNA) stated she had a conversation with Resident 47 which occurred after the resident was changed from a one-person staff assist to a two-person staff assist to provide cares. The resident told her Staff 16 reported there was a staff complaint that the resident enjoyed peri-care in a sexual manner. Staff 27 reported the resident was upset and cried. On 7/28/23 at 11:47 AM Staff 16 stated she had a conversation with Resident 47 in 7/2023 about staff reports of feeling uncomfortable when providing the resident peri-care. Staff 16 told the resident staff reported her/his response to peri-care appeared to be sexual arousal. Staff 16 reported the resident was shocked and upset as a result of the conversation. On 7/28/23 at 1:48 PM Staff 17 (RNCM) stated two agency CNAs on evening shift reported being uncomfortable when providing peri-care to the resident as the resident made sounds like it was pleasurable. Staff 17 stated no other CNAs had concerns with providing peri-care to Resident 47. Staff 17 stated the resident was changed to a two-person assist for all cares due to the situation. A review of Resident 47's clinical record revealed no documentation to indicate the facility thoroughly investigated or took into consideration the resident's diagnosed condition. On 7/31/23 at 11:05 AM Staff 1 (Administrator) and Staff 2 (DNS) stated two agency staff from evening shift reported concerns regarding Resident 47's sexual response during peri-care. The situation was discussed in a morning meeting. Staff 16 discussed the concern with the resident and how it made staff uncomfortable. Staff 1 and Staff 2 reported Resident 47 did not previously demonstrat sexual behavior and they did not interview other staff to see if they had concerns regarding this behavior. Based on the concern expressed by the two agency staff the resident was changed from one-person staff assist to two-person staff assist for all cares. Staff 1 and Staff 2 indicated there was no follow-up or monitoring regarding the incident.

Resident #47s care plan has been updated after consideration of resident 47s change in condition to reflect resident 47s preference for one person assist with peri care. All current residents that staff express a concern for changes in response to personal cares being provided are at risk for this alleged deficient practice. Director of Nursing Services or designee on 8/19/2023 completed an audit of all current residents that receive peri care to ensure that their care plan reflects the appropriate number of care givers need for peri care. The policy for resident rights and the policy for dignity have been reviewed. Additionally, the Director of Nursing Services or designee on or before 9/19/2023 re-educated staff to treating each resident with respect and dignity, with emphasis on communicating about care. Director of Nursing Services or designee will complete weekly audits using face-to-face interviews of up to 5 current residents to ensure that residents are being communicated to with dignity and respect in regard to their care. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation and interview the facility failed to ensure residents were treated with respect for their personal possissions for 1 of 1 sampled resident (#56) reviewed for choices. This placed residents at risk for lack of respecting private belongings. Findings include: Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke. On 7/24/23 at 12:16 PM Resident 56 stated on multiple occasions she/he requested for staff to ask permission before they retrieved something from her/his nightstand. Resident 56 stated staff continued to retrieve items from her/his nightstand without asking and this was very "upsetting because it's my private stuff!" Resident 56 was observed to be anxious and tearful when she/he expressed the concern. The night stand had the top drawer opened approximately four inches and the resident's personal items were visible inside the drawer. On 7/27/23 at 10:31 AM Staff 21 (LPN) stated Resident 56 had concerns regarding staff opening and grabbing things out of her/his nightstand without asking. Staff 21 stated the resident was upset because of her/his personal papers and own private items in the nightstand. Staff 21 stated this was an ongoing issue "mostly" with agency staff but all staff were expected to ask permission before getting into Resident 56's nightstand. On 7/27/23 at 11:37 AM Staff 19 (CNA) stated Resident 56 had ongoing concerns with staff not asking permission prior to getting into her/his nightstand and was "very upset" and "tearful." Staff 19 stated all staff were expected to ask permission before just "grabbing" items out of Resident 56's nightstand. On 7/28/23 at 2:03 PM Staff 17 (RNCM) stated she was unaware Resident 56 had concerns regarding staff getting into her/his nightstand without permission. Staff 17 stated she expected staff to ask permission prior to accessing items in Resident 56's nightstand.

Resident #56s care plan has been updated to reflect staff to request before opening his/her belongings. All current residents with personal property are at risk for this alleged deficient practice. The Administrator or designee on 8/21/2023 - 8/22/2023 completed an audit of current residents using face-to-face interviews to determine if residents felt their personal property was being respected by staff. Any resident who stated a concern had their care plan updated to reflect their preferences. The Administrator or designee on or before 9/19/2023 re-educated staff to residents rights to personal property, with emphasis on respecting residents right to privacy. The Administrator or designee will complete weekly audits using face-to-face interviews of up to five current residents to ensure residents' rights to personal property are being upheld. Any concerns identified will be investigated thoroughly with proper follow-up action. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, interview, and record review it was determined the facility failed to honor resident dining room choices and preferences for 3 of 3 sampled residents (#s 22, 37 and 50) reviewed for honoring choices. This placed residents at risk for increased isolation, lack of socialization and lack of self-determination. Findings include: Review of Resident Council Minutes revealed the following: 4/19/22: -Residents aired their concerns about D Hall Pantry/Dining Room closing and having to eat in the main dining room. -Too far for CNAs to travel, if something was forgotten on the meal tray. -Meals were delivered late. -Too much was expected from the CNAs so they were unable to do their job well. -Main dining room was loud, socializing was difficult, not a nice place to enjoy a meal and with so much going on and so many people crammed into a small space. -Resident 22 wrote concerns regarding the D Hall Pantry/Dining Room which revealed the following: -There is a sign in the front that states "Residents Do Not Live in Our Facility. We Work in Their Home." -Lately residents felt we had been invaded in our home and lost control of our care. -We were never asked for our opinion regarding our wants or needs. -Meals were delivered and CNAs did not stay long enough to make sure the meals were correct or hot. If anything was wrong it took 10 or 15 minutes before the concern was corrected and the meals were cold because of the extra time it took to pass out meal trays. The response/resolution from Staff 1 (Administrator) requested the residents to give the new dining situation a chance. In regards to meals delivared to resident's, CNAs were instructed to delivar a meal tray to whatever meal tray came up in the kitchen regardless of what hall the residents were on. 5/17/23: Resident Council was canceled due to Norovirus (a contagious virus that causes vomiting and diarrhea) outbreak. 6/28/23 and 7/19/23: Dining hours were 8:00 AM to 9:00 AM breakfast, 12:00 PM to 1:00 PM lunch and 5:00 PM to 6:00 PM dinner. -Residents stated meals were not delivered to their rooms until after hours. -Food was still periodically served cold on hot plates. -Inconsistent portions being served. -CNAs put residents to bed prior to meals being delivered. There was no indication or documentation the concerns related to dining from 6/2023 through 7/2023 were addressed or any follow up conversations regarding how residents were feeling regarding the closure of the D Hall Pantry/Dining Room. On 7/27/23 at 12:50 PM Staff 27 (CNA), at 1:00 PM Staff 32 (CNA) and at 3:15 PM Staff 17 (RNCM) all stated the residents who lived on the D Hall enjoyed the togetherness by having meals in the D Hall Dining room. One resident was so upset she/he cried as the resident did not want to go to the main dining room. Family members were also upset the D Hall Dining room was closed as they spent time with their family members and socialized with other residents in the D Hall Dining room during meals. On 7/27/23 at 2:35 PM Staff 33 (Activity Director) stated several residents were upset at the 4/19/23 Resident Council meeting and voiced their concerns after being informed the D Hall Dining room was being closed. Residents stated CNAs went a long distance to pick up their meal trays, drinks, and anything else that was forgotten in the main dining room. This resulted in longer call lights during meals and took time away from the residents. Management's response to the residents' concerns was to give the new dining situation a chance. The Sun Rise Room (a smaller room near the main dining room) was opened, but the residents from D Hall did not go because it was too far from their rooms. a. Resident 50 admitted to the facility in 9/2022 with diagnoses including Guillain-Barre syndrome (body's immune system attacks the nerves) and osteoarthritis. A Dallas Retirement Village Concern and Grievance Form Dated 4/10/23 from Resident 50 revealed the following concerns: -The D Hall Dining room was closed and moved to the main dining room so more residents would come out of their rooms and socialize. Where are they? -Resident 50 preferred to eat breakfast in her/his room and most of the time the meal was lukewarm. -During lunch and dinner in the main dining area the TV, music and noise from the kitchen was overwhelming and communication was almost impossible. -One of the first days in the main dining another resident was crying and when asked why she/he was crying she/he stated, "I don't eat here", change for some people was really hard without notification. -A few days in the main dining and multiple residents were not being attended too appropriately. -There was more care and easier communication with the small dining room than in the main dining. -Resident 50 ate her/his lunch as fast as possible because of the noise level and lack of socialization. The Summary of Findings/Action taken/Conclusion: Staff 16 (Social Service Director) spoke with Resident 50 about other dining options moving forward and explained the reason for the closure. The facility opened up a new dining room (the Sun Rise Room) and notified residents and invited the residents down for meals. On 7/24/23 at 11:50 AM Resident 50 stated since the facility closed the D Hall Dining the food was not always hot, but cold and the closure of the D Hall Dining area was "very upsetting" to her/him. Resident 50 stated staff had to go to the main dining/kitchen to warm-up food when her/his food was cold because staff no longer had access to a microwave. Resident 50 stated the main dining was too loud and hard to socialize with others and the "new" dining spot opened up was on the other side of the building. On 7/26/23 at 11:38 AM Staff 21 (CNA) and at 10:15 AM Staff 27 (CNA) both stated residents were "very upset" about the closure of the D Hall Dining and meals delivered to the D Hall were "often" cold even on a plate warmer because of the distance staff traveled to deliver meals. Staff 21 and Staff 27 stated if they needed to warm up a cold meal they returned to the main dining area to use the microwave because there was no longer one on the D Hall. Staff 27 stated a meeting was held regarding the closure of the D Hall Dining for family and residents but was just to "inform" them of the decision. On 7/27/23 at 10:31 AM Staff 20 (LPN) stated Resident 50 and other residents were upset regarding the closure of the D Hall Dining. Staff 20 stated meals were delivered to each residents' room "one at a time" from the kitchen for those residents who stayed in their rooms or did not care to go to the main dining for meals. Staff 20 further stated D Hall was the farthest from the kitchen and once meals were delivered to residents in their rooms they were "often" cold. Staff 20 further stated if residents requested staff to reheat the food it took a while because there was no microwave on the D Hall unit and this was an "ongoing issue." , b. Resident 22 admitted to the facility in 11/2018 with diagnoses including Parkinson's disease and depression. On 7/25/23 at 10:16 AM Resident 22 and Witness 4 (Family Member) expressed their frustrations since the D Hall Dining room closed. Resident 22 stated she/he and her/his neighbors were upset as several of them ate and socialized together in the D Hall Dining room. Resident 22 stated she/he was not given a straight answer as to why the D Hall Dining was closed. She/he was told the residents had to eat in the main dining room or their rooms. The facility eventually opened a new dining room (the Sun Rise Room) and invited residents. Resident 22 stated the Sun Rise Room was on the other side of the building and she/he did not want to go that far and remained in her/his room to eat all meals. Witness 4 stated several residents who went to the D Hall Dining room now ate all meals in their rooms. Resident 22 experienced cold food by the time the meal tray arrived. The D Hall Dining room had a microwave for staff to reheat cold food but it was no longer was available. Staff now walked to the main dining room to retrieve tea/coffee. Resident 22 worried the extra time it took staff to walk back and forth took time away from other residents who needed help. Resident 22 further stated she/he attended Resident Council meetings and brought concerns regarding the closure of the D Hall Dining. Resident 22 stated management did not address her/his concerns and she/he missed going to the D Hall Dining room. c. Resident 37 admitted to the facility in 1/2019 with diagnoses including diabetes. On 7/31/23 at 9:52 AM Resident 37 stated when the D Hall Dining room closed, staff had to bring down each meal tray from the main dining to residents room. Resident 37 stated the soup on her/his meal tray was cold daily. She/he asked staff to heat up the cold soup, but not anymore because, "it's not fair to the CNAs to have to walk all the way down there to the main dining room when they are already so busy taking care of us residents." Resident 37 was not made aware when the D Hall Dining room was closed. She/he verbalized concerns to the CNAs and nurses and was frustrated management did not do anything. Observations of the 7/27/23 lunch meal for the D Hall revealed multiple residents eating in their rooms. Staff had to carry each residents' meal tray individually to the residents' rooms. The first tray was delivered at 12:21 PM and the last tray was delivered at 12:53 PM. This took staff a total of 32 minutes. There were a total of 10 trays delivered to residents' in their rooms. Staff had to walk approximately 280 feet back and forth from the main dining room to residents room, every time they had to deliver a meal tray. On 7/27/23 at 1:09 PM Staff 1 (Administrator) stated D Hall Dining was closed back in 5/2023 because only five residents utilized the services. Staff 1 stated they opened up the "Sunrise Room" which had plenty of space for residents and family. Staff 1 stated residents and family were not happy regarding the closure at first and had to "work out the kinks which took a few months." When asked about accommodation of needs or honoring resident choices Staff 1 indicated she encouraged residents and family to give the new process time. Staff 1 stated she was unaware of ongoing complaints regarding D Hall Dining being closed and had not attended resident council but relied on staff to report concerns regarding D Hall Dining concerns.

Resident #50 was offered and accepted an alternate dining venue. Resident #22s preference is to continue dining in their room. Resident #37 not identified on the resident sample list. The Administrator or designee on 8/21/2023 - 8/22/2023 completed an audit of current residents using face-to-face interviews to ensure current D wing residents dining venue preferences are being honored. Any resident with a change in dining venue preference had their care plan updated. The Administrator or designee on or before 9/19/2023 re-educated the Interdisciplinary Team to residents right to self-determination, with emphasis on honoring residents dining venue preferences. The Administrator or designee will complete weekly audits using face-to-face interviews of up to 5 D Wing residents to ensure their dining venue preferences are being honored. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to obtain copies of Advance Directive for 1 of 4 sampled residents (#5) reviewed for Advance Directives. This placed residents at risk for lack of end of life choices being honored. Findings include: Resident 5 was admitted to the facility in 2023 with diagnoses including UTI and muscle weakness. Resident 5's 5/23/23 Admission MDS indicated she/he was cognitively intact. Resident 5's 5/23/23 Health Center Admission Agreement indicated the resident had an Advance Directive. Resident 5's 6/6/23 Care Conference Note indicated the resident's Advance Directive was not reviewed. Resident 5's clinical record revealed there was no copy of her/his Advance Directive. On 7/26/23 at 11:00 AM Staff 16 (Social Service Director) stated upon admission residents were asked if they had an Advance Directive and if so to provide a copy. Staff 16 stated if a copy of the resident Advance Directive was not provided on admission, her process was to follow-up within a few days to obtain a copy. Staff 16 stated she did not follow-up with Resident 5 to obtain a copy of her/his Advance Directive.

Resident #5 has discharged from the facility. All residents are at risk for the alleged deficient practice of not having their completed advance directive available to the facility upon admission. The Administrator or designee on 8/21/2023 - 8/22/2023 completed an audit of current resident records to identify resident records not containing an advance directive. Any resident identified to not have an advance directive was asked if they would like to provide an advance directive to the facility. The Administrator or designee on or before 9/19/2023 re-educated the Interdisciplinary Team to obtaining advance directives timely. The Social Worker or designee will complete daily, weekday audits to ensure newly admitted residents with advance directives have the appropriate documentation included in their resident record. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Social Worker or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of Advance Beneficiary Notification (ABN) for 1 of 4 sampled residents (#98) reviewed for discharge. This placed residents at risk for financial hardship. Findings include: Resident 98 admitted to the facility with Medicare Part A services on 5/30/23. The resident's last covered day of Medicare Part A services was 7/7/23. A 7/5/23 progress note indicated Staff 22 (Social Services Assistant) provided a NOMNC (Notification of Medicare Non-Coverage) to Resident 98 and the resident was informed if she/he did not discharge by midnight on 7/8/23 she/he would be charged $455 a day. There was no evidence in the clinical record to indicate a written Advanced Beneficiary Notification (ABN) was provided to explain the financial responsibilities for Resident 98 . On 7/28/23 at 9:51 AM and 12:30 PM Staff 22 stated she provided Resident 98 with the NOMNC and verbally explained the daily cost rate if the resident were to remain in the facility. Staff 22 stated if an ABN was provided then it would have been uploaded the same day in the medical record. Staff 22 acknowledged she did not provide an ABN to Resident 98. Refer to F660

Resident #98 has discharged from the facility. All residents that admit under Medicare A funded stays are at risk of this alleged deficient practice. The Administrator or designee completed an audit of residents with Medicare A stays ending on 6/30/2023 - 8/18/2023 which required an Advance Beneficiary Notice (ABN) to be issued. All additional residents identified as requiring an ABN received an ABN timely. The Administrator or designee on or before 9/19/2023 re-educated social workers to the importance of issuing financial liability notification documentation timely. The Administrator or designee will complete daily, weekday audits of residents with Medicare A stays ending to ensure that all Medicare A residents are receiving proper advanced notice of non-covered charges related to a continued stay in the facility. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation and interview it was determined the facility failed to maintain and provide a clean homelike environment for 4 of 6 halls reviewed for environment. This placed residents at risk for living in an unclean and an unhomelike environment. Findings include: On 7/24/23 and 7/28/23 the following observations were made: -Room 103: Had a dark black stain which measured approximately one foot by one and a half feet across and adjacent to the stain was another black stain which measured approximately six inches by one foot across. -Room 104: Had a dark black stain which measured approximately seven inches by 19.5 inches across, adjacent to that was two smaller black spots the size of approximately two silver dollars. -Room 105: Had a dark black stain which measured approximately one foot four inches by six inches wide. -Room 204: Had huge gouges in the wall behind the recliner with sheet rock exposed. The wall heater was partially disconnected from the wall and had a broken plastic vent. -Room 221: The pads on the wheelchair arm rests and wheelchair were covered with dried orange food substance. -The carpets near the D hall dining room had multiple scattered black stains in/down the hallway. -Room 159: Had a large dark black stain on the carpet. -The day room at the end of D hall had several scattered black stains on the carpet. On 7/28/23 at 2:00 PM Staff 23 (Maintenance Director) made observations of the identified rooms and acknowledged the multiple stained carpets, broken wall heater and the unclean wheelchair.

Rooms 103, 104, 105, 159 carpets have been cleaned. Room 204 wall and the wall heater unit have been repaired. Room 221s wheelchair has been cleaned. The carpets near the dining hall and the day room on D wing have been cleaned. All resident wheelchairs, walls in rooms near where furniture is used, and carpets are at risk for the potential alleged deficient practice of appearing to live in an unclean and unhomelike environment. The Administrator, Director of Nursing Services, Environmental Services Director, Maintenance Director and/or their designees on 8/24/23 completed an audit using visual observations of all current resident rooms and gathering spaces to ensure that rooms have a clean, home like appearance. Any identified areas of concern have been documented and scheduled for repair. The Administrator or designee on or before 9/19/2023 re-educated the Interdisciplinary Team to the importance of maintaining a clean, homelike environment and how to submit work request orders via facility system. The Interdisciplinary Team will complete weekly audits of up to 25% of resident rooms and wheelchairs, as well as all common areas. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to ensure a resident grievance was addressed for 1 of 2 sampled residents (#76) reviewed for personal property. This placed residents at risk for unresolved concerns and loss of personal property. Findings include: Resident 76 was admitted in 6/2023 with diagnoses including cancer. On 7/24/23 at 10:23 AM Resident 76 stated she/he was missing a crocheted bed spread and a green night gown for over a month. Resident 76 stated she/he reported the missing items and staff did not follow up. The 7/17/23 grievance form filled out by Resident 76's family member indicated the resident was missing a crocheted blanket (missing for two months) and a green night gown (missing for one month). The bottom of the grievance was not completed and there was no indication there was a resolution to the grievance as of 7/27/23. On 7/27/23 at 1:33 PM Staff 16 (Social Service Director) acknowledged Resident 76's 7/17/23 grievance indicated the crocheted blanket and night gown were missing for one or two months. Staff 16 stated the facility policy was to respond to grievances within seven days and there was no resolution to the grievance as of 7/27/23.

Resident #76s grievance has been satisfactorily resolved. All residents with grievance are at risk for this alleged deficient practice. The Administrator or designee on 8/23/2023 completed an audit of the grievance log. Resolutions for current open grievances have been identified by the Administrator or designee and communicated to the resident. The Administrator or designee on or before 9/19/2023 re-educated the Interdisciplinary Team to the facility grievance policy and procedure, with emphasis on identifying, documenting and communicating resolutions timely. The Administrator or designee will complete daily, weekday audits of the grievance log to ensure that grievances receive timely resolution and resolutions are communicated to the resident and/or resident representative. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to safe, resident-centered discharges for 2 of 4 sampled residents (#s 5 and 98) reviewed for discharge. This placed residents at risk for unmet care needs after discharge. Findings include: 1. Resident 98 admitted to the facility on 5/30/23 and discharged on 7/8/23 with diagnoses including respiratory failure and fibromyalgia (widespread muscle pain). A concern was reported to the State Agency on 7/11/23 which indicated Resident 98 was approved to stay at the facility under Medicaid after her/his skilled days ended. Facility staff informed Resident 98 if she/he did not discharge by 7/8/23 she/he would be charged $500 a day. Resident 98 discharged home on 7/8/23. Resident 98 was referred to a home health agency which she/he requested to not use. Review of progress notes revealed the following: -6/12/23 Resident 98 informed Staff 16 (Social Services Director) that she/he was unsure if she/he was ready to discharge home and needed more time to work on her/his "goals." Resident 98 indicated she/he did not want to live at the facility "forever" but wanted to stay until she/he was ready to discharge home. -6/27/23 Resident 98 was in the process of looking into long term placement at the facility and Social Services was working with her/his case worker. -7/5/23 Staff 22 (Social Services Assistant) provided Resident 98 with a NOMNC (Notification of Medicare Non-Coverage). Resident 98 wanted to file an appeal and was informed if she/he lost the appeal then she/he would be "expected" to discharge on 7/8/23 to "avoid any out of pocket costs to the facility." If Resident 98 did not discharge by midnight on 7/8/23 she/he would have to pay $455 a day. "At this time, [the resident] discharge plan is to go home." Resident 98 also requested a different home health provider than she/he previously had. On 6/29/23 Staff 30 (Medical Records) received an email indicating Resident 98 was approved for ICF (long-term level of care) under Medicaid. Review of therapy discharge notes indicated the following: -7/7/23 PT summary indicated discharge home was not recommended due to no supervision during the day and multiple balance issues during transfers and "falling" into the chair. -7/7/23 OT summary indicated a safety concern for discharge to independent home was noted but [resident] felt she/he was unable to "financially manage." A 7/8/23 discharge summary indicated Resident 98 admitted to the facility for therapy services. Resident 98 was identified to be cognitively intact. Resident was noted to be impulsive with poor safety awareness resulting in several non-injury falls in the facility. Resident 98 discharged home with home health orders. On 7/25/23 at 10:09 AM Witness 1 (Case Manager) stated Resident 98 wanted to remain in the facility and was approved to remain in the facility ICF. Witness 1 stated Social Services was aware as an approval notice was sent via email on 6/29/23. Witness 1 stated the resident was told she/he would have to pay $500 a day if she/he stayed at the facility past her/his skilled days. Witness 1 stated Resident 98 would not have to pay out of pocket because the resident was covered under Medicaid. On 7/27/23 at 12:39 PM Resident 98 stated she/he wanted to remain in the facility longer. Resident 98 stated she/he was going to appeal the NOMNC but was told she/he would have to pay per day if she/he lost the appeal and stayed past Saturday (7/8/23). Resident 98 stated the facility did not inform her/him that she/he was approved to stay at the facility ICF under Medicaid. Resident 98 further stated she/he told Social Services that she/he did not want the same home health agency as before and was "disappointed" when the same home health agency was sent. Resident 98 stated it took home health two weeks to see her/him and no bath aide showed up. On 7/28/23 at 9:32 AM Staff 30 stated she received an email indicating Resident 98 was approved for ICF on 6/29/23. Staff 30 stated the email was forwarded to Staff 16 on 7/1/23. On 7/28/23 at 9:51 AM Staff 22 stated she assisted with Resident 98's discharge. Staff 22 stated Staff 16 usually reached out the Medicaid office to determine if a resident was on Medicaid. Staff 22 stated she did not believe Resident 98 was on Medicaid. Staff 22 stated Resident 98 needed to pay privately if she/he stayed past 7/8/23. Staff 22 stated the resident did not want to pay as she/he indicated she/he could not afford the $455 daily rate. Staff 22 stated she and Staff 16 talked with Resident 98's case manager but were not sure if she/he was approved for ICF and had to pay anything towards her/his stay. Staff 22 stated she was not aware Resident 98 was approved to stay at the facility ICF under Medicaid as of 6/29/23. Staff 22 further stated there were several options for home health agencies and Resident 98 indicated she/he did not want the same home health agency she/he had previously. Staff 22 stated she "made sure" Resident 98 was not referred to the same home health agency. On 7/28/23 at 10:50 AM Staff 16 stated Resident 98 admitted to the facility with skilled services and discharged home with home health. Staff 16 stated she was in contact with Witness 1 and stated on 6/22/23 she requested information on the resident's ICF approval status. Staff 16 stated on 6/28/23 she reached out to Witness 1 to find out if Resident 98 was going to have an out of pocket cost to remain at the facility. Staff 16 stated Witness 1 emailed her on 6/29/23 informing her Resident 98 was approved for ICF under Medicaid. Staff 16 stated she responded back to Witness 1 on 6/29/23 to get an estimate of the resident's cost to stay at the facility but did not get a response back. Staff 16 stated she did not follow up with Witness 1 after 6/29/23. Staff 16 stated she did not know if Staff 22 was aware Resident 98 was approved for ICF. Staff 16 stated the 7/5/23 progress note was a template and the daily rate of $455 given to Resident 98 was the standard rate and the resident would have been told the information regardless. Staff 16 acknowledged she was responsible for Resident 98's discharge and the information provided to her/him. Staff 16 further stated she was aware Resident 98 did not want the same home health agency as she/he previously had but talked to the resident about using the same agency because they were already aware of her/him and could see the resident right away. Staff 16 acknowledged she referred Resident 98 to the same home health agency she/he requested not to have. , 2. Resident 5 was admitted to the facility in 2023 with diagnoses including UTI and muscle weakness. Resident 5's 5/22/23 Care Plan for discharge planning indicated a referral for durable medical equipment was to be ordered for discharge. The Care Plan indicated to follow-up with the physician to obtain orders for discharge including durable medical equipment. Resident 5's Discharge Summary dated 6/23/23 indicated a referral was made for durable medical equipment for discharge. Resident 5's clinical record revealed she/he was discharged from the facility on 6/23/23 to a family member's home. On 7/27/23 at 10:00 AM Staff 16 (Social Service Director) stated when Resident 5 was discharged from the facility on 6/23/23 the resident required a hospital bed and she made a referral for the bed to be delivered to the resident's home. Staff 16 stated the request for the hospital bed was denied for lack of documentation from the physician about the resident's need for the hospital bed and the bed was not delivered to the resident's home. On 7/27/23 at 10:15 AM Staff 25 (LPN) stated Resident 5 needed a hospital bed for discharge. On 7/31/23 at 8:04 AM Staff 7 (Physical Therapist/Director of Rehabilitation) stated during a weekly Utilization Meeting the resident's discharge needs were discussed and stated Resident 5 would have benefited from the use of a hospital bed. On 7/31/23 at 11:00 AM Staff 2 (DNS) stated her expectation was for any necessary medical equipment to be delivered to the resident's place of discharge prior to the resident being discharged. Staff 2 stated the facility did not have a physician's order for Resident 5's hospital bed on discharge. This is a repeat citation and was previously cited from the 5/1/23 complaint survey.

Resident #5 and #98 have been discharged from the facility. All residents that discharge from the facility to home are at risk of this alleged deficient practice. The Administrator or designee on 8/22/2023 completed an audit using telephone calls to all residents discharged from the facility on 6/30/2023 - 8/19/2023 to ensure home health services met the residents preferences and that all necessary durable medical equipment had been received. Additionally, the Administrator or designee on 8/22/2023 completed an audit using resident record review to ensure all residents eligible for Medicaid long term care were transferred to appropriate setting. The Administrator or designee on or before 9/19/2023 re-educated social workers to the discharge planning process, with emphasis on ensuring residents eligible for Medicaid long term care are transferred to the appropriate setting, resident preferences for home health services are honored, proper documentation is in place for residents to received necessary durable medical equipment. The Administrator or designee will complete daily, weekday audits of discharges to ensure residents eligible for Medicaid long term care are transferred to the appropriate setting, resident preferences for home health services are honored and proper documentation is in place for residents to received necessary durable medical equipment. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 4 sampled residents (#89) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 89 was admitted to the facility in 6/2023 with diagnoses including stroke. The resident discharged home on 7/17/23 on a resident initiated discharge. A review of Resident 89's medical record indicated there was no discharge summary documentation. On 7/31/23 at 11:13 AM Staff 2 (DNS) was not able to provide documentation of a discharge summary for Resident 89.

Resident #89 indicates that he/she did receive discharge instructions from the facility. All discharging residents are at risk for this alleged deficient practice of not providing discharge instructions. The Director of Nursing Services or designee on 8/21/2023 completed an audit of all residents discharged from the facility between 6/30/2023 - 8/19/2023 to ensure a discharge summary was provided to each resident. Resident records identified as not containing a discharge summary were provided with a discharge summary. The Director of Nursing Services or designee on or before 9/19/2023 re-educated licensed nurses to completing and provided a discharge summary for every resident discharging from the facility and ensuring a copy is maintained in the resident record. The Director of Nursing Services or designee will complete daily, weekday audits of discharges to ensure that all residents discharging from the facility are provided with a discharge summary. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, interview and record review it was determined the facility failed to follow physician orders and implement bowel care for 2 of 2 sampled residents (#s 24 and 249) reviewed for choices and constipation. This placed residents at risk for increased pain. Findings include: 1. Resident 24 admitted to the facility in 2015 with diagnoses including constipation. The 7/20/23 care plan indicated Resident 24 required extensive assistance for toileting. The 6/14/23 physician orders indicated Resident 24 was to receive the following: -Fiber-Stat liquid give 30 ml PO every 12 hours PRN constipation. -Milk of Magnesia (MOM) 400 mg/5 ml give 30 ml PO PRN constipation once daily. -bisacodyl suppository 10 mg insert one suppository rectally PRN for constipation once daily. Resident 24's 6/2023 and 7/2023 bowel records revealed the following days with no bowel movements: -7/3/23; 7/4/23; 7/5/23; 7/6/23 and 7/7/23 (five days). -7/9/23; 7/10/23; 7/11/23; 7/12/23; 7/13/23 and 7/14/23 (six days). There was no indication Resident 24 received or refused the ordered bowel medications on the identified dates. On 7/24/23 at 11:53 AM and 7/31/23 at 10:21 AM Staff 24 (LPN) reviewed the identified dates with no bowel movement and stated Resident 24 "sometimes goes a few days without having a bowel movement." Staff 24 stated if the resident did not have bowel movement for 72 hours staff were to offer Fiber Stat on day shift, MOM on swing shift and a suppository on night shift. Staff 24 further stated the resident's bowel medications were PRN and nursing staff did not document refusals. On 7/31/23 at 11:11 AM Staff 2 (DNS) acknowledged Resident 24 did not have bowel movements on the identified dates or documented refusals of bowel care. Staff 2 stated the expectation was after 72 hours of no bowel movement staff were to give fiber stat as ordered on day shift, MOM on evening shift and suppository on night shift. , 2. Resident 249 admitted to the facility in 7/2023 with diagnoses including a cervical fracture. A 7/17/23 signed physician order indicated Resident 249 was to maintain an [Aspen] cervical neck collar at all times for spinal precautions. An undated In Room Care Plan revealed Resident 249's head of the bed was to be at 30 degrees at all times and the resident was to have her/his "Aspen neck collar on at all times." On 7/25/23 at 2:53 PM Resident 249 was observed in bed with a cervical neck collar on. Resident 249 stated she/he was provided a bed bath on 7/19/23 and a CNA staff removed her/his cervical neck brace, which was not to be removed. Resident 249 stated she/he reported the incident to nursing staff because of increased pain "deeper pain than before." Resident 249 stated staff wanted to send her/him to the hospital but she/he refused and was administered pain medication to alleviate the pain. On 7/26/23 at 2:55 PM Staff 6 (CNA) stated she provided Resident 249 a bed bath on 7/19/23 and took the neck brace off to remove her/his shirt and put the neck brace on once she completed the bed bath. Staff 6 stated she did not review the In Room Care Plan and was not sure if Resident 249 had a "temporary" care plan in her/his room and was not sure if the neck brace was to be removed or not. On 7/26/23 at 6:03 PM Staff 5 (Agency/RN) stated Resident 249 had a neck brace on and the neck brace was not to be removed per physician orders. Staff 5 stated Resident 249 reported she/he was provided a bed bath and Staff 6 removed her/his neck brace and experienced excruciating pain. Staff 5 spoke to the physician and was told to send Resident 249 out to the hospital but the resident refused. Staff 5 stated she/he was administered pain medication to alleviate her/his discomfort. On 7/27/23 at 4:11 PM Staff 4 (Agency/RN) stated she was aware Resident 249's cervical neck brace was removed during a bed bath. Staff 4 stated she expected staff to follow physician orders and all staff were to review the In Room Care Plan prior to assisting residents. Staff 4 stated Resident 249 was administered pain medication to help alleviate her/his pain. On 7/31/23 at 10:21 AM Staff 2 (DNS) stated Resident 249's neck brace was not to be removed and she expected staff to implement and follow physician orders. Staff 2 further stated staff were expected to review care plans prior to providing residents care.

Resident #24s care plan has been updated to reflect his/her frequent refusal of bowel care medication. Resident #249s care plan was reviewed and reflects to not remove aspen collar. All residents are at risk for this alleged deficient practice of not following orders for bowel care and device removal. The Director of Nursing Services or designee on 8/22/2023 completed an audit of all current residents potential for prn bowel care medication needs. Additionally, the Director of Nursing Services or designee on 8/22/2023 completed an audit of all current residents with medical devices (braces, slings, etc.) for orders for use/removal. Resident care plans were updated as needed to reflect resident status/needs/choices. The policy and procedure for bowel care documentation was reviewed and updated to include refusal of medications. Additionally, the Director of Nursing services on or before 9/19/2023 re-educated all licensed nurses to the facility bowel care policy and procedure, removal of medical devices without provider orders and importance of following physician orders. The Director of Nursing Services or designee will complete daily, weekday audits of bowel care medication administration records to ensure all documentation is completed indicating given or refused. Additionally, the Director of Nursing Services or designee will complete daily, weekday audits of all medical devices for orders for use/removal upon admit or as needed when put into place by a provider, as well as observe use of up to 5 devices to determine compliance with orders. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, interview and record review it was determined the facility failed to ensure treatment and services to maintain vision abilities were provided for 1 of 1 sampled resident (#56) reviewed for vision. This placed residents at risk for impaired vision. Findings include: Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke. On 7/24/23 at 12:32 PM Resident 56 was observed wearing glasses and the right side of the glasses was wrapped in blue string to hold them together. Resident 56 stated she/he wore glasses all the time in order to see and the glasses were broken for greater than a month and staff were aware. Resident 56 stated first staff tried to glue the right side of the glasses together and then used "string" to fix the glasses. No evidence was found in the clinical record regarding Resident 56's broken glasses or any indication vision services were initiated or new glasses were ordered. On 7/26/23 at 11:28 AM Staff 21 (CNA) stated Resident 56 wore glasses all the time in order to see and her/his glasses were broken "three" different times and were broken greater than a month. Staff 21 stated someone used the "blue string" to hold the glasses together and she reported her concern to Staff 16 (Social Service Director) but nothing was done. On 7/27/23 at 10:31 AM Staff 20 (LPN) stated she was aware Resident 56 wore glasses and they were broken for roughly two months. Staff 21 stated she informed Staff 16 regarding the broken glasses. On 7/27/23 at 11:37 AM Staff 19 (CNA) stated Resident 56's glasses were broken for roughly two months and she used the "blue string" to hold the glasses together. When asked who she reported concerns to Staff 19 stated she reported the concern to the charge nurse and Staff 16. On 7/28/23 at 12:20 PM Staff 16 stated she was unaware of Resident 56's broken glasses and staff were expected to report these concerns to her. On 7/31/23 at 10:26 AM Staff 2 (DNS) acknowledged Resident 56's glasses were broken and staff were expected to verbally report concerns but could complete a grievance regarding the broken glasses which was addressed by Staff 16.

Resident #56 on 8/1/2023 was seen and evaluated by vision services. Resident #56 was offered to have his/her glasses replaced. Resident #56 refused new glasses stating he/she was happy with his/her current glasses. Director of Nursing Services or designee on 8/21/2023 - 8/22/2023 completed an audit of all current residents to determine need for vision services. Any resident requiring vision services had a follow-up appointment scheduled. Director of Nursing or designee on or before 9/19/2023 re-educated staff to the facility procedure for requesting vision services for residents as well as the importance of reporting needs in a timely manner. Director of Nursing Services or designee will complete weekly audits of current residents to determine if vision services are needed. Any residents identified as needing vision services will have a follow-up appointment scheduled. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, record review and interview it was determined the facility failed to ensure oxygen equipment was properly maintained for 1 of 2 sampled residents (#32) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 32 was admitted to the facility in 9/2019 with diagnoses including COPD (chronic obstructive pulmonary disease). Multiple observations from 7/25/23 through 7/28/23 revealed Resident 32 used a high-flow oxygen concentrator (oxygen supply system delivering 100% humidified and heated oxygen) through a nasal cannula (lightweight tubing with two prongs placed in nostrils). Resident 32's physician orders dated 6/9/23 indicated: -to use oxygen as needed via the nasal cannula to keep oxygen level at 90%. -change humidification bottle and tubing on concentrator every three days on night shift and date the bottle and tubing when done. -change the tubing and cannula every week on Sunday night shift. Date the tubing when changed. -clean the exterior of the concentrator once a week on Sunday night shift. -exchange external filter on the concentrator with a clean filter. Clean dirty filter with warm soapy water, rinse well and allow filter to dry completely, then store for next exchange every week on Sunday night shift. The 7/2023 TAR indicated on 7/23/23 the exchange of external filter on concentrator was completed by the night shift nurse. Observations from 7/25/23 through 7/28/23 revealed the external filter on the concentrator had a layer of dust when touched with a finger and left a noticeable mark. The concentrator machine also had a build up of noticeable dust. On 7/26/23 at 1:39 PM Staff 20 (LPN) and 7/27/23 at 9:55 AM Staff 17 (RNCM) both stated the night shift nurses were responsible for cleaning Resident 32's oxygen concentrator. On 7/28/23 at 11:02 AM Staff 2 (DNS) observed and acknowledged the external filter and concentrator had a build up of dust and the filter was not clean.

Resident #32s concentrator and exterior filter were cleaned on 07/28/23. All residents with oxygen needs that utilize a concentrator are at risk for this alleged deficient practice. Director of Nursing Services or designee on 7/28/2023 completed an audit of all current residents that utilize oxygen concentrators using observations to ensure cleanliness of oxygen concentrators and the exterior filter. Concentrators and filters were cleaned or exchanged as needed. Director of Nursing Services or designee on 08/10/23 reviewed facility oxygen policy and updated policy to include concentrator procedures. Additionally, Director of Nursing or designee on or before 9/19/2023 re-educated licensed nursing staff to facility oxygen policy with emphasis on the care of the concentrator. Director of Nursing Services or designee will complete weekly audits using observations of concentrators and filters to ensure cleanliness. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to ensure residents received pain medication as ordered for 1 of 1 sampled resident (#248) reviewed for pain. This placed residents at risk for unrelieved pain. Findings include: Resident 248 was admitted to the facility on 7/6/23 with diagnoses including atrial fibrillation (abnormal heart beat). The 7/6/23 hospital physician orders indicated Resident 248 had chronic back pain and was to receive pregabalin (pain medication) 75 mg every eight hours. The 7/2023 MAR indicated Resident 248 did not receive pregabalin as ordered on the following occasions: -7/6/23 at 10:00 PM -7/7/23 at 6:00 AM -7/7/23 at 2:00 PM -7/7/23 at 10:00 PM Progress notes indicated the pregabalin was not available on 7/6/23 and 7/7/23. The 7/6/23 Admission Summary and Admission Evaluation indicated the following: -Resident 248 stated her/his lower legs were "on fire;" -Resident 248 had a lot of pain and to make sure pain regimen is on schedule; -Resident 248 had a history of passing out/being unresponsive if she/he was in too much pain; -Resident 248 had "very severe, horrible" constant pain in the back and the legs, medication helped alleviate the pain and movement made the pain worse. The pain level summary indicated Resident 248 had pain that ranged from 0-4 on four occasions and 5-10 on nine occasions from 7/6/23 at 6:55 PM through 7/8/23 at 4:52 AM (prior to receiving the ordered pregabalin). On 7/24/23 at 2:14 PM Resident 248 stated she/he did not receive scheduled pain medications due to the facility not having them available. On 7/28/23 at 8:45 AM Staff 2 (DNS) acknowledged Resident 248 had chronic pain and missed the four doses of pregabalin on the identified dates.

Resident #248 has received pain medication as ordered. All residents with orders for pain medication are at risk for this alleged deficient practice of pain management not provided as ordered. The Director of Nursing Services or designee on 8/21/2023 completed a MAR to cart audit of active medication carts to ensure medication availability for current resident care needs. The Director of Nursing Services or designee on or before 9/19/2023 re-educated licensed nurses to ensuring residents with orders for pain medications have medications available for their immediate needs, addressing medication availability and notification to physician of medication unavailable. The Director of Nursing Services or designee will complete daily audits to ensure newly admitted residents have medications available for their immediate needs. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, interview and record review it was determined the facility failed to provide appropriate pre and post dialysis assessments and accurate documentation for 2 of 2 sampled resident (#s 30 and 58) reviewed for dialysis. This placed residents at risk for lack of dialysis assessments and complications. Findings include: 1. Resident 30 was re-admitted to the facility in 2023 with diagnoses including end-stage renal disease. Resident 30's 7/18/23 Quarterly MDS BIMS score indicated the resident was cognitively intact. Resident 30's 7/20/23 Care Plan 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. On 7/26/23 at 12:19 PM Resident 30 stated no one checked her/his new dialysis port after dialysis. Resident 30 stated she/he had a blood clot in the old dialysis site in her/his right arm and surgery was done on 7/19/23 to relocate the dialysis site to her/his neck. Resident 30 stated she/he took a piece of paper with vital signs and current weight to the dialysis center, gave it to the dialysis nurse who wrote things down and then gave it to the facility nurse upon return. On 7/26/23 at 12:33 PM Staff 14 (LPN) stated when a resident returned with dialysis paperwork she entered new orders in the computer, conducted a quick pain assessment, checked the resident's medications, checked for any new skin bruising and offered the resident lunch. On 7/26/23 at 1:10 PM Staff 10 (CNA) stated when a resident returned from dialysis he checked vital signs and obtained a post-dialysis weight. Staff 10 stated the resident dropped off the Dialysis Communication Report (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) at the nurse's station. On 7/26/23 at 1:18 PM Staff 17 (RNCM) stated when a resident returned from dialysis the Dialysis Communication Form was given to the nurse to complete, a copy was made and put in her box and she reviewed it for new orders. A review of Resident 30's clinical record revealed 56 Dialysis Communications Reports. Of the 56 reports, 43 did not include a post dialysis assessment by the facility. No other post-dialysis assessments were found in the clinical record. On 7/27/23 at 8:41 AM Staff 17 and Staff 2 (DNS) acknowledged the post-dialysis assessment was not completed for 43 out of the 56 forms. Staff 2 stated she expected the nurses to conduct a post-dialysis assessment and fill out the form. , 2. Resident 58 admitted to the facility in 3/2023 with diagnosis including Chronic Kidney Disease. A Physicians Order dated 3/25/23 indicated the dialysis communication form was to be filled out by the facility pre and post dialysis. Any new orders/communication from the dialysis center were processed from the form. The form was filed in the hard chart. Also note the dialysis access site was assessed upon arrival back from the facility. The status was documented on the dialysis communication form. Resident 58's Care Plan dated 4/6/23 revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) services three times a week outside the facility. On 7/26/23 at 1:32 PM Staff 11 (Agency/CNA) stated when Resident 58 returned from dialysis obtained vital signs, weighed the resident and offered the resident lunch. Staff 11 stated he was not aware of the location of the resident's dialysis fistula (access site) and obtained the resident's blood pressure from the resident's legs. On 7/27/23 at 8:13 AM Staff 37 (Agency/RN) stated he was not aware of the location of Resident 58's dialysis fistula and thought it was in the resident's left upper extremity. On 7/27/23 at 8:28 AM Resident 58 was observed to self-propel the wheelchair out of the dining room. Observations of Resident 58 did not reveal a dialysis fistula in either arm. Resident 58 stated she/he had a central catheter (dialysis catheter in a large vessel in the neck) and stated no one checked it when she/he returned from dialysis. On 7/31/23 10:42 AM Staff 4 (LPN) stated when Resident 58 returned from dialysis she completed a quick pain assessment, checked the resident's skin for new bruises, checked the resident's medications, offered Resident 58 lunch and let the resident rest. A review of Resident 58's clinical record revealed 13 Dialysis Communication Forms (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 13 reports located the following information was missing or incomplete on the following days: -4/23/23, 5/1/23, 5/22/23, 6/9/23, 6/21/23, 6/30/23, 7/12/23, 7/14/23, 7/17/23: Pre-Dialysis Assessment and Post-Dialysis assessments were not completed by the facility. -5/19/23 and 6/12/23 Pre-Dialysis Assessment were not completed by the facility. -There were no other Dialysis Communication Forms located in Resident 58's clinical record. On 7/27/23 at 4:00 PM Staff 2 (DNS) stated nurses were expected to complete the dialysis communication form prior to Resident 58's appointment and post dialysis upon Resident 58's return from facility.

Residents #30 and #58 pre and post dialysis assessments are being completed and documented. All residents on dialysis are at risk for this alleged deficient practice of pre and post dialysis assessments not being completed. The Director of Nursing Services or designee on 8/22/2023 completed an audit of all current residents receiving dialysis to ensure all dialysis communication forms were completed and maintained in the resident record. The Director of Nursing Services or designee on or before 9/19/2023 re-educated licensed nurses to ensuring pre and post dialysis assessments are completed timely and maintained in the resident record. The Director of Nursing Services or designee will complete weekly audits to ensure residents receiving dialysis have pre and post dialysis assessments completed timely and maintained in their record. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to ensure transportation was provided to a medical appointment for 1 of 1 sampled resident (#249) reviewed for follow up appointments. This placed residents at risk for delayed care. Findings include: Resident 249 admitted to the facility in 7/2023 with diagnoses including a cervical fracture. A 7/17/23 hospital discharge order revealed Resident 249 had a follow up orthopedic appointment scheduled on 7/20/23 at 3:45 PM. No evidence was found in the clinical record regarding transportation being scheduled for the 7/20/23 appointment. On 7/24/23 at 2:44 PM Resident 249 stated the facility did not schedule transportation for her/his orthopedic appointment on 7/20/23 due to poor communication and the appointment had to be rescheduled. On 7/27/23 at 4:11 PM Staff 4 (Agency/RN) stated she was aware of the missed appointment for Resident 249 and was not sure how the appointment was missed but possibly was overlooked when staff reviewed her/his admission orders. On 7/28/23 at 9:41 AM Staff 30 (Medical Record Director) stated they received appointment/transportation requests from the nursing staff and she scheduled transportation/medical appointment for residents. Staff 30 stated the 7/20/23 appointment for Resident 249 was overlooked upon admission. On 7/28/23 at 10:23 AM Witness 7 (Family Member) stated Resident 249 had a follow up appointment with an orthopedic clinic which was scheduled while she/he was in the hospital but Resident 249 missed the appointment because the facility did not set up/provide transportation to the appointment. Witness 7 stated she emailed Staff 16 (Social Service Director) but never heard back from her. On 7/28/23 at 12:38 PM Staff 16 stated she received the email from Witness 7 and let medical records know because they were responsible for setting up transportation for the residents. Staff 16 was aware Resident 249 missed her/his scheduled 7/20/23 follow up appointment due to no transportation. On 7/31/23 at 10:21 AM Staff 2 (DNS) stated staff were expected to review all new orders upon admission to ensure medical appointments and transportation were scheduled. Staff 2 acknowledged Resident 249 missed her/his follow up appointment on 7/20/23.

Resident #249 was rescheduled for his/her appointment on 07/27/23 and was transported. Resident #249 did not experience any negative outcomes from his/her missed appointment. All residents with medical appointments outside of the facility are at risk for this alleged deficient practice of ensuring transportation is not provided to medically necessary appointments. Director of Nursing Services or designee on 8/22/2023 - 8/23/2023 completed an audit of all current residents to ensure transportation was scheduled for all appointments scheduled for 8/22/2023 - 9/30/2023. Appointments in specified date range had transportation scheduled as needed. Director of Nursing Services or designee on or before 9/19/2023 re-educated licensed nursing staff to the facility procedure for scheduling transportation for appointments. The Director of Nursing Services or designee will complete daily, weekday audits of appointments scheduled to ensure transportation is scheduled for appointments outside of the facility. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner for 1 of 5 sampled residents (#32) reviewed for unnecessary medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 32 was admitted to the facility in 9/2019 with diagnoses including schizophrenia (serious mental disorder that affects how a person perceives and interprets reality), depression and anxiety. Pharmacy recommendations from 4/24/23, 5/22/23 and 6/26/23, revealed the following: evaluation of physician's orders to determine if Resident 32 was at the lowest effective dose for Abilify (an antipsychotic), Olanzapine (an antipsychotic), Lexapro (an antidepressant), Duloxetine (an antidepressant), Buspirone (an antianxiety medication), and Clonazepam (an antianxiety medication). Resident 32's record revealed no documentation of any physician follow-up or response to the 4/24/23, 5/22/23 and 6/26/23 pharmacy recommendations. On 7/28/23 at 11:10 AM Staff 2 (DNS) acknowledged there was no follow up to the 4/24/23, 5/22/23 and 6/26/23 pharmacy recommendations.

Resident #32s pharmacy recommendation has been reviewed by his/her provider and received back to the facility. All residents that receive pharmacy recommendations are at risk of this alleged deficient practice of untimely pharmacy recommendation reviews by providers. Director of Nursing Services or designee on 8/23/2023 completed an audit of all current residents receiving psychotropic medications to ensure pharmacy recommendations were reviewed and addressed. Director of Nursing Services or designee on or before 9/19/2023 re-educated licensed nurse supervisors to the importance of reviewing and addressing pharmacy recommendations. Director of Nursing Services or designee will complete weekly audit of up to 5 current residents with orders for psychotropic medications to ensure pharmacy recommendations were reviewed and addressed timely. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to complete quarterly psychotropic medication reviews for 2 of 5 sampled residents (#s 17 and 42) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include: 1. Resident 17 admitted to the facility in 2023 with diagnoses including anxiety and depression. Review of the 6/8/23 physician orders indicated Resident 17 received clonazepam (antianxiety), duloxetine (antidepressant), quetiapine (antipsychotic) and melatonin. A Lifestyles form with review dates of 3/28/23, 3/29/23, 4/26/23 and 6/27/23 listed Resident 17's psychotropic medications with the diagnoses, and order date. The form indicated sleep and behaviors with no other information provided. A progress note dated 6/28/23 indicated the facility IDT team and pharmacy reviewed Resident 17's psychotropic medications and to see the Quarterly Psychotropic Medication Assessment. Review of Resident 17's medical record revealed no indication of a Quarterly Psychotropic Medication Assessment completed. On 7/27/23 at 8:56 AM Staff 16 (Social Services Director) stated she wrote the 6/28/23 progress note, and the Quarterly Psychotropic Medication Assessment was not completed for Resident 17. Staff 16 stated she was behind in completing the quarterly psychotropic medication assessments. 2. Resident 42 admitted to the facility in 2021 with diagnoses including hallucinations, anxiety, insomnia, and anxiety. A 3/23/23 Psychotropic Medication Assessment indicated Resident 42 received clozapine (antipsychotic), trazadone (antidepressant), melatonin and venlafaxine (antidepressant). Review of Resident 42's medical record indicated no Psychotropic Medication Assessment was completed for June. On 7/27/23 at 8:56 AM Staff 16 (Social Services Director) stated the Quarterly Psychotropic Medication Assessment was not yet completed for Resident 42. Staff 16 acknowledged a psychotropic medication review was to be completed at least quarterly.

Residents #17 and #42 have had their quarterly psychotropic medication assessments completed. All residents receiving psychotropic medications are at risk for this alleged deficient practice of not completing quarterly psychotropic medication assessments timely. Director of Nursing Services or designee on 8/23/2023 completed an audit of all current residents with orders for psychotropic medications to ensure quarterly psychotropic medication assessments were current. Any resident identified as not having a current quarterly psychotropic medication assessment had one completed. Director of Nursing Services or designee on or before 9/19/2023 re-educated Interdisciplinary Team to completing quarterly psychotropic medication assessments timely. The Director of Nursing Services or designee will complete monthly audits of quarterly psychotropic medication assessments to ensure they are in place. Audits will be conducted monthly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, interview and record review it was determined the facility failed to ensure routine dental services were provided to 1 of 1 sampled resident (#56) reviewed for dental services. This placed residents at risk for a lessened quality of life. Findings include: Resident 56 admitted to the facility in 10/2021 with diagnoses including a stroke. On 7/24/23 at 12:32 PM Resident 56 was observed missing one of her/his upper teeth on the right side of her/his mouth. Resident 56 stated her/his tooth fell out two plus weeks prior, staff were aware and supposed to get the missing tooth fixed but nothing occurred. No evidence was found in the clinical record regarding Resident 56's missing tooth or any indication dental services were initiated or a dental appointment was made. On 7/26/23 at 11:28 AM Staff 21 (CNA) stated Resident 56 was missing one of her/his upper teeth for greater than two weeks and was not sure if any staff reported the concern to Staff 16 (Social Service Director). On 7/27/23 at 10:31 AM Staff 20 (LPN) stated she was aware Resident 56 had a missing upper tooth for approximately six weeks and she reported the concern to Staff 16. On 7/28/23 at 12:20 PM Staff 16 stated she was unaware Resident 56 was missing a tooth and staff were expected to report concerns to her. On 7/31/23 at 10:26 AM Staff 2 (DNS) acknowledged Resident 56 was missing a tooth and staff were expected to verbally report concerns and could complete a "grievance" regarding the missing tooth which would be addressed by Staff 16.

Resident #56 refused to be seen by the in house dental provider. Appointment is being made with an outside provider. All residents with dental needs are at risk for this alleged deficient practice. Director of Nursing Services or designee on 08/24/23 completed an audit of all current residents to determine need for dental services. Any resident requiring dental services had a follow-up appointment scheduled. Director of Nursing Services or designee on or before 9/19/2023 re-educated staff to the facility policy and procedure for requesting dental services as well as the importance of reporting needs timely. Director of Nursing Services or designee will complete weekly audit of current residents to determine if dental services are needed. Any residents identified as needing dental services will have a follow-up appointment scheduled. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, interview and record review it was determined the facility failed to ensure food textures and food temperatures were maintained for food trays served from 1 of 1 facility kitchen and for 4 of 4 sampled residents (#s 17, 22, 47 and 50) reviewed for food service. This placed residents at risk for food that was not palatable or appetizing. Findings include: Interview with residents indicated the following: -On 7/24/23 at 11:50 AM Resident 50 stated the food was not always hot. Resident 50 stated the food was not great tasting and lacked quality. -On 7/24/23 at 12:09 PM Resident 17 stated the food was terrible and she/he often refused to eat it. Resident 17 stated the food was served cold most of the time. -On 7/24/23 at 2:49 PM Resident 47 stated the food was terrible and cold when it was delivered. -On 7/25/23 at 10:16 AM Resident 22 stated she/he ate in her/his room and experienced cold food by the time it arrived to her/his room. Resident 22 stated when they had the smaller dining room staff were able to warm up food in the microwave but now staff had to walk all the way to the big dining room to reheat food which took time. Resident 22 stated butter did not melt when placed on the vegetables due to the food not being warm enough. Resident 22 further stated the issue was brought up in Resident Council, but nothing was done. Review of Resident Council notes revealed the following: - 4/2023 residents indicated the meatloaf was flavorless, the pasta was overcooked, and weekend meals were served late. - 6/2023 residents indicated food was served cold even when on the hot plates. On 7/27/23 at 1:03 PM a test tray was sampled with the survey team; the meal consisted of chicken strips, french fries and cooked carrots. The french fries were lukewarm and soggy, and the carrots were overdone. On 7/27/23 at 1:09 PM Staff 1 (Administrator) acknowledged the fries were lukewarm and mushy and the carrots were overdone.

Residents #17, 22, 47, 50 were encouraged to alert facility staff right away when a meal does not meet their preferences. All residents are at risk for this alleged deficient practice. Administrator or designee on 8/21/2023 completed an audit using face-to-face interviews of all residents about their meal preferences. Additionally, all residents were re-educated to the facilitys available alternative meals. Administrator or designee on or before 9/19/2023 re-educated dining services staff to the importance of ensuring residents receive meals that are palatable and appetizing. Administrator or designee will complete daily, weekday meal observations to ensure meals are palatable and appetizing. Additionally, the Administrator or designee will complete weekly temperature audits of 5 meal trays. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to provide rehabilitation services for 1 of 1 sampled resident (#17) reviewed for rehabilitation services. This placed residents at risk for declined mobility and lack of quality of life. Findings include: Resident 17 admitted to the facility in 2023 with diagnoses including pain and fibromyalgia (widespread muscle pain). On 5/12/23 a concern was reported to the State Agency which indicated Resident 17 did not receive therapy as ordered and only received one session the following week. On 7/24/23 at 10:55 AM and 7/26/23 at 9:52 AM Resident 17 stated she/he did not receive therapy when she/he was supposed to. Resident 17 stated she/he never refused therapy and was never out of the building to miss therapy. Resident 17 stated she was never approached to make-up for the missed sessions. Review of the 5/2023 therapy notes indicated Resident 17 was to receive OT three times a week and PT two times a week. Review of therapy the Service Log Matrix indicated Resident 17 received one session of PT (one session missed) and one session of OT (two session missed) during the week of 5/7/23 to 5/13/23. On 7/26/23 at 8:58 AM Staff 23 (Physical Therapy Director) acknowledged Resident 17 missed two session of OT and one session of PT for the time frame indicated and did not offer any explanation for why the sessions were missed.

Resident #17 is currently receiving physical and occupation therapy services. All residents that receive therapy services are at risk of the alleged deficient practice of missed therapy appointments. Director of Therapy Services on 8/23/2023 completed an audit of current residents receiving physical and occupation records for missed therapy sessions. Any therapy sessions identified as missed were rescheduled. Director of Therapy Services on or before 9/19/2023 re-educated therapy staff to importance of completing all scheduled therapy sessions, documenting and rescheduling any missed sessions. The Director of Therapy Services or designee will complete weekly audits of scheduled therapy sessions to ensure current residents receiving physical, occupational and/or speech therapies are receiving therapy as scheduled. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Therapy Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment for 1 of 1 sampled facility. This placed residents at risk for lack of quality of care and quality of life. Findings include: On 7/31/23 at 12:20 PM the 6/8/23 Facility Assessment was reviewed. The assessment was not comprehensive and did not include information on the following: -Facility staffing levels; -Staff competencies that were necessary to provide the level and types of care needed for the resident population; -Ethnic or cultural factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services; -The facility's resources, including but not limited to all personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; and contracts, memorandums of understanding. On 7/31/23 at 12:30 PM Staff 1 (Administrator) reviewed the Facility Assessment and acknowledged the assessment was not comprehensive and did not include the identified information.

Administrator or designee on 8/9/2023 completed a comprehensive facility assessment. All residents are at risk related to this alleged deficient practice of a facility assessment that is not comprehensive. Resident population, staff training/competencies, activities, dining will be reviewed based on the outcome of the updated facility assessment and updated as needed to provide for the day-to-day operations and resident cares. Administrator or designee on or before 9/19/2023 re-educated the Interdisciplinary Team to the importance of maintaining current facility assessment. Administrator or designee will complete monthly audit of the facility assessment to ensure current residents needs can be met. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on observation, interview and record review it was determined the facility failed to ensure records were complete and accurate for 5 of 8 sampled residents (#s 30, 32, 47, 58 and 89) reviewed for medications, dialysis and planned discharge. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 58 admitted to the facility in 3/2023 with diagnoses including Chronic Kidney Disease. Resident 58's Care Plan dated 4/6/23 revealed the resident received dialysis (a procedure to remove waste products from the blood when the kidneys stop working) three times a week outside the facility. On 7/26/23 at 1:32 PM Staff 11 (Agency/CNA) stated he did not know where Resident 58's dialysis fistula (a surgical connection between an artery and a vein) was located and used the resident's legs for blood pressures. On 7/27/23 at 8:13 AM Staff 37 (Agency/RN) stated he thought Resident 58's dialysis fistula was in her/his left upper extremity. On 7/27/23 at 8:28 AM Resident 58 stated staff did not monitor her/his dialysis catheter in her/his neck. Observation of Resident 58's upper extremities revealed no dialysis fistulas. A review of Resident 58's TARs from 4/2023 through 7/2023 revealed staff were monitoring the following: -Resident 58 had a dialysis fistula and staff were to check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals. Every day and evening shift for dialysis care. -Dialysis fistula care. Staff were to check the color and temperature of the fingers and the radial pulse of the access arm when performing routine care and at regular intervals. Every day and evening shift for dialysis care. -Staff were to check the fistula patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access. This was done daily or as ordered by the physician every day shift for dialysis site patency check. On 7/27/23 at 4:00 PM Staff 2 (DNS) confirmed and acknowledged Resident 58 did not have a fistula and the 4/2023 through 7/2023 TARs were inaccurate. Staff 2 stated staff were expected to document accurately in the medical record and document the appropriate access site. , 2. Resident 47 was admitted to the facility in 2023 with diagnoses including pneumonia, PTSD (Post-Traumatic Stress Disorder), anxiety disorder and depression. Resident 47's 6/12/23 Care Plan indicated staff were to observe the resident for signs of anxiety and depression (including crying), and if present to document the symptom occurrences in the clinical record. On 7/24/23 at 2:30 PM Resident 47 stated a couple of weeks ago Staff 16 (Social Service Director) came to her/his room and said staff reported that she/he was sexually aroused during peri-care (genital cleaning) which made the staff uncomfortable. Resident 47 denied being sexually aroused during peri-care and stated the conversation upset her/him and she/he cried. On 7/28/23 at 11:47 AM Staff 16 stated in early July 2023 she had a conversation with Resident 47 about staff reports of feeling uncomfortable when the resident was provided peri-care due to the resident's sexual arousal response. Staff 16 stated the resident was shocked and upset as a result of the conversation. Staff 16 stated she did not document the conversation with the resident in the clinical record. No information was found in the the clinical record regarding the above incident. On 7/28/23 at 1:48 PM Staff 17 (RNCM) verified there was no documentation in Resident 47's progress notes regarding the incident. On 7/31/23 at 11:05 AM Staff 2 (DNS) confirmed she expected staff to document interactions regarding this incident. Refer to F550. 3. Resident 30 admitted to the facility in 2022 with diagnoses including end-stage renal disease. Resident 30's 7/18/23 Quarterly MDS BIMS score indicated the resident was cognitively intact. Resident 30's Care Plan dated 7/20/23 revealed the resident received dialysis (a process used to remove waste products from the blood when the kidneys stop working) three times a week outside of the facility. A Progress Note dated 7/20/23 at 2:55 AM indicated the resident returned to the facility via stretcher from Salem Hospital Emergency Room for a fistula clot. A Progress Note dated 7/21/23 at 4:20 AM indicated the resident had a wrap covering the previous AV shunt (tube used for dialysis) in the left upper extremity and a new dialysis shunt was placed in the resident's right lateral neck following a 7/19/23 emergency room visit. On 7/26/23 at 12:19 PM Resident 30 stated staff did not check the new dialysis site in her/his neck. A review of Resident 30's TARs from 7/1/23 through 7/31/23 revealed staff were monitoring the following: Dialysis-Fistula patency check: Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear a bruit of blood flow through the access. This should be done daily. Staff check marked it was completed. Dialysis-Fistula Care CMS (circulation, movement, sensation) check: check the color and temp of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals every day and evening shift. Staff check marked it was completed. Facility would monitor hemodialysis central lines at a minimum of twice a day for bleeding and s/s of infection: Staff check marked it was completed. On 7/27/23 at 4:00 PM Staff 2 (DNS) confirmed and acknowledged Resident 30 did not have a fistula in her/his arm and the 7/2023 TARs were inaccurate. Staff 2 stated staff were expected to document accurately in the medical record and document the appropriate access site. , 4. Resident 32 was admitted to the facility in 9/2019 with diagnoses including diabetes, stage 3 chronic kidney disease, and severe obesity. Resident 32's 6/2023 and 7/2023 MARs indicated the following: -Insulin Aspart Solution 100 unit/ml- inject as per SS for diabetes start date 10/18/22: If CBG was 200 to 399 staff were to inject six units below the skin at bedtime If CBG was 400 to 800 staff were to inject 10 units below the skin with meals A review of the resident's clinical record revealed a signed physician order dated 6/8/23 which directed staff to administer the insulin only at bedtime and not with meals. The 6/8/23 order did not change the ordered amount of insulin but clarified that the insulin was only to be administered at bedtime, and not with meals. However, the 6/8/23 was not transcribed on Resident 32's MARs so the order was unchanged since 10/18/22. No evidence was found in the resident's medical record to indicate the order was administered with meals instead of at bedtime despite the error on the MARs. On 7/27/23 at 3:40 PM Staff 17 (RNCM) acknowledged the 6/8/23 order was not entered and verified Resident 32's 6/2023 and 7/2023 MARs' instructions were inaccurate . 5. Resident 89 was admitted to the facility in 6/2023 with diagnoses including a stroke. Resident 89's discharge summary was incomplete and in accurate. The Resident/Responsible Party signature line and Nurse signature line were blank and included a discharge date of 8/20/22. Resident 89's correct discharge was 7/17/23. The medications listed on the 8/20/22 discharge summary were not the same medications Resident 89 was ordered prior to her/his 7/17/23 discharge. On 7/31/23 at 11:13 AM Staff 2 (DNS) acknowledged the 8/20/22 discharge summary was not correct for Resident 89. She/he was unable to provide other documentation.

Residents #58 & #30 dialysis protocol orders have been updated. All residents that receive dialysis are at risk for this alleged deficient practice of incorrect dialysis protocol orders. Director of Nursing or designee on 8/17/2023 completed an audit of all residents receiving dialysis to ensure correct orders in place. Resident records were updated as needed. Director of Nursing or designee on or before 9/19/2023 re-educated licensed nurses to facility procedure for documenting residents skin and corresponding treatment orders. Director of Nursing or designee will complete weekly audits of residents receiving dialysis to ensure documenting residents skin and corresponding treatment orders. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance. Resident #47s care plan has been updated after consideration of resident 47s change in condition to reflect resident 47s preference for one person assist with peri care. All current residents that staff express a concern for changes in response to personal cares being provided are at risk for this alleged deficient practice. Director of Nursing Services or designee on 8/19/2023 completed an audit of all current residents that receive peri care to ensure that their care plan reflects the appropriate number of care givers need for peri care. The policy for resident rights and the policy for dignity have been reviewed. Additionally, the Director of Nursing Services or designee on or before 9/19/2023 re-educated staff to treating each resident with respect and dignity, with emphasis on communicating about care. Director of Nursing Services or designee will complete weekly audits using face-to-face interviews of up to 5 current residents to ensure that residents are being communicated to with dignity and respect in regard to their care. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance. #32 order for insulin immediately clarified on 7/27/203. All residents that receive insulin are at risk for this alleged deficient practice. Director of Nursing Services or designee on 08/19/23 completed an audit of all residents receiving insulin for order accuracy. Insulin orders clarified as needed. Director of Nursing Services or designee on or before 9/16/2023 re-educated licensed nurses to facility procedure for entering insulin orders. Director of Nursing Services or designee will completely weekly audits of insulin orders to ensure accuracy. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance. Resident #89 indicates that he/she did receive discharge instructions from the facility. All discharging residents are at risk for this alleged deficient practice of not providing discharge instructions. The Director of Nursing Services or designee on 8/21/2023 completed an audit of all residents discharged from the facility between 6/30/2023 - 8/19/2023 to ensure a discharge summary was provided to each resident. Resident records identified as not containing a discharge summary were provided with a discharge summary. The Director of Nursing Services or designee on or before 9/19/2023 re-educated licensed nurses to completing and provided a discharge summary for every resident discharging from the facility and ensuring a copy is maintained in the resident record. The Director of Nursing Services or designee will complete daily, weekday audits of discharges to ensure that all residents discharging from the facility are provided with a discharge summary. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review, it was determined the facility failed to have policies and procedures in place in the event of a facility closure for 1 of 1 sampled facility. This placed residents at risk for displacement. Findings include: On 7/31/23 the facility was asked to provide a policy and procedure in the event of a pending or potential facility closure. On 7/31/23 at 11:31 AM Staff 1 (Administrator) stated the facility did not have a policy and procedure for pending or potential facility closure .

Administrator or designee on 8/9/2023 developed a policy and procedure for pending or potential facility closure. All residents are at risk related to this alleged deficient practice of not having a policy and procedure for pending or potential facility closure. Resident population, care needs and day-to-day operations will be reviewed, the policy and procedure for pending or potential facility closure will be updated as needed. Administrator or designee on or before 9/19/2023 re-educated Interdisciplinary Team to importance of maintaining facility policy and procedure for pending or potential facility closure. Administrator or designee will complete monthly audit of the facility policy and procedure for pending or potential facility closure to ensure current residents needs can be met. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Administrator or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to provide a qualified social service worker. This placed all residents at risk for unmet medically related emotional and social service needs of the residents. Findings include: The Facility Assessment dated 6/8/23 revealed the following information regarding qualifications for the Social Service Director: -(A) Have bachelor's or master's degree in behavioral sciences with at least on years' experience in a health care setting; or -(B) An associate degree in behavioral sciences with two years' experience in a health care setting; or -(C) Receive regular on-site consultation, no less often than quarterly, from an individual who has a bachelor's or master's degree in social work or related behavioral science, and one year's experience in a long-term care setting working directly with individual resident, and have written procedures for referring resident in need of social services to appropriate resources; -The Social Service Director of a facility with more than 120 beds shall be full-time and shall meet requirements in either paragraph (A) or (B) of this rule. A review of Staff 16's (Social Service Director) work history/resume indicated she did not have one year of supervised work experience in a health care setting working directly with individuals. The facility's approved bed capacity was 121 beds and included Medicare and Medicaid contracts with a license expiration date of 8/31/23. On 7/31/23 at 8:46 AM and 7/28/23 at 10:50 AM Staff 16 (Social Service Director) stated her degree was in criminal justice with a minor in human services. Staff 16 stated she was hired in 11/2022 and the facility had her complete a 10-hour online course for social service work. Staff 16 stated she only received one day of training from the previous social service director before that individual left. Staff 16 stated she corresponded with a Social Service Director from another facility but only for the first two or three months. Staff 16 stated she did not correspond with anyone currently regarding social service concerns and she had no prior experience in a long-term care facility setting. Staff 16 further stated she was in charge of training the social service assistants including Staff 22 (Social Service Assistant). During the survey the following concerns were identified related to social services and determined to reflect a systemic failure to provide adequate social services to all residents within the facility: - Residents Rights/treated with dignity (Refer to F550). -Follow up related to Advance Directives (Refer to F578). -Medicaid/medicare Coverage/liability (Refer to F582). -Grievances (Refer to F585). -Discharge planning process (Refer to F660). -Maintaining vision services (Refer to F685). -Provisions of medically related services regarding medical appointments (Refer to F745). -Psychotropic medication assessments (Refer to F758). -Routine and dental services (Refer to F790). -Residents medical records accurate and complete (Refer to F842).

A Social Services Consultant meeting the minimum requirements will be contracted to provide ongoing supervision and training of current Social Services designee. The Social Services Consultant will complete a thorough audit of all current social services processes and knowledge and develop an educational plan based on the results of the audit. The Social Services Consultant will re-educate the Social Services designee based on the educational plan developed from the audit completed. The Social Services Consultant will provide 8 hours of in-facility support weekly for 6 months, as well as being available via telephone, email and/or video conference when not in person at the facility. After 6 months, the Social Services Consultant will provide 8 hours of in-facility support quarterly, as well as being available via telephone, email and/or video conference when not in person at the facility.

Based on observation, interview and record review it was determined the facility failed to provide a safe environment for the storage of oxygen tanks for 1 of 2 sampled residents (#32) reviewed for respiratory care. This placed residents at risk for accidents. Findings include: Resident 32 was admitted to the facility in 9/2019 with diagnoses including COPD (chronic obstructive pulmonary disease). Multiple observations from 7/25/23 through 7/28/23 revealed empty and unsecured oxygen tanks stored inside Resident 32's doorway and right outside of Resident 32's door. On 7/28/23 at 10:21 AM Staff 19 (CNA) stated oxygen tanks were to be secured or stored in a locked closet by the nurses station. On 7/28/23 at 10:23 AM Staff 2 (DNS) provided the facility's Oxygen Administration policy revised 7/2023, which stated "Oxygen tanks must be stored securely in a stand." On 7/28/23 at 11:02 AM Staff 2 was shown the unsecured oxygen tanks and Staff 2 stated oxygen tanks needed to be either secured or stored in the locked oxygen closet by the nurses station.

Resident #32 portable oxygen tank on 7/28/2023 were immediately removed from the residents room and stored properly. All residents using oxygen are at risk for this alleged deficiency. Director of Nursing Services or designee on 7/28/2023 completed an audit using observation of all resident rooms for improperly stored oxygen tanks. No other improper storage was identified. Director of Nursing Services or designee on or before 9/19/2023 re-educated licensed nursing staff to proper storage of portable oxygen tanks. Director of Nursing Services or designee will complete weekly audits of up to 25% of resident rooms to ensure portable oxygen tanks are stored properly. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

Based on interview and record review it was determined the facility failed to provide a Leaving the Nursing Facility brochure at discharge for 1 of 4 sampled residents (#89) reviewed for discharge. This placed resident at risk of not being informed of their rights when leaving the nursing facility. Findings include: Resident 89 admitted to the facility in 6/2023 with diagnoses including a stroke. The resident discharged home on 7/17/23. Review of Resident 89's medical record revealed no evidence she/he was provided a Leaving the Nursing Facility brochure upon discharge. On 7/31/23 at 11:13 AM Staff 2 (DNS) stated the charge nurse discharging a resident was to review the brochure with the resident and obtain a signature to keep on file in their medical record. Staff 2 acknowledged there was no evidence Resident 89 was provided the brochure.

Resident #89 indicates that he/she did receive a Leaving the Nursing Facility document from the facility. All discharging residents are at risk for this alleged deficient practice of not providing a Leaving the Nursing Facility. The Director of Nursing Services or designee on 8/21/2023 completed an audit of all residents discharged from the facility between 6/30/2023  8/19/2023 to ensure a "Leaving the Nursing Facility" document was signed by each resident and/or resident representative. Residents whose records were identified as not containing a "Leaving the Nursing Facility" document were provided with the document. The Director of Nursing Services or designee on or before 9/19/2023 re-educated licensed nurses to completing and providing a "Leaving the Nursing Facility" document for every resident discharging from the facility and ensuring a copy is maintained in the resident record. The Director of Nursing Services or designee will complete daily, weekday audits of discharges to ensure that all residents discharging from the facility are signed and are provided with a "Leaving the Nursing Facility" document. Audits will be conducted weekly until substantial compliance is reached. Results of the audits will be presented by the Director of Nursing Services or designee at the monthly Quality Assurance Performance Improvement meetings for three months to determine if continued audits are indicated based on compliance.

************************ OAR 411-085-0310 Residents' Rights: Generally Refer to F550, F557, F561, F578 and F585 ************************ OAR 411-085-0320 Residents' Rights: Charges and Rates Refer to F582 ************************ OAR 411-087-0100 Physical Environment: Generally Refer to F584 ************************ OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F660 ************************ OAR 411-086-0110 Nursing Services: Resident Care Refer to F684, F685, F695, F697 and F698 ************************ OAR 411-086-0160 Nursing Services: Discharge Summary Refer to F661 ************************ OAR 411-086-0240 Social Services Refer to F745 and F850 ************************ OAR 411-086-0260 Pharmaceutical Services Refer to F756 ************************ OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care Refer to F758 ************************ OAR 411-086-0210 Dental Services Refer to F790 ************************ OAR 411-086-0250 Dietary Services Refer to F804 ************************ OAR 411-086-0220 Rehabilitative Services Refer to F825 ************************ OAR 411-086-0110 Administrator Refer to F838 ************************ OAR 411-086-0300 Clinical Records Refer to F842 ************************ OAR 411-085-0015 License Expiration, Termination of Operation, License Return Refer to F846 ************************ OAR 411-087-0100: Physical Environment Generally Refer to F921

Based on observation, interview and record review it was determined the facility failed to ensure dignity and respect for 2 of 4 sampled residents' (#s 4 and 5) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: Resident 4 was admitted to the facility in 3/2018 with diagnoses including dementia. A 12/14/22 Care Plan identified Resident 4 was at risk for alteration in psychosocial mood including decreased verbalization due to depression. Resident 5 was admitted to the facility in 1/2022 with diagnoses including major depressive disorder. A 9/22/22 Care Plan identified Resident 5 was at risk for alteration in psychosocial well being including negative feelings due to depression. A 6/23/22 Facility Incident Report revealed Staff 19 (CNA) engaged in inappropriate conversations and wore inappropriate attire in front of Residents 4 and 5. The facility indicated Staff 19 discussed with Residents 4 and 5 her recent breast augmentation and reported Staff 19 would often wear inappropriate articles of clothing as a means to expose her breast area which was uncomfortable for Residents 4 and 5. On 4/25/23 at 1:15 PM Staff 18 (LPN) confirmed Staff 19 referred to her recent breast augmentation to Residents 4 and 5 on numerous occasions and often wore attire that would expose parts of breasts to other residents. On 4/25/23 at 1:37 PM Staff 15 (LPN) stated Staff 19 was disciplined several times related to the discussion of her breasts with residents. Staff 15 stated Staff 19 continued to engage in these discussions despite several warnings. On 4/25/23 at 1:57 PM Staff 2 (DNS) confirmed findings related to Staff 19's behavior regarding discussions related to Staff 19's recent breast augmentation. On 4/25/23 at 4:04 PM Staff 19 confirmed she discussed with Residents 4 and 5 regarding her recent breast augmentation. On 5/1/23 at 12:30 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the findings.

All residents are at risk for this alleged deficient practice. Resident 4 and 5 no longer reside at this facility. Staff 19 no longer works for the facility. Nursing staff have been educated on appropriate conversations to have with residents and will continue to be educated on this. Staff will be educated on the dress code policy and will be sent home if not in compliance with it. The IDT team will do daily rounds to ensure staff are wearing appropriate clothes and following the dress code policy. Any concerns regarding a staff members clothing will be addressed and then reported in morning meeting.

, Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 5 sampled resident (#12) reviewed for abuse. This placed residents at risk for skin injuries. Findings include: Resident 12 was admitted to the facility in 5/2022 with diagnoses including cerebral infarction (stroke). A 10/31/22 Care Plan identified Resident 12 with displayed behaviors of crying, screaming, yelling, hallucinations, rejection of care, and suicidal ideation. A 4/13/22 Facility Incident Report revealed Staff 21 (CNA) held Resident 12's arm's down during performed care tasks. Staff 21 reported she attempted to place Resident 12 into bed which caused Resident 12 to become combative. Staff 21 confirmed she grabbed Resident 12 arms and held her/him down to provide care for the resident and scratched Resident 12's arm as a result. On 5/1/23 at 12:16 PM Staff 1 (Administrator) confirmed findings and stated Resident 12's scratch marks on her/his arm were caused by Staff 21.

All residents are at risk for this alleged deficient practice. Resident 12 no longer resides in the facility. Staff 21 was removed from the schedule while the investigation was completed and her contract was terminated upon determining abuse did occur. Staff will continue to be educated on abuse and the importance of care plans being followed. The RN Unit Managers will audit 25% of residents on each wing weekly to make sure that the care plan is being followed in regards to ADL interventions. The RN Unit Managers will turn the audit into the Administrator each Friday and the results of the audit will be reviewed monthly in QAPI for 3 months or until 100% compliance.

, Based on observation, interview, and record review it was determined the facility failed to report an incident of injury of unknown source to the appropriate State Agency within 24 hours for 1 of 1 sampled resident (#2) reviewed for incidents. This placed resident at risk for further incidents and potential for abuse. Findings include: Resident 2 was admitted to the facility 5/2020 with diagnoses including cerebral infarction (stroke). A 4/17/23 BIMS evaluation identified Resident 2 as cognitively impaired. On 4/24/23 at 10:34 AM Witness 2 (Complainant) identified on 4/12/23 a notable bruise under the left eye of Resident 2. Witness 2 upon assessment indicated she was unable to determine the source of the bruised left eye. A 4/12/23 Facility Incident Report revealed the facility identified Resident 2 had a bruised left eye of unknown origin. On 4/24/23 at 10:54 AM Staff 2 (DNS) stated the facility did not file a report with the State Agency.

All residents are at risk for this alleged deficient practice. Resident 2 still resides in the facility. All injuries of unknown source will be reported to the state via FRI report and an investigation will be completed. The abuse coordinator and designee have been educated on the reporting expectations of abuse. All injuries of unknown source will be audited to ensure that they were reported and/or investigated. The audit results will be reported in QAPI monthly for three months or until 100% compliance.

, Based on observation, interview, and record review it was determined the facility failed to thoroughly investigate and rule out potential abuse for 1 of 1 sampled resident (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 2 was admitted to the facility 5/2020 with diagnoses including cerebral infarction (stroke). A 4/17/23 BIMS evaluation identified Resident 2 as cognitively impaired. On 4/24/23 at 10:34 AM Witness 2 (Complainant) identified on 4/12/23 a notable bruise under the left eye of Resident 2. Witness 2 upon assessment indicated she was unable to determine the source of the bruised left eye. A 4/12/23 Facility Incident Report revealed facility identified Resident 2 with a bruised left eye of unknown origin. On 4/24/23 at 10:54 AM Staff 2 (DNS) stated the facility did not conduct an investigation as they concluded the source of the bruise was due to Resident 2 sleeping with her/his glasses on. Staff 2 confirmed no assessment was completed to verify the facility's conclusion. On 4/24/23 at 11:03 AM Staff 4 (RNCM) and Staff 1 (Administrator) stated Resident 2 informed the facility she/he's source of the bruised left eye was caused by the resident leaving her/his glasses on while asleep the night before and not as a result of being hit in eye. Staff 1 confirmed no investigation was conducted by the facility as the facility believed the source of the injury was caused by Resident 2 leaving her/his glasses on overnight. On 4/24/23 at 11:36 AM Resident 2 stated she/he did not have a history of leaving her/his glasses on while sleeping due to fear of them breaking. Resident 2 confirmed the appearance of a bruise on her/his left eye but did not recall how it was obtained or informing the facility of how it was obtained. On 4/24/23 at 11:39 AM Staff 5 (LPN) indicated Resident 2 did not have a history of sleeping with her/his glasses on. Staff 5 reported she discovered the black eye on 4/12/23 and confirmed Resident 2 had not worn her/his glasses to bed the night before. A Review of Resident 2's clinical record revealed no statement from Resident 12 related to the source of the bruised left eye, no investigation for injury of unknown origin was documented and no skin assessment completed for day of incident. On 5/1/23 at 12:30 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed findings.

All residents are at risk for this alleged deficient practice. Resident 2 still resides in the facility. All injuries of unknown source will be reported to the state via FRI report and an investigation will be completed. The abuse coordinator and designee have been educated on the reporting expectations of abuse. All injuries of unknown source will be audited to ensure that they were reported and/or investigated. The audit results will be reported in QAPI monthly for three months or until 100% compliance.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#18) reviewed for discharge. This placed residents at risk for unmet care needs after discharge. Findings include: Resident 18 admitted to the facility in 12/2022 with diagnoses including chronic respiratory failure, heart failure, malnutrition and anxiety disorder. On 4/16/23 at 12:43 PM Witness 9 (Complainant) stated Resident 18 was unsafely discharged home and had no assistance with bathing. Witness 9 stated Resident 18 was Medicaid approved to stay in the ICF (intermediate) level of care however the facility told the resident if she/he planned to remain at the facility for ICF care it would cost Resident 18 hundreds of dollars every day and would lose her/his social security benefits. The 2/8/23 Physician Order indicated Resident 18 could discharge home with home health services on 2/9/23. Resident 18's MDS schedule revealed Resident 18 was discharged to the hospital on 2/8/23, re-admitted to the facility on 2/11/23 and discharged to the community (home) on 3/18/23. The 3/3/23 Social Service Note revealed the resident's representative worked to get Resident 18 approved for Medicaid and planned to request Resident 18 transfer to the ICF level of care however if she/he was not approved by the time of discharge the resident would go home because she/he could not afford the out of pocket cost of ICF. The 3/17/23 Functional Abilities and Goals assessment indicated Resident 18 required supervision and physical assistance with showering. The 3/18/23 Discharge Summary revealed Resident 18 discharged home. Review of Resident 18's medical record revealed no physician order to discharge home after Resident 18 re-admitted from the hospital. On 4/25/23 at 9:11 AM Witness 11 (Case Manager) stated Resident 18 was approved for Medicaid services on 12/28/22, if Resident 18 needed more assistance she/he was approved to stay in the ICF level of care and stated the facility did not reach out to him prior to discharge. Witness 11 further stated Home Health Physical Therapy did not start until 4/10/23 and Resident 18 physically lost all that she/he had gained during her/his SNF stay at the facility. On 4/25/23 at 9:42 AM Staff 6 (Social Service Director) stated she knew Resident 18 was approved for Medicaid services but her understanding was the Resident would be responsible for $450 a day for care and when she discussed this with Resident 18 she/he was adamant she/he could not afford to stay. Staff 6 verified she did not get updated discharge or home health orders to discharge Resident 18 home but instead used the 2/8/23 discharge order. Staff 6 stated she initiated contact for home health services but last communicated with the home health agency on 3/11/23 and did not verify the services would start at the time of Resident 18's discharge. On 4/25/23 at 11:19 AM Staff 1 (Administrator) stated the facility was unaware Resident 18 was approved for Medicaid ICF services and stated if they had known the facility "would have pushed for [her/him] to stay ICF long term." Staff 1 further stated the facilty did not think Resident 18's discharge home was safe and attempted to set the resident up with home health, equipment and APS (Adult Protective Services) was involved.

All residents are at risk for this alleged deficient practice. Resident 18 no longer resides in the facility. The Social Services department has been educated on ensuring discharge orders are current and accurate. Social Services will create a discharge checklist for each resident to make sure that the appropriate services and equipment are setup. The business office will also be running residents Medicaid numbers to check eligibility upon admission given that there is a Medicaid number on the face sheet. The Administrator will do a weekly audit of all discharges. The audit will be reported monthly in QAPI for three months or until 100% compliance.

Based on interview and record review it was determined the facility failed to ensure medications were administered as ordered for 1 of 3 sampled residents (#3) reviewed for medications. This placed residents at risk for decreased efficacy. Findings include: Resident 3 admitted to the facility in 9/2022 with diagnoses including right femur fracture and stroke. The 2/2/23 Physician Order revealed an order for Plavix (antiplatelet medication) 75 mg to be administered daily. The February 2023 MARs revealed Plavix 75 mg was to administered daily at 6:00 PM. The 2/10/22 Facility Investigation indicated Resident 3 verbalized a concern about receiving her/his Plavix a few hours late with a specific LPN. When Resident 3 requested the medication from the LPN, the LPN informed the resident she did not want to walk back down to the medication cart to get the medication. The investigation determined late administration of the Plavix occurred on two separate occasions and neglect of care was substantiated. On 4/25/23 at 12:35 PM Staff 2 (DNS) stated Resident 3 was administered Plavix late on 2/8/23 and 2/9/23.

All residents are at risk for this alleged deficient practice. Resident #3 still resides in the facility and was not affected by this alleged deficiency. The medication administration policy will be reviewed and staff will be educated on it. Staff will also continue to be educated on abuse. Weekly audits will be completed by the Director of Nursing Services for late medications. The DNS will report findings weekly in morning meeting until 100% compliance.

************************ OAR 411-085-0310 Residents' Rights: Generally Refer to F550 ************************ OAR 411-085-0360 Abuse Refer to F600, F609 and F610 ************************ OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F660 ************************ OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ************************

Based on interview and record review it was determined the facility failed to ensure a resident's family concern was responded to in a timely manner for 1 of 3 sampled residents (#1) reviewed for incontinence. This placed residents and involved parties at risk for unresolved concerns. Findings include: A facility Grievance Policy last reviewed 1/2018 revealed the facility was to support and assist the residents and their representative in their right to file a grievance in order to resolve concerns. Grievances and/or complaints could be submitted orally or in writing. The person submitting the grievance would receive a response within seven days and may obtain a written response upon request. Resident 1 was admitted to the facility in 2022 with diagnoses including a stroke. A 9/17/22 Admission CAA indicated Resident 1 had a stroke, was not able to speak but could appropriately nod her/his head yes and no. The resident was not able to move her/his right side and required assistance to transfer and perform ADLs. The resident was frequently incontinent and it was unclear if the resident's ability to sense her/his need for toileting was related to the resident's impaired communication. Staff were to initiate routine toileting. A 9/22/22 Care Conference Notes form indicated the RNCM and Social Services Director (SSD) attended (staff names not specified), the resident and family did not attend but family called prior to the conference. When the family called they reported when they visited on two occasions, on the evening shift, the resident was found to have soaked incontinent briefs. On 12/29/22 at 11:56 PM Staff 1 (Former Social Service Director/SSD) stated she vaguely recalled the resident and may have spoken to the resident's family but did not recall the nature of the conversation. If the family had concerns related to incontinence the issue would be referred to the RNCM to investigate. The RNCM was then responsible to ask staff to see if the resident was, in fact, left soiled. On 12/22/22 at 10:13 AM and 10:24 AM Staff 2 (RNCM) stated she vaguely recalled the care conference and the concern related to Resident 1 being left soiled on the evening shift. Staff 2 looked at the resident's care plan and stated the care plan was updated the day after the care conference, so she likely spoke to staff but could not recall. On 12/21/22 at 2:56 PM Witness 2 (Family) stated the facility did not communicate with her after the care conference related to the resident's soaked incontinence briefs. On 12/29/22 at 12:54 PM Staff 3 (DNS) stated if family called and reported a concern related to care, they were to look into the concern and follow up with the family. It was expected the RNCM would communicate with the family member to let them know if any changes were made to address the identified concerns. A request was made to Staff 3 to provide documentation to verify Resident 1's family concern was looked into to ensure care was provided and follow up was made to the family. No additional information was provided .

Resident #1 has since been discharged from the facility. All residents and involved parties are at risk for this alleged deficient practice of having unresolved concerns. An audit of any grievances received since January 1st, 2023 will be conducted to assure there has been follow up. The Grievance policy and been reviewed and updated. Health Center Inter Disciplinary Team (IDT) have been educated on the policy on 1/19/2023. All grievances will be reported in morning meeting by social services or designee to the IDT team. Social services will do a weekly audit of grievances to ensure there has been follow up timely and it is documented. The audit will be turned in to the Administrator each Friday. The results of the audit will be reported monthly in QAPI for 3 months or until 100% compliance is met.

Based on interview and record review it was determined the facility failed to ensure a resident's medication was not misapporpriated for 1 of 3 sampled residents (#2) reviewed for lost and stolen items. This placed residents at risk for pain. Findings include: Resident 2 was admitted to the facility in 2017 with diagnoses including chronic pain and had orders for baclofen (muscle relaxant)10 mg. Resident 5 was admitted to the facility in 2022 with diagnoses including pain and had orders for baclofen 10 mg. A 12/9/22 FRI and associated investigation revealed on 12/9/22 Staff 4 (Agency LPN) reported Resident 2's baclofen card was located in Resident 5's mediation slot. A line was drawn through Resident 2's name and Resident 5's name was written on the card. All staff who administered medications were interviewed and it was not able to be determined who placed Resident's 2 baclofen card in Residents 5 medication slot to be used or when it occurred. On 12/22/22 at 12:32 PM Staff 4 stated she worked in the facility a few days prior and she did not see Resident 2's card in Resident 5's medications slot. She reported the concern immediately. Resident 2's December 2022 MAR revealed she/he received her/his baclofen as ordered. Resident 2' December 2022 Progress Notes did not indicate the resident had unrelieved pain. Resident 5's December 2022 MAR revealed she/he received her/his baclofen as ordered. The facility completed the investigation of the incident on 12/12/22 which included an audit of the medication cart. On 12/16/22 the Past Noncompliance was corrected when the facility implemented the Plan of Correction which included: 1. Staff education on facility Mission, Nursing Standards of Practice, Abuse Policy including misappropriation of property, process to correctly obtain medications, when to notify a physician for missed medications, consequences of infarctions and employee expectations.

Based on interview and record review it was determined the facility failed to ensure investigations were completed timely for 2 of 3 sampled residents (#s 1 and 6) reviewed for falls. This placed residents at risk for continued falls. Findings include: A facility Event Management Policy last reviewed 3/2021 revealed event investigation summaries were to be completed no later than five days after the event. Causative factors were to be reviewed and the care plan was to be updated as needed to prevent reoccurrences. 1. Resident 1 was admitted to the facility in 2022 with diagnoses including a stroke. A base line care plan initiated on 9/12/22 indicated Resident 1 was at risk for falls and staff were to keep frequently used items within reach and staff were to frequently observe the resident. a. A 9/14/22 Fall investigation revealed Resident 2 was found on the floor, the call light was not activated and a staff member was with the resident moments prior to the fall. An 11/21/22 Incident Note indicated it was a follow-up note to the 9/14/22 fall. The cause of the fall was that the resident's belongings were likely not close to the resident. This analysis was completed more than two months after the fall. On 12/22/22 at 10:07 AM Staff 5 (RN) stated she was not the resident's RNCM but was helping out. The summary analysis should be completed in less than one week and was not sure the reason it was not completed timely. On 12/29/22 at 12:53 PM Staff 3 (DNS) stated she was not sure the reason Resident 1's fall investigation was not completed within five days. b. A Fall investigation dated 9/26/22 indicated Resident 1 was found on the floor, the call light was not activated and the resident indicated she/he attempted to self-transfer. A 12/21/22 Incident Note indicated it was a follow-up to the 9/26/22 fall. The resident was found on the floor after an unsuccessful self-transfer and was seen just minutes before the fall. The root cause of the fall was poor safety awareness. On 12/22/22 at 10:34 AM Staff 2 (RNCM) stated she often did the fall follow-ups and updated the care plans after the falls but did not document the investigation summary. Staff 2 acknowledged the investigative summary should be completed within five days. On 12/29/22 at 12:53 PM Staff 3 (DNS) was not sure the reason Resident 1's fall investigations were not completed within five days. 2. Resident 6 was admitted to the facility in 2020 with diagnoses including brain bleed. A care plan initiated 8/2020 indicated Resident 6 was at risk for falls and staff were to place a bolster (wedge) to the left side of her/his bed at night and the right side was to be against the wall. a. An 11/24/22 fall investigation indicated the resident was observed on the floor and had a recent room change. An Incident Note dated 12/7/22 indicated it was a follow-up note for 11/24/22 fall. The root cause of the fall was weakness and a new environment. The resident was just moved to the Covid-19 unit and the room was not set up like her/his room and it was likely disorienting for the resident. On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged she did the follow-up analysis of the fall investigation and was not sure the reason the investigation was not completed within five days. b. An 11/29/22 at 9:13 PM Fall investigation indicated Resident 6 was found with her/his legs off the bed and her/his upper body remained on the bed. The resident was confused and was assessed to have a small open area to the right knee. An Incident Note dated 12/7/22 indicated it was a follow-up to the 11/29/22 fall. The analysis indicated the resident was in a new environment and the resident did not have a bolster on her/his bed. However, the bolster did not always keep the resident from falling or attempting to get out of bed. The note indicated the resident was currently back to her/his normal room and the bolster was in place. On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged she did the follow-up analysis of the fall investigation and was not sure the reason the investigation was not completed within five days. Staff 3 indicated she did not know the bolster was not in place until the summary was completed. The staff initiating the fall investigation should make note of the interventions and implement if not present at the time of the fall. Refer to F689 example 2. c. A 12/1/22 at 10:41 PM revealed there resident had an unwitnessed fall and was found kneeling on her/his knees. An Incident Note dated 12/7/22 indicated it was a follow up note to the 12/1/22 fall when the resident was found on the floor on her/his knees. The resident was found to have a skin tear to the elbow. The note indicated the bolster remained off the bed as the resident was not in her/his permanent room. On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged she did the follow-up analysis of the fall investigation and was not sure the reason the investigation was not completed within five days. Staff 3 indicated she did not know the bolster was not in place until the summary was completed. Refer to F689 example 2. d. A 12/1/22 at 2:31 AM Witnessed Fall Investigation indicated the resident rolled out of bed. The resident was confused at the time of the fall. A 12/7/22 Incident Note indicated the note was a follow-up to the 12/1/22 fall. The resident was observed to roll out of bed. The root cause of the fall was the resident's bolster was not in place and the resident was in a new room due to Covid-19. On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged she did the follow-up analysis of the fall investigation and was not sure the reason the investigation was not completed within five days. Staff 3 indicated she did not know the bolster was not in place until the summary was completed. Refer to F689 example 2.

Resident 1 has since been discharged from the facility. Resident 6’s care plan has been reviewed to ensure all interventions are in place to help prevent falls. All residents that fall are at risk for this alleged deficient practice of untimely event investigations. An audit of fall investigations in the last 30 days will be completed for timely investigations. The Event Management policy was reviewed and education provided to nursing staff on 2/13/2023 with emphasis on initial investigations including a root cause, an intervention and a review of care plan to assure interventions are in place. Additional education provided to Nurse Mangers on timely completion and thoroughness of investigations on 1/27/2023. All event reports that need to be created, investigated and completed will be gone over in morning meeting. The Resident Nurse Managers (RNMs) will do a weekly audit of all event reports that need to be completed to meet the timeline requirements and will be emailed to the Administrator as well as the Director of Nursing every Friday. The results of the audit will be reported monthly in QAPI for 3 months or until 100% compliance is met.

Based on interview and record review it was determined the facility failed to ensure a resident was assisted with showers for 1 of 3 sampled residents (#3) reviewed for bathing. This placed residents at risk for lack of hygiene. Findings include: Resident 3 was admitted to the facility 11/1/22 with diagnoses including bone infection of the right foot and ankle. Resident 3 discharged on 12/8/22. An 11/13/22 Admission CAA indicated Resident 3 was cognitively intact and was unable to walk due to pain to the right foot. Due to her decrease in her/his ability to do her/his ADLs a care plan was developed. A care plan initiated 11/14/22 indicated the resident at times refused showers but staff were to encourage her/him to shower and one staff was to assist the resident as needed twice a week and PRN. An 11/2022 through 12/2022 Bathing record revealed the resident refused one shower and received one shower. The resident had nine missed bathing opportunities for her/his facility stay. On 12/29/22 at 9:26 AM Resident 3 stated at one point she/he did not get assistance with showers for at least 10 days. On 12/22/22 at 10:57 AM Staff 2 (RNCM) acknowledged only three showers were documented including one shower which was provided by therapy. A request was made for documentation to show bathing was offered to Resident 3. No additional information was provided.

Resident 3 has since discharged from the facility. All residents who need assistance with showering are at risk for the alleged deficient practice of not assisting a resident with a shower. An audit of the last 2 weeks of showers/baths will be completed for documentation completeness. The Bathing/Showering Policy was reviewed and updated. Education given to CNA staff on 1/20/2023 with emphasis on documentation of the bath/shower. The Resident Nurse Managers (RNMs) will do a weekly audit of residents who need assistance with showers. The audit will be of 25% of the residents on each wing to ensure showers are being given or offered. The RNMs will turn in the audit to the Administrator each Friday. The results of the audit will be reported monthly in QAPI for 3 months or until 100% compliance is met.

Based observation, interview and record review it was determined the facility failed to ensure fall interventions were in place for 2 of 3 sampled residents (#s 4 and 6) reviewed for falls. This placed residents at risk for injury. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including a fractured leg. A 10/18/22 Admission CAA indicated the resident was cognitively impaired, had poor safety awareness and did not request staff for assistance. The resident's call light was to be kept within reach, but the resident was not yet seen using the call light. Additional interventions indicated the resident's bed was also to be kept at knee height in case the resident attempted to stand without assistance. Resident 4's 10/26/22 care plan reflected the bed was to be at knee height and the call light was to be within reach. a. On 12/21/22 at 2:03 PM Resident 4 was observed in bed and the bed was at least hip height. On 12/21/22 at 2:11 PM Staff 6 (CNA) stated she just left the resident's room and acknowledged the bed was not lowered to knee height after care was provided. b. On 12/22/22 at 9:35 AM Resident 4 was observed in bed. The resident's call light was on the floor. Staff 4 (LPN) was notified and acknowledged the call light was not within the resident's reach and stated the resident at times used the call light. On 12/22/22 at 9:39 AM Staff 7 (CNA) stated when he assisted the resident up for breakfast the resident's call light cord was tangled in the bed control and when the bed was elevated the call light must have fallen off the bed. 2. Resident 6 was readmitted to the facility 11/2022 on hospice services. An 11/2022 Significant Change MDS and CAAs revealed the resident was cognitively impaired, did not request assistance for her/his needs and had a history of multiple falls in the past year related to impulsiveness and poor safety awareness. The resident often attempted to transfer her/himself. Multiple interventions were to be implemented including at night a bolster (wedge shaped pillow) was to be placed on the left side of the bed. An 11/29/22 at 9:13 PM Unwitnessed fall investigation and associated Incident Note (post fall review) revealed Resident 6 was observed with her/his legs out of the bed and her/his upper body in bed, and attempted to get out of bed bed without assistance. The resident was recently moved to a new room due to Covid-19 infection and was not familiar with her/his environment and the bed lacked a bolster. The note indicated the bolster did not always stop the resident from exiting the bed. Fall investigations revealed Resident 6 fell two times on 12/1/22. On 12/1/22 at 2:31 AM the resident was witnessed to roll out of bed. The resident stated she/he was going to church. On 12/1/22 at 10:41 PM the resident was found kneeling by her/his bed. The resident stated she/he was trying to get up to see her/his spouse. The associated Incident Notes indicated the resident did not have the bolster on the bed for both falls. On 12/22/22 at 10:38 AM Staff 2 (RNCM) stated she was not sure the reason the bolster was not taken with Resident 6 to the Covid-19 unit. The bolster did not prevent falls because Resident 6 was able to go over and/or around the bolster but it was a fall intervention that was not in place at the time of the 11/29/22 and 12/1/22 falls. On 12/29/22 at 12:53 PM Staff 3 (DNS) acknowledged the resident was to have the bolster in place at night, the resident fell three times on the night shift while on the Covid-19 unit and the resident's bolster was not in place. The nurse initiating the investigation should have reviewed the care plan to ensure all interventions were in place at the time of the fall. Staff 3 stated when she completed the post fall review she identified the bolster was not in place.

Resident 4 and 6 are still in the facility and their care plans have been reviewed to include all interventions that are in place to help prevent them from falling. All residents who at risk for falls are at risk for the alleged deficient practice of not having fall interventions in place. An audit of those resident who are considered high risk of falling by their Morse Scale score or who have had a fall in the last 3 months, will have their care plan reviewed to assure it has appropriate interventions and then an audit tool will be created. The Event Management policy was reviewed and education provided to nursing staff on 2/13/2023 with emphasis on initial investigations including a root cause, an intervention and a review of care plan to assure interventions are in place. Additional education provided to Nurse Mangers on daily rounding of unit to visualize that fall interventions are in place as care planned. The Resident Nurse Managers (RNMs) will do a daily audit of all the resident’s rooms who are at risk for falls to ensure there are interventions are implemented per care plan. The audit will be of 100% of the residents on each wing. The RNMs will turn in the audit to the Administrator each Friday. The results of the audit will be reported monthly in QAPI for 3 months or until 100% compliance is met.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment was free from accident hazards and a care plan was followed to prevent falls for 1 of 3 sampled residents (#7) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 7 was readmitted to the facility 2/2023 with diagnoses including altered mental status. A 1/23/23 CAA indicated Resident 7 had a history of falls, at times self-transferred and used her/his call light. A Care Plan initiated 1/31/23 and last updated 2/21/23 revealed the resident was at risk for falls related to gait/balance problems and weakness following hospitalization for heart disease. Interventions included nonskid socks at all times, frequent checks and her/his call light was to be within reach. Progress notes revealed on 2/26/23, early am, Resident 7 had an unwitnessed fall. The resident did not activate the call light and reported she/he attempted to transfer to the wheel chair, lost balance and fell. On 2/27/23 at 11:45 AM Resident 7 was observed in a recliner approximately four feet from her/his bed. The recliner foot rest was elevated. The resident's call light was on the bed and not within the resident's reach. On 2/27/23 at 12:00 PM Staff 8 (RN) stated Resident 7 was more confused since readmission to the facility but at times activated her/his call light. Staff 7 confirmed Resident 7's call light was to be within reach and it was not currently accessible. Staff 8 indicated Resident 7 was able to transfer from the recliner to a standing position and was able to lower the recliner foot rest. When Staff 8 requested Resident 7 to lower the foot rest the resident was unable to do so. Staff 8 stated if the resident attempted to stand without lowering the footrest it would become a fall hazard. On 2/27/23 at 1:18 PM Staff 2 (RNCM) stated Resident 7 readmitted to the facility 2/10/23 and after readmission to the facility was diagnosed with pneumonia. Resident 7 continued to work with therapy but fatigued easily. Staff 2 indicated Resident 2 fell on 2/26/23 from bed due to a self-transfer and did not activate the call light prior to the fall. Staff 2 acknowledged if Resident 7 was not able to lower the leg rests and attempted to self-transfer it could become a fall hazard. Staff 2 indicated the resident's use of the recliner was not assessed.

Resident 7 is still in the facility. A recliner assessment will be completed for the resident to ensure it is not considered a fall risk. A recliner consent will also be completed for Resident 7. All residents that use a recliner as well as a call light are at risk for this alleged deficit practice. An audit of all residents that have recliners will be conducted to make sure that they are not a fall risk. This audit will be completed quarterly after the initial one to ensure the recliners for each resident do not develop into a fall risk. This audit will be ongoing and brought to QAPI quarterly. A call light audit will be completed weekly to include 25% of the residents on each wing. The audit will be completed each week by the RN Unit Manager and will consist of them checking to make sure the call light is within reach. This audit will be brought to QAPI each month for three months or until 100% compliance.

OAR 411-085-0310 Residents ' Rights: Generally

Refer to F585 *************** OAR 411-085-0360 Abuse Refer to F602 and F610 *************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F676 *************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689 ****************

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

Based on interview and record review it was determined the facility failed to provide adequate freedom from abuse for 1 of 4 sampled residents (#3) reviewed for abuse. This placed the residents at risk for abuse. Findings include: The facility's 1/2022 revised Freedom from Abuse, Neglect, and Exploitation Policy defined abuse included but is not limited to: freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraints not required to treat the resident's medical symptoms. Resident 3 was admitted to the facility in 2021 with diagnoses including hemiplegia (paralysis) after a CVA affecting the left non dominant side. Resident 3's 8/30/22 quarterly MDS indicated the resident was cognitively intact and the resident required extensive assistance with bed mobility, transfers, toileting and dressing. Resident 3 was incontinent of both bowel and bladder. Resident 4 was admitted in 2022 with diagnoses including right below the knee amputation and diabetes. Resident 4's 5/10/22 quarterly MDS indicated the resident was cognitively intact; used a walker and a wheelchair. Resident 4's 3/2022 Behavior Care Plan indicated resident had exhibited sexually inappropriate behaviors and repeatedly said inappropriate sexual comments to staff. The 7/2022 records revealed the facility initiated an investigation into Resident 3's sexual abuse allegation by Resident 4 and the allegation was substantiated by the facility. On 10/24/22 at 12:39 PM Resident 3 stated Resident 4 would see her/him in the dining room, come over and have coffee and then follow Resident 3 back to Resident 3's room. Resident 3 stated Resident 4 would come into her/his room and "feel me from the neck clear down". Resident 3 stated this happened a few times. Resident 3 stated this was reported to "the CNA's" and Staff 18 (LPN). Resident 3 also reported it to their physician. Resident 3 did not remember the exact dates when the incident occurred. On 10/24/22 at 12:55 PM Staff 18 (LPN) stated Staff 20 (CNA) informed her that resident 4 was inappropriately touching Resident 3's breasts. Staff 18 stated she reported it immediately to Staff 11. On 10/25/22 at 2:39 PM Staff 20 (CNA) stated Resident 3 told her Resident 4 was in her/his room several times in July or August but could not recall the dates. Staff 20 stated Resident 3 told her Resident 4 would go to the left side of the bed on Resident 3's affected side and would put her/his hands up Resident 3's shirt. Staff 20 stated she reported it to Staff 18 (LPN). On 10/25/22 at 12:11 PM Staff 19 (CNA) stated she was aware Resident 4 would go to other resident's rooms and sit inside the door or at the bedside in the wheelchair and would talk with the female residents. Staff 19 stated this seemed strange to her because some of those residents were not cognitively intact. Staff 19 stated these conversations would take place around 11:00 PM and Resident 4 would not always leave when asked to. Staff 19 stated she had spoke to multiple nurses about Resident 4's actions. On 10/25/22 at 4:33 PM Staff 11 (former RN Manager) stated she immediately informed Administration about Resident 4's inappropriate sexual conduct. Staff 11 stated Resident 4 would visit other female residents in doorways. Staff 11 stated Resident 4 had entered other resident's rooms previously and now interventions were put in to place to monitor Resident 4. On 10/28/22 Staff 2 (DNS) stated residents should be free from abuse.

Resident 3 is still in the facility and was monitored for mood and behavioral changes after the event. Resident 4 has been discharged from the facility. All residents are at risk deficient practice for abuse. In person abuse training took place on 11/9/22 and 11/11/22 for all Health Center staff. Additionally, all Health Center staff were assigned abuse training in Relias which was due 11/15/22. All new hire staff are receiving Relias on abuse and the Administrator is going over abuse reporting in new hire orientation. The Administrator and/or designee will pull 5% of the Health Center staff a month to do an audit on abuse education. This will be ongoing for three months or until 95% compliance is reached and the results will be reported in QAPI. Date of compliance will be December 16th, 2022.

Based on interview and record review it was determined the facility failed to timely report allegations of abuse for 2 of 5 sampled residents (#'s 1 and 2) reviewed for abuse. This placed residents at risk for abuse and neglect. Findings include: 1. Resident 2 was admitted to the facility in 2022 with diagnoses including hemiparesis (Paralysis) affecting the right dominant side and a fractured right femur. The facility investigation dated 2/1/22 indicated an allegation of staff to Resident 2 abuse occured on 2/1/22 at 2:37 PM. The FRI report was received by the State on 2/2/22 at 8:15 AM. On 10/28/22 at 3:30 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the incident was reported late to the State. 2. Resident 1 was admitted to the facility in 2022 with diagnoses including weakness and repeated falls. The facility investigation dated 9/5/22 indicated an allegation of staff to Resident 1 abuse occured on 9/2/22 at 6:00 PM. The FRI report was received by the State on 9/5/22 at 1:30 PM. On 10/24/22 at 11:46 AM Staff 1 (Administrator) stated she expected allegations of abuse to be reported within two hours. Staff 1 confirmed this allegation was reported late.

All residents are at risk for this alleged deficient practice for timely reporting of allegations of abuse. All directors were educated on the abuse protocols, which include timely reporting, in the Health Center on 11/4/2022. In person abuse training took place on 11/9/22 and 11/11/22 for all Health Center staff. In both in person training, the two-hour reporting time frame was emphasized heavily. Additionally, all Health Center staff were assigned abuse training in Relias which was due 11/15/22. All new hire staff are receiving Relias on abuse and the Administrator is going over abuse reporting in new hire orientation. The Administrator and/or designee will pull 5% of the Health Center staff a month to do an audit on abuse education regarding timely reporting. This will be ongoing for three months or until 95% compliance is reached and the results will be reported in QAPI. Date of completion will be December 16th, 2022.

Based on observation, interview, and record review it was determined the facility failed to provide adequate transfer assistance for 1 of 4 sampled residents reviewed for abuse (# 2). This placed the residents at risk pain and improper transfers. Findings include: Resident 2 was admitted to the facility in 2021 with diagnoses including a stroke with hemiplegia (paralysis) affecting resident's right side and a fractured right femur. Resident 2's annual 9/29/22 MDS indicated Resident 2 was cognitively intact and the revised 1/27/22 care plan indicated the resident was a one person assist with transfers. On 10/24/22 at 11:48 AM Resident 2 stated Staff 10 (CNA) assisted her/him by placing their arm under mine and lifting which hurt a lot. Resident 2 stated they made Staff 10 aware of the pain and asked them not to do that again. Resident 2 further recounted when Staff 10 assisted her/him to bed Staff 10 lifted Resident 2's right arm which hurt, and she/he cried. Resident 2 also stated this was not the first time Staff 10 had transferred her/him this way. Resident 2 was unable to recall a date or time. On 10/24/22 at 3:52 PM Staff 10 stated she was a traveling CNA and worked with Resident 2. Staff 10 stated during an assisted transfer Resident 2 said, 'no, not like that'. Staff 10 confirmed she might have used too much force during the transfer. Staff 10 confirmed Resident 2 did cry. On 10/28/22 Staff 2 (DNS) stated our residents should be free from abuse. On 2/2/22 Staff 1 (Administrator) investigated the allegation of rough handling and Staff 10 was removed from the floor and asked not to return.

All residents who are one person transfers are at risk for this alleged deficient practice. In person abuse training took place on 11/9/22 and 11/11/22 for all Health Center staff. During this training staff were educated on what to do if a resident says they are being hurt during cares. An audit of all one person transfers will be done to ensure their care plan is appropriate. There will be an in-person training on transfers on 12/9/22. An audit will be done on one person transfers which will consist of the RN Unit Managers asking the applicable residents if they are experiencing pain during transfer. The audit frequency will consist of 25% of one person transfers a week. The audit will go on for three months or until 95% compliance is met. The audit will be reported in QAPI for 3 months or until compliance is met.

*************************** OAR 411-085-0360 Abuse Refer to F600 *************************** OAR 411-085-0360 Abuse Refer to F609 *************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ***************************

Based on observation and interview it was determined the facility failed to ensure survey results were in a readily accessible area for residents and visitors for 1 of 1 survey result binders reviewed for public information. This placed residents and visitors at risk for not being informed of the facility's survey history. Findings include: On 6/30/22 at 12:42 PM a laminated sheet of paper reading "Survey Information Available Upon Request" was observed on a table in the reception area of the facility. On 6/30/22 at 12:44 PM the survey result binder was requested from Staff 8 (Receptionist). Staff 8 provided the survey result binder from behind the reception desk. There were no signs at the reception desk indicating where the binder was located or if residents and visitors were free to go behind the desk and retrieve it. On 6/30/22 at 2:02 PM Staff 1 (Administrator) acknowledged the survey result binder was kept behind the reception desk and stated residents and visitors could ask staff to retrieve it.

All residents have the possibility of being affected by this as the survey binder was not readily available. The survey binder was placed in the lobby of the Health Center on 6/30/2022 for all residents to have easy access to at any time. A weekly audit will be done by the Administrator to ensure the survey binder is readily available for anyone to view at any given time. The audits will be done for three months and reported in QAPI for 3 months.

Based on interview and record review it was determined the facility failed to obtain copies of Advance Directives if available or periodically review resident's wishes to execute an advance directive for 3 of 3 sampled residents (#s 28, 60, 66) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 28 admitted to the facility in 2021 with diagnoses including heart disease and high blood pressure. A review of the medical record revealed Resident 28 did not have an advance directive and there was no information to indicate the facility periodically followed up with the resident related to her/his desire to execute an advance directive. On 6/30/22 at 11:48 AM Staff 4 (LPN/Health Center Navigator) stated residents were asked at admission about advance directives. Staff 4 added if a resident was interested in executing an advance directive they were referred to social services for assist. On 6/30/22 at 4:15 PM Staff 1 (Administrator) stated advance directives were addressed at time of admission. Staff 1 added advance directives should be reviewed annually. Staff 2 (DNS) indicated advance directives were not reviewed with residents during care conference meetings. 2. Resident 60 admitted to the facility in 2021 with diagnoses including diabetes and end stage kidney disease. A review of the medical record did not include information related to advance directives. On 6/30/22 at 12:25 PM Resident 60 was asked about advance directives. Resident 60 did not know what an advance directive was, denied having one or the facility asking about advance directives. On 6/30/22 at 11:48 AM Staff 4 (LPN/Health Center Navigator) stated residents were asked at admission about advance directives. Staff 4 added if a resident was interested in executing an advance directive they were referred to social services for assist. On 6/30/22 at 4:15 PM Staff 1 (Administrator) stated advance directives were addressed at time of admission. Staff 1 added advance directives should be reviewed annually. Staff 2 (DNS) indicated advance directives were not reviewed with residents during care conference meetings. , 3. Resident 66 admitted to the facility in 2018 with diagnoses including diabetes. A 3/10/22 Annual MDS revealed Resident 66 had a BIMS score of 15 which indicated she/he was cognitively intact. Care Conference Notes on 3/15/22 and 6/7/22 revealed a care conferences were held for Resident 66 and there was no documentation regarding an advance directive being offered or reviewed. In an interview on 6/30/22 at 2:44 PM Staff 6 (RN Unit Manager) stated the facility preferred to have Physician's Order for Life Sustaining Treatment (POLST) for the residents and was unaware of the process for advance directives. In an interview on 6/30/22 at 3:14 PM Staff 5 (Social Services Director) stated POLSTs were reviewed, however was unaware of the process for advance directives. On 6/30/22 at 4:15 PM Staff 1 (Administrator) stated advance directives were addressed at time of admission. Staff 1 added advance directives should be reviewed annually. Staff 2 (DNS) indicated advance directives were not reviewed with residents during care conference meetings.

All residents have the possibility to be affected by Advance Directives not being reviewed annually. The policy and procedure was reviewed. Upon admission, the Health Care Navigator will ask the resident for the Advance Directive information. The resident will either provide the information or the Health Care Navigator will note that they refused. The Advance Directive will be reviewed annually for new and current residents by Social Services. Audits of Advance Directives will be broken down by halls or part of halls to be done monthly and reviewed quarterly in QAPI ongoing. A full audit of all residents and their Advance Directives will be done and completed by August 20th.

Based on interview and record review it was determined the facility failed to notify a resident's representative for 1 of 3 sampled residents (#53) reviewed for change in condition. This placed resident responsible parties at risk for not being informed. Findings include: Resident 53 admitted to the facility in 5/2020 with diagnoses including bilateral amputations below the knees and diabetes. A Physician Progress Note dated 8/25/21 revealed Resident 25 was seen by a physician and had a polyp (a growth in the outside ear canal or middle ear) removed in her/his left ear canal. No documentation was found in the clinical records Resident 53's representative was notified of the medical procedure to remove the polyp. On 6/30/22 at 5:00 PM Witness 2 (Complainant) confirmed Witness 1 was not notified of the procedure on 8/25/21. On 7/1/22 at 3:11 PM Staff 11 (RN/Nurse Manager) stated Witness 1 was not notified of the 8/25/21 appointment or procedure. Staff 11 stated she expected staff to notify family of upcoming appointments or procedures.

Resident 53’s responsible is aware of procedure that took place on 8/25/21. All residents and their responsible parties are at risk for this deficit practice. An audit will be done of all appointments that have been scheduled July 10th through July 25th, 2022 for documentation in the progress notes that notification was made to resident/responsible party regarding the appointment. If no notification note was made, one will be made in the progress notes. Change of conditional policy was reviewed and revised to include notification of appointments. Nursing was educated will be education on 8/8/22 on updated policy. Appointments are reviewed in morning meeting each business day an the nurse manager will audit to ensure there has been a progress note placed that resident responsible party have been notified of the appointment. 100% of appointments will be audited for 4 weeks, then 50% for four weeks and then 25% of appointments for four weeks. Results will be brought to QAPI monthly meeting and if results trend downward on compliance auditing will go to the higher prior rate until compliance is met in monthly QAPI.

Based on observation, interview and record review it was determined the facility failed to revise a care plan for 1 of 1 sampled resident (#21) reviewed for hospice. This placed residents at risk for unmet care needs. Findings include: Resident 21 was admitted to the facility in 2016 with diagnoses including heart disease and depression and admitted to hospice services in 10/2021. Random observations from 6/27/22 through 6/30/22 revealed Resident 21 was up in the wheelchair at meal times or in bed. Resident 21's care plan was revised on 10/28/21 for terminal diagnosis and admission to hospice services. The care plan was not revised to include the absence of a spouse for support or visits, lack of participation in facility activities, current day to day routines, decline in ADL abilities, location of dining, refusals of denture care and discharge plan. On 6/30/22 at 2:40 PM Staff 3 (RN Nurse Manager) was asked about care plan revisions and agreed Resident 21's care plan did not reflect her/his current needs.

The care plan for resident 21 has been updated to reflect his/her current needs. All residents on hospice are at risk for this deficient practice. An audit of all residents on hospice services will be conducted to review their care plans and evaluate if care plans are reflective of his/her current needs. Care plans will be updated if they are not reflective. Comprehensive care plan policy was reviewed. Education will be provided to the interdisciplinary team on 8/1/22. The hospice program policy was reviewed and updated. Education to nursing will be done on 8/5/22 and 8/8/22. The interdisciplinary team will be educated on 8/1/22. 100% of hospice care plans will be audited for the next 6 months with MDS schedule with results brought to monthly QAPI. Additionally, 25% of care plan revisions will be reviewed by the Director of Nursing and brough to QAPI monthly for 3 months to ensure accuracy.

Based on observation, interview and record review it was determined the facility failed to assess and monitor bruising for 1 of 1 sampled residents (# 59) reviewed for skin conditions. This placed residents at risk for unmet needs. Findings include: Resident 59 was admitted to the facility in 3/2022 with diagnoses including diabetes. On 6/29/22 at 1:50 PM and 6/30/22 at 2:49 PM Resident 59 was observed to have multiple bruises to her/his left arm and hand. The bruises were dark purple and dime size to a half dollar size. A review of Resident 59's medical record revealed no documentation, assessment or monitoring for the bruises. On 7/1/22 at 8:35 AM Staff 14 (LPN) acknowledged they were aware of Resident 59's bruises but had not completed a skin sheet, assessment nor monitored the bruises.

A monitor was placed in the treatment administration record to monitor the bruise for resident 59 daily. All residents with skin conditions are at risk for this deficient practice. An audit of the last two weekly skin checks will be done to ensure that there is a treatment monitor in place for each skin condition. If a monitor is not in place, one will be added. The pressure ulcer management policy was reviewed and revised to reflect emphasis on the weekly skin check and placing monitors/obtaining orders for skin conditions. Nursing staff will be educated on 8/5/22 and 8/8/22. The nurse manager will audit weekly skin checks and monitor the compliance in weekly skin meeting. Compliance will consist of weekly skin check and corresponding skin condition monitor. Results of these audits will be reported monthly in QAPI or until 95% compliance.

Based on observation, interview and record review it was determined the facility failed to ensure safety interventions were in place for 1 of 1 sampled resident (#30) reviewed for accidents. This placed residents at risk for elopement. Findings include: Resident 30 admitted to the facility in 5/2018 with diagnoses including dementia and depression. An 8/10/18 care plan revealed Resident 30 had an ADL self-care performance deficit related to dementia and weakness. Resident 30 used her/his wheelchair to self-propel around the facility. A revised 12/16/21 care plan revealed Resident 30 wandered which placed her/him at risk for elopement and she/he wore a Wander Guard (a device thatsets off an alarms) bracelet to alert staff if she/he attempted to elope. Elopement incident dated 3/23/22 revealed the following: -On 3/19/22 Resident 30 was found by staff in the front parking lot outside of the lobby but did not leave the facility property. Resident 30 was returned to the dining area for breakfast and scheduled medications. -Resident 30 had a Wander-Guard on her/his wrist during the incident but because staff where unable to hear Resident 30's alarm they were unaware of her/his location. -Resident 30 was unable to explain why she/he was outside but was distressed about being outside and cold. Elopement incident dated 6/28/22 revealed the following: -On 6/10/22 Resident 30 was found outside the building in the enclosed courtyard at approximately 3:15 AM she/he was last seen at approximately 3:00 AM when she/he woke up for a snack. -Resident 30 was heard yelling outside in the enclosed courtyard. -Resident 30 was assisted inside, warmed up and consoled because it had been raining outside and when staff brought Resident 30 in her/his clothes were soaked. -The door Resident 30 exited on 6/10/22 would not have sounded an alarm because other residents could exit the door to go outside into the enclosed courtyard area. The facility placed a stop sign to the back door of the courtyard to dissuade Resident 30 from going out in the courtyard without staff assistance. -On 6/12/22 Resident 30 had no recollection of the 6/10/22 incident. Random observations on 6/27/22 through 6/29/22 revealed Resident 30 was able to self-propel in her/his wheelchair without assistance throughout the facility. On 6/30/22 at 8:16 AM Staff 11 (CNA) stated she was not present for either of the elopements but indicated Resident 30 was to have frequent checks because she/he wandered "a lot" and she/he was hard to keep track of in the building. Staff 11 stated Resident 30 wore a Wander-Guard. On 7/1/22 at 11:59 AM Staff 13 (LPN) stated she recalled the incident on 3/19/22 because she was going to administer Resident 30's medication and was unable to locate her/him. Staff 13 stated Resident 30 was found outside the front lobby area and the alarm had sounded due to her/his Wander-Guard going off but staff could not hear the alarm because she/he was too far away and there was not a staff person at the front desk entrance of the building. Staff 13 further stated staff were to check on Resident 30 every 15 minutes for safety but was difficult to do at times. On 7/1/22 at 1:32 PM Staff 10 (CNA) and at 12:56 PM Staff 12 (CNA) stated Resident 30 was pleasantly confused and she/he could self-propel in her/his wheelchair throughout the facility. Staff 10 and Staff 12 stated they were supposed to check on Resident 30 every 15 minutes but were not always able to check on her/him that frequently. On 7/1/22 at 3:11 PM Staff 3 (RN/Nurse Manager) stated she completed both incident reports on the 3/11/22 and 6/10/22 elopements and both incidents she/he was found outside confused, cold and distressed. Staff 3 stated Resident 30 could not recall either incident from 3/11/22 or 6/10/22 the following day. Staff 3 stated on the 3/11/22 incident staff could not hear the alarm sounding because of where Resident 30 was located. Staff 3 stated the 6/10/22 incident the exit door on the D hall would not have sounded because it did not have an alarm on it. Staff 3 further stated staff were expected to check on Resident 30 every 15 to 30 minutes for safety purposes.

A monitor has been placed to state the location of resident 30 in the facility every 15 to 30 minutes. Further interventions were placed after each elopement, including a WanderGuard placed closer to the nursing station and a stop sign placed on the door of the courtyard. All residents with potential to wander are at risk of this alleged deficient practice. An audit of all residents with potential to wander will be done. Those residents found to be at risk of wandering will have a WanderGuard bracelet placed if interdisciplinary team deems appropriate. All staff will be made of aware residents who at risk to wander. Wandering resident policy and missing resident policy has been reviewed. Nursing staff to be educated on 8/5/22 and 8/8/22 on the expectations of a wandering or missing resident. Additionally, communication regarding WanderGuard activation is sent to the iPhone and staff will be educated about the iPhone responsibilities. Nurse managers will report if the WanderGuard is still in place at the weekly nurse manager meeting. Nurse managers will report if any resident with the WanderGuard have attempted to elope in morning meeting. Interdisciplinary team will place a new intervention in place for the wandering resident in morning meeting if not already done. Results of elopement attempts and care plan interventions to be brought to monthly QAPI meetings by Social Services which will be ongoing.

, Based on observation, interview and record review it was determined the facility failed to ensure safety interventions were in place for 1 of 1 sampled resident (#301) reviewed for accidents. This placed residents at risk for elopement. Findings include: Resident 301 admitted to the facility in 2020 with diagnoses including a stroke and dementia. The 4/25/22 Dementia CAA indicated the resident had a diagnosis of dementia and was at risk for injury due to poor safety awareness and had difficulty recognizing and reporting her/his needs to staff. The Behavior and Dementia Care Plans, last updated 4/2022, indicated the resident went into other residents' rooms without permission and the resident had impaired cognition due to dementia. There was no evidence on the care plan to indicate the resident was at risk for elopement/had eloped, had a Wanderguard (alarm device used to prevent elopement), or was on frequent checks. The 7/25/22 Wandering Risk Assessment indicated the resident was "At Risk to Wander." An 8/24/22 Progress Note indicated the resident walked outside the facility to visit a friend at the facility across the parking lot. A staff member from the other building returned the resident to the facility "unharmed." The resident was noted as unable to find her/his was back to the facility and was "scared." The resident was noted to daily open the door to see what the weather "was doing" and went outside to visit friends in the outside smoking area. The resident was placed on alert for wandering. Progress Notes reviewed from 8/24/22 through 9/22/22 indicated the following: *8/24/22 at 6:33 PM: Resident has not wandered from the facility. She/he walked around "per usual." *8/25/22 at 2:48 PM: Resident up and about the facility per her/his "usual." *8/25/22 at 5:34 PM: Resident had not wandered from the facility, walked around per her/his "usual" and checked in with the nurse often. The Wanderguard was noted as "in place." *8/25/22 at 11:30 PM: The resident wears a Wanderguard after "elopement." The resident took frequent walks so staff were to ensure they kept "an eye on [her/him]" and to respond to door alarms. *8/29/22 at 1:11 PM: Resident was upset that she/he was now wearing a Wanderguard and was not able to go outside unattended any longer. *8/30/22 at 11:05 PM: Resident was very difficult to redirect. The resident wanted to know why she/he was unable to speak to her/his son through the TV remote and mistook the remote for the telephone. The resident was noted as "pleasantly confused" for most of the evening. *9/2/22 at 1:35 AM: The resident's "anxious wandering" had increased. The resident was re-directable but had circular conversations and increased short-term memory deficits. The note indicated staff spent three hours reorienting the resident that shift. The resident stated she/he was experiencing memory loss and it "frightens [her/him]." The note further indicated the resident seemed to be "sundowning." *9/4/22 at 9:39 PM: The resident had behaviors starting at 7:45 that evening. The resident went to bed and came back out with her/his robe undone and was only wearing underwear. The resident insisted she/he was wearing two pairs of pants and was verbally abusive to staff when they tried to intervene. *9/5/22 at 13:24 PM: Resident up per her/his usual ambulating the halls. *9/9/22 at 12:22 PM: Resident up and ambulating around facility per her/his normal routine. *9/13/22 at 12:37 PM: Resident continued to walk around facility with walker. *9/15/22 at 3:50 PM: Wanderguard bracelet removed by staff. *9/19/22 at 11:39 AM: The resident had the Wanderguard removed as the resident "would not stop opening the door or going outside on [her/his] own." *9/19/22 at 7:38 PM: Behavior Management meeting indicated there were no mood/behavior concerns for Resident 301, the resident was at baseline for cognition, mood, and behaviors and there were no elopement incidents. Alert monitoring was discontinued. On 9/22/22 at 12:02 PM A Location Audit for Resident 301 was observed in her/his room and indicated the resident was to be observed every hour. The last entry was for on 9/21/22 at 11:00 PM. On 9/22/22 at 11:47 AM Resident 301 was observed to leave her/his room and go across the hall into another resident's room and ask if staff had picked up the resident's tray. The other resident was overheard stating "lunch hasn't happened." On 9/22/22 at 12:03 PM Staff 6 (LPN) was at the nurse's station and stated she also kept a log for visualizing Resident 301. The log included entries for every hour after 11:00 PM on 9/21/22 up until 6:00 AM. The last entry was for 9/22/22 at 8:00 AM. On 9/22/22 a request was made to the facility to provide an investigation for the 8/24/22 incident. On 9/22/22 at approximately 1:30 PM An Alert Note completed by Staff 2 (RNCM) was provided to the surveyor dated 9/22/22, with a time stamp of 11:17 AM. The note indicated Resident 301 went to visit a friend at a facility across the parking lot, but the door the resident used previously required a key card and was locked. The resident went to another entrance but once inside the building the resident became lost and confused. A staff member from the other facility assisted the resident back to the facility and notified staff. A Wanderguard was placed on the resident but was recently removed as the resident had increased distress about the doors alarming. Staff attempted to to explain the Wanderguard to the resident but due to the resident's impaired cognition the resident became distressed. When the Wanderguard was removed, "location audits" were put in place to ensure staff could locate the resident. Resident 301 was encouraged to notify staff when she/he was leaving the building as the resident "often" would. However, the note indicated due to Resident 301's impaired memory, the resident would at times not notify staff, which was why the location audits were put in place to prevent further elopement incidents. On 9/22/22 at 11:54 AM Staff 4 (CNA) and Staff 5 (LPN) stated Resident 301 currently wore a Wanderguard and went outside to visit her/his friends in the smoking area out in front of the building unsupervised. Staff 4 stated the resident was able to find her/his way back to the facility independently and she was unaware of the resident ever becoming lost. On 9/22/22 at 2:07 PM Staff 3 (LPN) stated the incident on 8/24/22 was the first time Resident 301 had ever become lost when going outside. Staff 6 stated a Wanderguard was placed and then removed as the resident opened doors to check the weather. Staff 6 stated the concern was alarms were being ignored by staff due to the assumption it was Resident 301, but it could have been other residents who wore Wanderguard devices. Staff 6 further stated Resident 301 went outside unattended to the smoking area, which was her/his usual routine and staff were to check on the resident every 30 minutes to an hour. On 9/22/22 at 2:11 PM Staff 2 (RNCM) confirmed the investigation for the 8/24/22 incident was not completed until 9/22/22. Staff 2 stated the expectation was to complete investigations within five days of the incident. Staff 2 stated Resident 301 did not wander but ambulated around the facility throughout the day and went outside to check the weather and visit friends. Staff 2 stated the resident usually communicated to staff if she/he was leaving the facility but if she/he did not see staff then would leave without telling anyone. Staff 2 stated the Wanderguard was removed, and location audits were initiated instead. Staff 2 stated the resident was to be checked on and the audit logs completed every 30 minutes. Staff 2 confirmed the resident's care plan did not include frequent checks or wandering behaviors. On 9/22/22 at 2:40 PM Staff 1 (DNS) stated Resident 301 had cognitive deficits and did not have good recall. Staff 2 stated the resident's friend who lived at the other facility (where Resident 301 lived previously) would visit the resident but on 8/24/22 Resident 301 decided to go visit the other facility and became disoriented. Staff 2 was unsure how long Resident 301 was out of facility on 8/24/22. Staff 2 stated frequent checks were initiated and staff were to observe the resident every 30 minutes. Staff 2 confirmed the Location Audit Logs indicated staff were to check the resident every hour and confirmed the logs were not completed every half hour or hour as indicated. Staff 2 stated Resident 301 was not to leave the facility unattended. Staff 2 confirmed the 8/24/22 investigation was not completed timely.

Resident 301 was affected by this deficit practice. All residents with potential to wander are at risk of this alleged deficient practice. A care plan was developed for wandering. All residents at risk for care plan were reviewed and updated as needed. Those residents found to be at risk of wandering will have a WanderGuard bracelet placed if interdisciplinary team deems appropriate. All staff will be made of aware residents who at risk to wander. Wandering resident policy and missing resident policy has been reviewed. Half hour location monitoring was implemented for resident 301 with audit tool which staff are to write down location, date and time and turn in daily. Management also implemented a GPS tracker for affected resident and placed on walker in case of emergency. Nursing staff was educated on 8/5/22 and 8/8/22 on the expectations of a wandering or missing resident. Results of elopement attempts and care plan interventions to be brought to monthly QAPI meetings by Social Services which will be ongoing.

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 3 of 5 sampled residents (#s 28, 30 and 41) reviewed for unnecessary medications. This placed residents at risk for medication complications. Findings include: 1. Resident 28 admitted to the facility in 2021 with diagnoses including heart disease and high blood pressure. A recommendation for a gradual dose reduction (GDR) of an antidepressant was made in 5/2022 and repeated in 6/2022. On 6/30/22 at 2:53 PM Staff 3 (RN Nurse Manager) was asked about pharmacy recommendations and stated they were sent to the provider for consideration. Staff 3 stated she followed up each week and if the provider failed to address the recommendation after 30 days, the recommendations were sent to the Medical Director by the DNS. On 7/1/22 at 3:37 PM Staff 2 (DNS) stated she sent a list of the pharmacy recommendations to the medical director that were not addressed by the providers. Staff 2 added the medical director signed the recommendations as acknowledgment but did nothing to assist the facility to get other providers to address the recommendations. , 2. Resident 41 admitted to the facility in 4/2022 with diagnoses including dementia and anxiety. A physician order dated 4/28/22 revealed Resident 41 received Haloperidol (an antipsychotic) every two hours as needed for nausea, vomiting, hallucinations and agitation. A physician order dated 4/28/22 revealed Resident 41 received Lorazepam (an antianxiety) every two hours as needed for restlessness, anxiety and insomnia. The 4/27/22, 5/30/22 and 6/27/22 Consultant Pharmacist Medication Regimen recommended to discontinue as needed medications or add a stop date which did not exceed the 14 days from initiation. If the as needed medications could not be discontinued at this time, current regulations required the provider to directly examine the resident to determine if the medications were still needed and document the specific condition being treated prior to issuing a new as needed order. A review of Resident 41's clinical record revealed no documentation from the physician to address the pharmacist's recommendation. On 7/1/22 at 3:11 PM Staff 3 (RN/Nurse Manager) stated they struggled with physicians responding to pharmacy recommendations for Resident 41 and acknowledged no response was received for the 4/25/22, 5/30/22 or 6/27/22 recommendations for Haloperidol and Lorazepam. , 3. Resident 30 admitted to the facility in 5/2018 with diagnoses including dementia and depression. A physician order dated 12/11/21 revealed Resident 30 received Risperidone (an antipsychotic) three times daily for dementia with behaviors. The 4/25/22, 5/30/22 and 6/27/22 Consultant Pharmacist Medication Regimen recommended a GDR (gradual dose reduction) to Risperidone. A review of Resident 30's clinical record revealed no documentation from the physician to address the pharmacist's recommendation to attempt a GDR or present a clinical rational for continued use of Risperidone. No adverse consequences were documented for the continued use of Risperidone. On 7/1/22 at 3:11 PM Staff 3 (RN/Nurse Manager) stated they struggled with physicians responding to pharmacy recommendations for Resident 30 and acknowledged no response was received for the 4/25/22, 5/30/22 or 6/27/22 GDR reduction recommendation for Risperidone.

Residents 28, 30 and 41 pharmacy recommendations have been addressed. All residents are at risk for this alleged deficient practice. An audit of all the June 2022 recommendations will be conducted to see if they have been returned within the last 30 days. The pharmacy recommendation policy was reviewed and discussed with the medical director. Medical Director will be made aware of the missing recommendations and will contact the physicians prior to addressing the recommendations themselves. Policy updated to reflect this. Monthly Pharmacy recommendations will be reviewed weekly by Nurse Managers for unreturned recommendations. Recommendations that remain unreturned will be re-sent to physicians by the Nurse Manager and will continue to be reviewed weekly until response received. Unreturned recommendations will be made known to the DNS or designee weekly. Medical Director will then assist/respond to unanswered pharmacy recommendations. Trends will be brought to QAPI on pharmacy recommendation responses and need to involve medical director for three months.

Based on observation, interview and record review it was determined the facility failed to ensure proper flavor and food temperatures were maintained for food trays served from 1 of 1 facility kitchens and 4 of 4 sampled residents (#s 5, 7, 60 and 66) reviewed for food service. This placed residents at risk for food that was not palatable, safe or appetizing. Findings include: Interviews revealed the following food concerns: On 6/27/22 at 3:12 PM Resident 5 stated the food had no flavor was not hot and the soups were "always" cold. On 6/28/22 at 9:54 AM Resident 7 stated meals were not always hot when she/he received them. On 6/28/22 at 12:16 PM Resident 66 stated the meals had no flavor and were sometimes cold. On 6/28/22 at 3:13 PM Resident 60 was asked about food quality and she/he stated it was getting better but the hot food was not hot. On 6/30/22 at 1:03 PM two lunch trays were provided to survey staff and each meal was served on a plate. One plate had mashed potatoes with gravy, breaded rosemary chicken and steamed mixed vegetables. The second plate had boneless ribs with barbecue sauce over them and buttered noodles. The kitchen staff did not provide a salad, soup or dessert which was part of the lunch items. All meals were tasted and the survey team agreed the ribs were cold, the breaded chicken was soggy with no flavor and the noodles had no taste. The vegetables were not flavored and hard to chew additionally the gravy over the top of the mashed potatoes was salty. On 6/30/22 at 1:10 PM Staff 1 (Administrator) and Staff 2 (DNS) were present and agreed there were temperature issues with the identified meals. Staff 2 stated the ribs and rosemary chicken were warm and the chicken breading had no flavor and was chewy. Staff 2 further stated the noodles had no butter flavor, the steamed vegetables were not flavored and hard to chew, and the gravy was salty.

All residents are at risk for this deficient practice. The kitchen has increased the temperatures of the warming/holding ovens, steam tables and soup wells. The kitchen has also implemented increased levels of seasonings and sauces for food. Staff will be education on what the proper temperatures should be on 8/5/22 and 8/8/22. An audit of temperature logs will be done and reported in monthly QAPI. Taste tests will also be implemented and audited to ensure all food is tried prior to being served. The taste audit will be reported monthly in QAPI. A resident dining committee has also been formed to ensure that the solutions are being sustained. The committee will meet quarterly.

Based on observation and interview it was determined the facility failed to dispose of personal protective equipment safely for 2 of 5 resident halls (A and F) reviewed for infection control. This placed residents at risk for further infection. Findings include: 1. On 6/27/22 at 11:45 AM observations of hall A revealed three rooms (107, 109 and 113) on droplet and contact precautions. The three rooms were observed to have garbage cans in the hallway outside the bedroom doors, all garbage cans overflowed with used gowns and gloves. On 6/28/22 at 2:25 PM Resident room 113 was observed to have a garbage can in the hallway outside the bedroom door. The garbage can overflowed with used gowns and gloves. On 6/28/22 at 5:45 PM Staff 2 (DNS) stated staff were to dispose of gloves and gowns in the garbage cans in resident rooms. Staff 2 acknowledged staff had not safely disposed of PPE. On 6/29/22 at 2:33 PM Staff 20 (RN) stated she was told to placed garbage cans outside of the resident's door for the dirty gloves and gowns. Staff 20 stated staff should have put the dirty gloves and gowns in the garbage can in the resident's room after they had doffed their PPE. , 2. On 6/28/22 hall F was placed on droplet and contact precautions related to an exposure to COVID 19. On 6/28/22 at 3:25 PM Resident rooms 217, 218, 219, 221, 222, 223, 224, 225, 226, 227 and 230 were all observed to have a garbage can in the hallway outside the bedroom doors, all garbage cans were observed to have no lids and were filled with used gowns. On 6/28/22 at 3:34 PM Staff 17 (Housekeeper) removed her gown and gloves in doorway, exited room 226 and disposed of her gown and gloves in the garbage can in the hallway next to the bedroom door. On 6/28/22 at 3:35 PM Staff 18 (CNA) removed her gown and gloves in the doorway, exited room 223 and disposed of her gown and gloves in the garbage can in the hallway next to the bedroom door. In an interview on 6/28/22 at 3:39 PM Staff 19 (LPN) stated staff were directed to dispose of used PPE in the garbage cans in the hallway. In an interview on 6/28/22 at 5:45 PM Staff 2 (DNS) stated the staff were to dispose of gloves and gowns in the garbage cans in resident rooms. Staff 2 acknowledged the staff were not safely disposing of PPE. On 6/30/22 at 9:34 AM Room 219 was observed to have a garbage can outside the room in the hallway, the garbage can was overflowing with used gowns. In an interview on 6/30/22 at 11:48 AM Staff 7 (Director of Staff Development) acknowledged the garbage cans with used PPE were again in the hallway that morning.

Halls A and F were continually monitored and corrective actions were being implemented at the time of survey (education to staff and placing garbage cans into rooms). All rooms on Covid-19 transmission based precautions are at risk for this alleged deficient practice infection control practice. Daily audits of all rooms on Covid-19 transmission based precautions will be conducted for two weeks at random times to observe where garbage cans are placed and if personal protective equipment discard is overflowing. Garbage cans with lids have been ordered for use in the hallways for transmission based precaution rooms. Personal Protective Equipment policy created specific to Covid-19 transmission based precautions. Nursing staff to be educated on Aug 5th and 8th, 2022 with emphasis on location of garbage cans, emptying of garbage and proper disposal of personal protective equipment. Audits of all rooms on Covid -19 transmission based precautions will be done for overflowing trash and if garbage can is outside of room that lid is in place. Audits will also check to see if Person Protective Equipment is being disposed of properly. These audits will be done 5 days a week for 4 weeks, then 3 days a week for 4 weeks, then 2 days a weeks ongoing. Audits will be conducted by the Infection Preventionist. Results of audits will be brought to the monthly QAPI meeting.

Based on interview and record review it was determined the facility failed to maintain appropriate RN coverage for 6 of 30 days reviewed for staffing. This placed residents at risk for unmet needs and delayed care. Findings include: A review of the facility's Direct Care Staff Daily Report sheets from 6/1/22 through 6/30/22 revealed the facility did not have RN coverage on day or evening shift on 6/3/22, 6/4/22, 6/7/22, 6/8/22, 6/10/22 and 6/16/22. In an interview on 7/1/22 at 12:29 PM Staff 1 (Administrator) acknowledged the facility did not have the appropriate RN coverage.

All residents could be impacted by this deficiency. One 6/19/22 an agency RN started which has allowed the facility to meet the RN staffing requirements. Staffing will be reviewed every day to ensure compliance and that all shifts are covered. An audit will be completed to monitor and make sure we are recruiting. We will proactively review the following three days to go over past staffing as well as future to plan ahead for openings. Agency will be utilized as much as they are available. Wages and sign-on bonuses were recently increased to attract staff. Bonuses are offered to staff to encourage them to pick up shifts.

*************************************** OAR 411-085-0030 Required Postings Refer to F577 *************************************** OAR 411-086-0040 Admissions of Residents (Advance Directives) Refer to F578 *************************************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 *************************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 *************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 *************************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689 *************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F756 **************************************** OAR 411-086-0250 Dietary Services Refer to F804 **************************************** OAR 411-086-0330 infection control and Universal Precautions Refer to F880

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

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 01/17/2022 and 01/23/2022, 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 medications were administered with dignity and respect for 1 of 4 sampled residents (#3) reviewed for abuse. This placed residents at risk for lack of respect. Findings include: Resident 3 admitted to the facility on 10/13/21 with diagnoses including chronic pain. On 10/27/21 a public complaint was received which reported when Resident 3 requested pain medication the nurse who administered the medication was grumpy and stated to Resident 3 "now you can't say I don't do shit for you". Witness 3 (Family) was on the phone with Resident 3 at the time of the incident. Review of Resident 3's medical record revealed no documentation of the incident. On 12/9/21 Witness 3 verified she was on the phone with Resident 3 when the nurse entered the room and was rude to Resident 3. On 12/8/21 at 2:07 PM Staff 14 (RNCM) stated Resident 3 believed the medications were administered incorrectly. The nursing staff attempted to clarify the oxycodone dosage because Resident 3 wanted a higher dose than the hospital physician prescribed and was cursing at the staff. During this time Staff 25 (LPN) brought Resident 3 her/his medications, was not friendly toward Resident 3 and did not treat Resident 3 with respect and dignity. Witness 3 notified the facility immediately and Staff 25 was removed from the floor. Staff 14 stated she resumed care of Resident 3 and resident 3 was not negatively impacted by the exchange of words.

Resident #3 has discharged from the facility. All residents have the potential to be affected by this alleged deficient practice. Corrective action was taken with staff member at the time of the event and education has been provided. The policy and procedure on resident rights has been reviewed. Education will be provided to all staff on January 13th, 2022 regarding treatment of residents with dignity and respect. An audit will be completed weekly for each hall and will include 2 observations and 2 interviews. Audits will consist of observations of how staff interact with residents to observe that Residents are being treated with dignity and respect. Interviews will also be conducted with residents to assure they are being treated with dignity and respect. Nurse Managers or designees will be completing the audits. Audits will be reviewed at Risk meeting weekly and trends will be brought to QAPI until 100% compliance is sustained.

Based on interview and record review it was determined the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options and alternatives prior to administering antipsychotic medication for 1 of 4 sampled residents (#1) reviewed for medications. This placed residents and families at risk for being uniformed and not involved in the residents care. Findings include: Resident 1 admitted to the facility in 2018 with diagnoses including dementia. A 11/10/21 Physician Order revealed an order for risperidone (antipsychotic medication) 0.25 mg twice daily for dementia. A 11/10/21 Progress note revealed Staff 7 (LPN) attempted to notify Witness 1 (Family) of the new risperidone medication order but Witness 1 was unavailable. The note further indicated Witness 9 (Family) was then notified via telephone. Witness 9 gave Staff 7 verbal consent to administer the medication, the consent form was filled out, signed and placed in Resident 1's medical record. The 11/10/21 Consent for Use of Psychotropic Medication Therapy indicated Witness 9 gave consent for the risperidone medication and Staff 7 and Staff 8 (LPN) signed as confirming staff members. The 11/2021 MARs revealed Resident 1 began to receive risperidone twice daily on 11/11/21. On 12/14/21 at 12:06 AM Staff 7 stated when a new medication was ordered she would inform the family/representative about the medication, what the medication was for, side effects, the dose prescribed, why the medication was ordered and then obtain consent. Staff 7 stated she would attempt to answer all the family/representative questions prior to obtaining consent to administer the medication. Staff 7 further stated a second nurse would then talk to the family/representative about the medication prior to obtaining consent. Staff 7 verified she talked to Witness 9 about the risperidone order, obtained consent to administer the medication and stated Staff 8 talked to Witness 9 directly on the phone to obtain consent as the second staff member. On 12/14/21 at 3:10 PM Staff 8 stated she had not talked to any family over the phone to obtain consent to administer a medication. Staff 8 stated Staff 9 brought Resident 1's consent form over to her while she was performing her medication pass, informed her she had called Resident 1's family, received consent and then asked Staff 9 to sign the consent form which she did. Staff 8 verified she did not listen in on or participate in any call to Resident 1's family. On 12/7/21 at 8:40 AM Witness 1 stated Resident 1 was started on risperidone prior to any resident representative being informed. On 12/7/21 at 12:24 PM Witness 9 stated she was not notified and did not give authorization to start Resident 1 on risperidone.

Psychoactive medication consent for Risperdal was re-consented for resident #1. All residents that take psychoactive medications and have had a telephone consent done are at risk for this alleged deficient practice. An audit of all psychoactive medications in which a telephone consent was done will be conducted nursing staff will then confirm with resident/responsible party that they are aware of the medication being provided. A procedure was written on obtaining psychoactive medication consent and the psychoactive medication consent was revised. Education to nursing staff will be given on January 13th, 2022 on the procedure on obtaining the psychoactive medication consent process and on the new consent form. Social services team will audit psychoactive medication consents on new psychoactive medications and psychoactive medication changes to assure that a consent was obtained timely. Social Services will be following up on all verbal psychoactive consents with the resident and/or family to confirm consent was given. Social services will then document in PCC. Results will be reviewed weekly in the Lifestyles meeting on Fridays. Trends of the audit review will be brought to QAPI for the next three quarterly meetings.

Based on observation and interview it was determined the facility failed to ensure resident equipment was maintained with a cleanable surface for 1 of 3 sampled residents (#1) reviewed for environment. This placed residents at risk of utilizing unclean wheelchairs. Findings include: Resident 1 admitted to the facility in 2018 with diagnoses including dementia. On 12/6/21 at 9:15 AM Resident 1 was observed to utilize a wheelchair which the right top covering of the armrest was three quarters off and was not a cleanable surface. The left armrest had most of the padding and outer cover ripped off which left a non-cleanable surface. On 12/10/21 at 9:44 AM Staff 9 (LPN) acknowledged the wheelchair armrests were not cleanable in their current condition.

Arm rests for resident 1's wheelchair have been replaced. All wheelchair arm rests will be audited by 1/27/2022 and an order for new equipment will be placed. Plant operations will audit 8 wheelchairs a week for prevention and maintenance. They will notate their audits on a log that will be turned into the Administrator to assure that the wheelchair is in good working condition. Wheelchair audits will be discussed in quarterly QAPI meetings indefinitely to ensure that the wheelchairs are sanitary, comfortable and functional. With plant operations doing 8 wheelchairs a week, that would mean that every wheelchair is inspected at least once a quarter.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse and neglect of care for 2 of 4 sampled residents (#s 1 and 4) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 1 admitted to the facility in 5/2018 with diagnoses including dementia. The 11/4/21 BIMs (cognitive) assessment indicated Resident 1 had significant cognitive impairment. Resident 4 admitted to the facility in 6/2021 with diagnoses including stroke and a brain disorder effecting cognition. Resident 4's 9/12/21 BIMs assessment indicated mild cognitive impairment. 1. The 9/23/21 Facility Abuse Investigation indicated physical contact of a potentially sexual nature occurred on 9/19/21 between Resident 1 and Resident 4. The 9/23/21 abuse investigation report further indicated Resident 1 and Resident 4 were witnessed to have engaged in sexual activity on 9/20/21. On 12/14/21 at 10:00 AM Staff 24 (CNA) confirmed that physical contact of a sexual nature occurred on 9/20/21. On 12/14/21 at 10:54 AM Staff 17 (LPN), confirmed that physical contact of a sexual nature occurred on 9/20/21. On 12/14/21 at 2:19 PM Staff 3 (RNCM) confirmed that physical contact of a sexual nature occurred on 9/20/21. Staff 3 further stated physical contact of a sexual nature likely also occurred on 9/19/21. On 12/21/21 at 12:35 PM Staff 1 (Administrator) confirmed abuse occurred. 2. The 9/24/21 Facility Abuse Investigation indicated Resident 1 and Resident 4 were witnessed engaged in sexual activity on 9/23/21. On 12/14/21 at 2:19 PM Staff 3 (RNCM) confirmed physical contact of a sexual nature occurred, and she had to separate Resident 1 and Resident 4 on 9/23/21. On 12/21/21 at 12:35 PM Staff 1 (Administrator) confirmed abuse occurred. 3. The 9/27/21 Facility Abuse Investigation indicated Resident 1 and Resident 4 were witnessed to have engaged in sexual activity on 9/26/21. The Facility Abuse Investigation further indicated a Velcro stop sign, put in place to restrict Resident 1 from entering Resident 4's room, was not in place. On 12/10/21 at 10:20 AM Staff 21 (LPN) confirmed the stop sign used to discourage Resident 1 worked before it went missing. On 12/14/21 at 10:39 AM Staff 7 (LPN) confirmed the stop sign used to discourage Resident 1 worked until it went missing. On 12/14/21 at 2:19 PM Staff 3 (RNCM) confirmed the stop sign used to discourage Resident 1 worked however the sign was"'lost for two days", and eventually found under a wheelchair cushion in Resident 1's room. Staff 3 further confirmed Resident 1 and Resident 4 had engaged in sexual activity on 9/26/21. On 12/21/21 at 12:35 PM Staff 1 (Administrator) confirmed abuse occurred.

Resident #1 remains in the facility. Resident #4 has discharged from the facility. Interventions were put in place at the time of the interactions. A second stop sign is now available. All residents are at risk of this alleged deficient practice. Abuse policy has been reviewed. Education will be provided to all staff on January 13th, 2022 regarding freedom from abuse, neglect and exploitation. Education will include what to do immediately if interventions are not working or disappear.. Abuse education will be mandatory in KPA for all staff working in the Health Center and is to be completed by 1/27/22. Discussion of all occurrences of abuse will be discussed the next business day in morning meeting by interdisciplinary team to see if interventions are working that were put into place at time of occurrence and if more interventions need to be added to prevent a further occurrence of abuse. Trends of timely reporting of allegations will be brought to the next three quarterly QAPI meetings.

Based on interview and record review it was determined the facility failed to report an allegation of abuse and neglect of care to the State Agency within the required timeframe for 3 of 7 sampled residents (#1, 2 and 4) reviewed for abuse and falls. This placed residents at risk for continued abuse and neglect of care. Findings include: 1. Resident 1 admitted to the facility in 5/2018 with diagnoses including dementia. The 11/4/21 BIMs (cognitive) assessment indicated Resident 1 had significant cognitive impairment. Resident 4 admitted to the facility in 6/2021 with diagnoses including stroke and a brain disorder effecting cognition. Resident 4's 9/12/21 BIMs assessment indicated mild cognitive impairment. a. The 9/23/21 Facility Abuse Investigation indicated physical contact of a potentially sexual nature occurred on 9/19/21 between Resident 1 and Resident 4. The 9/23/21 abuse investigation report further indicated Resident 1 and Resident 4 were witnessed to have engaged in sexual activity on 9/20/21. The 9/21/21 FRI, submitted to the State Agency at 12:00 PM on 9/21/21, reported the incidents occurred on 9/19/21 and 9/20/21. On 12/20/21 at 11:06 AM Staff 2 (DNS) verified the FRI for Resident 1 and Resident 4's sexual activity was reported to the State Agency outside the required timeframe. b. The 9/27/21 Facility Abuse Investigation report indicated Resident 1 and Resident 4 were witnessed to have engaged in sexual activity on 9/26/21. The 9/27/21 FRI form, submitted to the State Agency at 10:00 AM on 9/27/21, reported the incident occurred on 9/26/21. On 12/20/21 at 11:06 AM Staff 2 (DNS) verified the FRI for Resident 1 and Resident 4's sexual activity was reported to the State Agency outside the required timeframe. , 2. Resident 2 admitted to the facility in 2019 with diagnoses including osteoarthritis and obesity. On 12/8/21 at 11:50 AM Resident 2 stated Staff 22 (CNA) did not turn her/him correctly and hurt her/his shoulder when she/he was turned in bed. Review of Resident 2's medical record revealed no documentation of a shoulder injury related to physical care provided by the facility staff. On 12/7/21 at 3:05 PM Staff 2 (DNS) stated the facility had no documentation of the alleged shoulder injury. On 12/8/21 at 2:01 PM Staff 2 acknowledged it was reported to her Resident 2 alleged Staff 22 rolled her/him over and hurt her/his shoulder. Staff 2 acknowledged the facility did not complete a formal investigation into the allegation or report the allegation to the State Agency.

Resident #1 remains in the facility. Resident #4 has discharged from the facility. Resident #2 remains in facility and formal investigation has been completed. All residents are at risk of this alleged deficient practice. Abuse policy has been reviewed. Education will be provided to all staff on January 13th, 2022 regarding importance of ensuring that all alleged allegations of abuse, neglect, mistreatment, exploitation, injuries of unknown source and misappropriation of residents belongings are reported immediately but not later than two(2) hours after the allegation is made. Education will include the appropriate channels of who to report abuse to. Abuse education will be mandatory in KPA for all staff working in the Health Center and is to be completed by 1/27/22. When reviewing the investigation special attention will be on when the incident was reported. An audit will take place to ensure that the incident was reported in the correct amount of time. All allegations will be discussed the following business day in morning meeting. Trends of timely reporting of allegations will be brought to the next three quarterly QAPI meetings.

Based on interview and record review the facility failed to investigate a complaint of neglect of care and to rule out abuse and neglect for 2 of 7 sampled residents (#s 2 and 12) reviewed for abuse and falls. This placed residents at risk for physical injury. Findings include: 1. Resident 2 admitted to the facility in 2019 with diagnoses including osteoarthritis and obesity. Review of Resident 2's medical record revealed no documentation of a shoulder injury related to physical care provided by the facility staff. On 12/7/21 at 3:05 PM Staff 2 (DNS) stated the facility had no documentation of the alleged shoulder injury. On 12/8/21 at 11:50 AM Resident 2 stated Staff 22 (CNA) did not turn her/him correctly and hurt her/his shoulder when she/he was turned in bed. Resident 2 stated she/he received therapy for the injury. On 12/8/21 at 1:38 PM Staff 3 (RNCM) stated in early October 2021 Resident 2 reported a CNA did not know how to reposition her/him and hurt her/his shoulder. Resident 2 did not complain of any additional pain. Staff 3 stated Resident 2 requested Occupational Therapy (OT) which was provided. On 12/8/21 at 1:25 PM Staff 10 (Therapy Manager) stated OT treated Resident 2 two to three times a week for a shoulder injury. Resident 2 reported to staff she/he was rolled over incorrectly but could not say if the injury was sustained. Staff 10 stated he originally offered to request an order for additional pain medication and OT which Resident 2 initially declined. Approximately two weeks later Resident 2 requested OT services which have helped her/him. On 12/8/21 at 2:01 PM Staff 2 acknowledged it was reported to her Resident 2 alleged Staff 22 rolled her/him over and hurt her/his shoulder. Staff 2 acknowledged the facility did not complete a formal investigation into the allegation. 2. Resident 12 admitted to the facility in 2020 with diagnoses including dementia. An 11/19/21 Progress Note indicated Resident 12 sustained an assisted fall to the floor. The 11/19/21 Fall Investigation documented a summary of the fall on 12/6/21. The investigation did not rule out abuse or neglect of care. On 12/16/21 at 12:53 PM Staff 2 (DNS) confirmed the fall investigation did not rule out abuse or neglect. Staff 2 further stated the investigation was not completed until 12/7/21; 18 days after the fall occurred.

Resident #2 remains in facility and formal investigation has been completed. Resident #12 fall investigation has been amended to state that abuse and neglect has been ruled out. All residents with an alleged allegation of abuse neglect or mistreatment are at risk of this alleged deficient practice all residents that sustained falls are at risk at this alleged deficient practice. The policy for fall prevention was reviewed and revised. Nursing staff will be educated on the policy on January 13th 2022 regarding timely completion of fall investigations and that it must state abuse and neglect have been ruled out in the investigative summary. All staff will be educated on how proper alleged abuse violations are to be investigated and prevent further potential abuse, neglect exploitation or mistreatment occurrences while the investigation is in process. Abuse education will be mandatory in KPA for all staff working in the Health Center and is to be completed by 1/27/22. Audits will be conducted of 100% of fall investigations for four weeks, then 50% of fall investigations for two weeks then 25% of fall investigations for two weeks then random audits of all fall investigations will continue. All abuse investigations will be audited to ensure abuse and neglect have been ruled out. Audits of fall investigation and abuse investigations will be completed by Abuse Coordinator or designee.

Based on interview and record review it was determined the facility failed to ensure staff adhered to accepted professional standards related to nursing care and services for 1 of 3 sampled residents (#1) reviewed for medication. This placed residents at risk for unnecessary antipsychotic medications. Findings include: 851-045-0070 Conduct Derogatory to the Standards of Nursing Defined Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (1) Conduct related to general fitness to practice nursing: (b) Demonstrated incidents of dishonesty, misrepresentation, or fraud. Resident 1 admitted to the facility in 2018 with diagnoses including dementia. A 11/10/21 Physician Order revealed an order for risperidone (antipsychotic medication) 0.25 mg twice daily for dementia. A 11/10/21 Progress note revealed Staff 7 (LPN) attempted to notify Witness 1 (Family) of the new risperidone medication order but Witness 1 was unavailable. The note further indicated Witness 9 (Family) was then notified via telephone. Witness 9 gave Staff 7 verbal consent to administer the medication, the consent form was filled out, signed and placed in Resident 1's medical record. The 11/10/21 Consent for Use of Psychotropic Medication Therapy indicated Witness 9 gave consent for the risperidone medication and Staff 7 and Staff 8 (LPN) signed as confirming staff members. The 11/2021 MARs revealed Resident 1 began to receive risperidone twice daily on 11/11/21. On 12/14/21 at 12:06 AM Staff 7 stated when a new medication was ordered she would inform the family/representative about the medication, what the medication was for, side effects, the dose prescribed, why the medication was ordered and then obtain consent. Staff 7 stated she would attempt to answer all the family/representative questions prior to obtaining consent to administer the medication. Staff 7 further stated a second nurse would then talk to the family/representative about the medication prior to obtaining consent. Staff 7 verified she talked to Witness 9 about the risperidone order, obtained consent to administer the medication and stated Staff 8 talked to Witness 9 directly on the phone to obtain consent as the second staff member. On 12/14/21 at 3:10 PM Staff 8 stated she had not talked to any family over the phone to obtain consent to administer a medication. Staff 8 stated Staff 9 brought Resident 1's consent form over to her while she was performing her medication pass, informed her she had called Resident 1's family, received consent and then asked Staff 9 to sign the consent form which she did. Staff 8 verified she did not listen in on or participate in any call to Resident 1's family. On 12/7/21 at 8:40 AM Witness 1 stated Resident 1 was started on risperidone prior to any resident representative being informed. On 12/7/21 at 12:24 PM Witness 9 stated she was not notified and did not give authorization to start Resident 1 on risperidone. Refer to F552 and F842.

Psychoactive medication consent for Risperdal was re-consented for resident #1. All residents that take psychoactive medications and have had a telephone consent done are at risk for this alleged deficient practice. An audit of all psychoactive medications in which a telephone consent was done will be conducted nursing staff will then confirm with resident/responsible party that they are aware of the medication being provided. Staff members involved have received education regarding proper consent process. Nursing staff will be educated on January 13th, 2022 on Conduct derogatory to the Standards of Nursing. A procedure was written on obtaining psychoactive medication consent and the psychoactive medication consent was revised. Education to nursing staff will be given on January 13th, 2022 on the procedure on obtaining the psychoactive medication consent process and on the new consent form. Social services team will audit psychoactive medication consents on new psychoactive medications and psychoactive medication changes to assure that a consent was obtained timely. Social Services will be following up on all verbal psychoactive consents with the resident and/or family to confirm consent was given. Social services will then document in PCC. Results will be reviewed weekly in the lifestyle meeting on Fridays. Trends of the audit review will be brought to QAPI for the next three quarterly QAPI meetings.

Based on observation, interview and record review it was determined the facility failed to provide ADL assistance to 1 of 3 sampled residents (#1) reviewed for ADL assistance. This placed residents at risk for lack of hygiene and grooming. Findings include: Resident 1 admitted to the facility in 2018 with diagnoses including dementia. a. The 8/10/18 ADL Care Plan indicated Resident 1 needed extensive assistance for bathing. Scheduled shower days were Tuesday and Friday on day shift. On 12/6/21 at 9:13 AM Resident 1 was observed to have dirty, unkempt hair. A review of the CNA task shower documentation from 11/1/21 through 12/6/21 revealed in November Resident 1 received a shower on the 2nd, 19th and 26th. Resident 1 refused showers on November 5, 9, 12, 16, 23 and 30. The documentation further revealed no showers were given in December and one shower refused on 12/3/21. [Last shower was 10 days prior]. On 12/6/21 Staff 5 at 11:00 AM (Graduate Nurse Aide) acknowledged Resident 1's hair was dirty and unkempt. Staff 5 stated Resident 1 would often refuse showers if the shower was not offered when she/he was ready to get up for the day. Staff 5 stated staff would reapproach throughout their shift if Resident 1 refused but Resident 1 would not accept because she/he was already up. Staff 5 further stated if a shower was refused staff would not offer another shower until the next scheduled shower day. On 12/13/21 at 11:05 AM Staff 3 (RNCM) acknowledged Resident 1 did not receive any showers between 11/2/21 through 11/18/21 and Resident 1's last shower was completed on 11/26/21 which was ten days prior. Staff 3 stated the facility failed to provide Resident 1 with showers as needed. b. The 8/10/18 ADL Care Plan indicated Resident 1 was often able to complete the majority of dressing independently but might need assistance at times. On 12/6/21 at 9:13 AM Resident 1 was observed to wear pants with multiple red stains on the upper left thigh area. The stains appeared to be dried blood. [Resident 1 had multiple open wounds to her/his thighs bilaterally]. On 12/6/21 Staff 5 at 11:00 AM (Graduate Nurse Aide) acknowledged Resident 1's pants had multiple red stains on the upper left leg and stated she had not had time to assist Resident 1 with dressing that morning. c. The 8/10/18 ADL Care Plan indicated Resident 1 required limited assistance at times for hygiene, and was able to complete many hygiene tasks when set-up and cueing assistance was provided. Staff were to encourage Resident 1 to participate in hygiene, assist with completion as needed and to assist with toileting every two hours. The 11/22/21 Incontinence Care Plan further indicated Resident 1 had urine incontinence, to provide Resident 1 with urinary continent supplies and ensure the supplies were available in the room. On 12/7/21 at 12:34 PM Witness 9 (Family) stated she had just returned with Resident 1 from the dentist office. Witness 9 stated she spoke with staff earlier in the morning and requested Resident 1 to wear a brief. Resident 1 had a brief on however all of Resident 1's clothes were "super wet" and Resident 1 left the dental chair wet. Witness 9 further stated Resident 1's clothes were soiled from the of her/his pants to the bra-line of the shirt. Witness 9 stated the facility did not always send incontinent supplies or extra clothes to outside appointments. On 12/13/21 at 11:47 AM Witness 10 (Dentist's Main Assistant) verified when Resident 1 got up from the dental chair the chair was soiled. Witness 10 stated there were two separate incidents when Resident 1 arrived in wet, soiled clothing. The first time Resident 1's daughter attempted to clean her/him up in the restroom and the incontinence was "all over the restroom. It was very potent." Witness 10 stated both times Resident 1 arrived in wet clothing and was very odorous. On 12/8/21 at 1:00 PM Staff 3 (RNCM) stated she was aware Resident 1 was recently sent to a dental appointment without any incontinent products. Staff 3 stated the standard of practice would be to ensure the resident was dressed and send with the resident everything they needed. Staff 3 stated she did not know if staff sent extra incontinent products or clothes when Resident 1 went out to appointments. On 12/10/21 at 9:44 AM Staff 9 (LPN) stated Resident 1 was "sometimes" sent with extra briefs and wipes but not with extra clothing. d. The 8/10/18 ADL Care Plan indicated Resident 1 required oral care twice daily. A review of the CNA task documentation revealed Resident 1 received oral care twice daily. On 12/7/21 at 12:34 PM Witness 9 (Family) stated Resident 1 returned from the dentist and she was told by the dentist the facility did no hygiene care on Resident 1's teeth. Resident 1 arrived with food on her/his teeth and her/his gums bled profusely. On 12/13/21 at 11:47 AM Witness 10 (Dentist's Main Assistant) stated Resident 1's gum tissue around the upper front teeth were very inflamed with food debris and Resident 1's gums and teeth were "in very bad shape" and "it was obvious no hygiene had been performed." On 12/6/21 at 11:00 AM Staff 5 (Graduate Nurse Assistant) stated Resident 1's gums "bleed pretty bad". On 12/8/21 at 1:00 PM Staff 3 (RNCM) stated she was unaware of any tooth brushing or oral hygiene concerns.

Care plan was updated to reflect resident #1s current needs. Showers, oral care, grooming, toilet hygiene and clean clothes will be offered daily for this resident. All residents that need assistance with ADLs are at risk. All care plans will be reviewed and updated as needed by 1/27/2022. The ADL policy was reviewed and appropriate. Nursing staff will be educated on ADL practices including bathing, dressing, hygiene, incontinence care and oral care on January 13th, 2022. Resident #1 will be supplied with clean clothes and incontinence pads in a backpack when going to appointments. Audits of 4 residents per hall per week will be performed for observation of lack of personal hygiene, toilet hygiene, bathing/showering, clean clothes and oral hygiene. Audits will be performed by nurse managers or designees. Results will be reported in weekly risk meeting.

Based on observation, interview and record review it was determined the facility failed to monitor, assess and treat skin wounds for 3 of 3 sampled residents (#s 1, 12 and 13) reviewed for skin conditions. This placed residents at risk for untreated skin wounds and infection. Findings include: 1. Resident 1 admitted to the facility in 2018 with diagnoses including dementia. On 12/7/21 at 8:40 AM Witness 1 (Family) stated on 11/2/21 Resident 1 was observed to have multiple open sores on her/his bilateral lower extremities. Witness 1 stated she spoke with Staff 3 (RNCM) and found out no treatments were in place. Witness 1 further stated after speaking to Staff 3, Staff 3 recommended a wound consultation. The 8/26/21 Social Service Review revealed Resident 1 had behaviors including scratching her/his skin which caused injury. An 11/2/21 Progress Note indicated Witness 1 reported Resident 1 had two wounds; one to the right extremity and one to the left extremity. Witness 1 was concerned she was not notified of the the wounds, questioned if the physician was aware of the wounds and what the plan for monitoring the wounds was. Staff 3 informed Witness 1 the wound on the right extremity would come and go and the facility would notify the provider and request orders to monitor and treat the wounds. An 11/3/21 Progress Note indicated Resident 1's physician was notified of Resident 1's chronic open areas to her/his bilateral lower extremities and requested a wound consultant to evaluate and treat the wounds. Skin and wound records were initiated on 11/3/21 for the left calf open lesion and the right thigh open lesion. Review of Resident 1's medical record revealed no skin assessments of Resident 1's lower extremity wounds prior to 11/3/21. An 11/5/21 Progress Note revealed the physician placed an order for a wound consultant to evaluate and treat Resident 1's wounds. On 12/8/21 at 1:00 PM Staff 3 verified Witness 1 reported two wounds to Resident 1's lower extremities to her but stated this was incorrect as Resident 1 "had more [wounds] than that." Staff 3 verified at the time of the 11/2/21 phone call no monitoring, assessment or treatments of the wounds were in place. Staff 3 further stated Resident 1 had creams in place but nothing specifically for the wounds. 2. Resident 12 admitted to the facility in 2020 with diagnoses including dementia. An 11/26/21 Incident Note revealed a 11/5/21 incident when Resident 12 was found to have an abrasion to her/his mid-back between the should blades. The nurse cleansed the wound and applied skin protectant. On 11/6/21 Resident 21 informed staff she/he acquired the abrasion from using a butter knife to relieve an itch between her/his shoulder blades. A review of Resident 12's medical record revealed no skin monitoring or assessments of the skin abrasion. On 12/13/21 at 1:44 PM Staff 2 (DNS) stated Resident 12 had no formal skin assessments completed. 3. Resident 13 admitted to the facility in 2020 with diagnoses including heart failure and peripheral vascular disease. A 12/1/21 Progress Note revealed Resident 13 self reported "cellulitis right at the top curve of my butt cheek." The nurse visualized a dime sized open area. A 12/2/21 Progress Note revealed a Nurse Practitioner assessed the area and determined the wound to be moisture associated skin damage (MASD) and prescribed treatment orders and monitoring of the dressing placement and for signs of infection every shift. The 12/2/21 Physician Order revealed an order to clean the coccyx skin tear with wound cleanser, cover with adhesive dressing and check for signs of infection to the open area on the coccyx. A review of Resident 13's medical record revealed no skin assessment of the coccyx wound. On 12/13/21 at 1:59 PM Staff 16 (RNCM) stated staff do not complete formal wound assessments on any wound unless it is pressure related. Staff 16 stated no skin assessment was completed for Resident 13's coccyx wound.

All residents will be audited on the weekly skin audit the week of 1/17/22. All breaks in the skin and identified areas of bruising or discoloration will be noted. Weekly skin assessment to be done by licensed nurse in PCC the first bath of the week to capture all wounds. Ongoing, the weekly skin assessment will continue to be completed the first bath day of the week. Skin assessments will all be reviewed weekly by the unit manager and log of non-pressure injuries will be kept on the unit. All breaks in the skin and identified areas of bruising or discoloration will be noted. IDT will review weekly to assure that wounds are followed, treatments are followed and that the wounds are healing or the physician has been notified. Healed wounds are to be documented.

Based on observation, interview and record review it was determined the facility failed to replace hearing aides in a timely manner for 1 of 3 sampled residents (#1) reviewed for missing items. This placed residents at risk for a decline in hearing and impaired communication. Findings include: Resident 1 was admitted to the facility in 2018 with diagnoses including dementia. On 12/6/21 at 9:13 AM Resident 1 was observed without hearing aides. On 12/8/21 at 12:53 AM Staff 4 (Social Service Assistant) stated she was aware Resident 1 had missing hearing aides and further stated she was unaware how long the hearing aides had been missing. On 12/8/21 at 1:00 PM Staff 3 (RNCM) stated she did not know how long Resident 1 hearing aides had been missing but had heard they went missing "last Spring" 2021. Staff 3 further stated the facility agreed to pay for replacement hearing aides.

Resident #1 has received new bottom dentures and family as well as the facility are working on getting replacement glasses and hearing aids. All residents are at risk for missing items. Missing item policy was created and the grievance policy was reviewed. Social Services will do an investigation to locate missing items. Missing items will be replaced or reimbursed per policy. A letter to residents and families went out on 1/12/2022 that included the grievance and missing item policies and procedures. Going forward a log will be kept of all missing item(s) and who reported the item(s) missing. Record of missing items and their resolution will be reported the following business day in morning meeting and in each quarterly QAPI.

Based on interview and record review it was determined the facility failed to ensure accurate documentation for informed consent records for 1 of 3 sampled residents (#1) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 1 admitted to the facility in 2018 with diagnoses including dementia. A 11/10/21 Physician Order revealed an order for risperidone (antipsychotic medication) 0.25 mg twice daily for dementia. A 11/10/21 Progress note revealed revealed Witness 9 (Family) gave Staff 7 (LPN) verbal consent to administer the medication, the consent form was filled out, signed and placed in Resident 1's medical record. The 11/10/21 Consent for Use of Psychotropic Medication Therapy indicated Witness 9 gave consent for the risperidone medication and Staff 7 and Staff 8 (LPN) signed as confirming staff members. On 12/7/21 at 12:24 PM Witness 9 stated she was not notified and did not give authorization to start Resident 1 on risperidone. On 12/14/21 at 12:06 AM Staff 7 stated she talked to Witness 9 about the risperidone order, obtained consent to administer the medication and stated Staff 8 talked to Witness 9 directly on the phone to obtain consent as the second staff member. On 12/14/21 at 3:10 PM Staff 8 stated she had not talked to any family over the phone to obtain consent to administer a medication. Staff 8 stated Staff 9 brought Resident 1's consent form over to her while she was performing her medication pass, informed her she had called Resident 1's family, received consent and then asked Staff 9 to sign the consent form which she did. Staff 8 verified she did not listen in on or participate in any call to Resident 1's family.

Psychoactive medication consent for Risperdal was re-consented for resident #1. All residents that take psychoactive medications and have had a telephone consent done are at risk for this alleged deficient practice. An audit of all psychoactive medications in which a telephone consent was done will be conducted nursing staff will then confirm with resident/responsible party that they are aware of the medication being provided. Staff members involved have received education regarding proper consent process. Nursing staff will be educated on January 13th, 2022 on Conduct derogatory to the Standards of Nursing. A procedure was written on obtaining psychoactive medication consent and the psychoactive medication consent was revised. Education to nursing staff will be given on January 13th, 2022 on the procedure on obtaining the psychoactive medication consent process and on the new consent form. Social services team will audit psychoactive medication consents on new psychoactive medications and psychoactive medication changes to assure that a consent was obtained timely. Social Services will be following up on all verbal psychoactive consents with the resident and/or family to confirm consent was given. Social services will then document in PCC. Results will be reviewed weekly in the lifestyle meeting on Fridays. Trends of the audit review will be brought to QAPI for the next three quarterly QAPI meetings.

Based on interview and record review it was determined the facility failed to ensure eight hours of RN coverage between day and evening shifts for 13 of 30 days reviewed for staffing. This placed residents at risk for lack of comprehensive assessments. Findings include: The Direct Care Staff Daily Reports from 11/1/21 through 11/30/21 revealed the facility did not have an RN charge nurse on duty for eight consecutive hours between day and evening shifts for the following dates: 11/3/21 11/4/21 11/9/21 11/12/21 11/13/21 11/14/21 11/17/21 11/18/21 11/22/21 11/23/21 11/26/21 11/27/21 11/28/21 On 12/20/21 at 12:35 PM Staff 1 (Administrator) confirmed the lack of RN coverage on the identified dates.

All residents could be impacted by this deficiency. A waiver for the RN staffing requirement was submitted to the state on 1/11/2022 and the facility is awaiting a response. On 1/13/2022 a RN will be starting orientation and once on the floor will allow the facility to meet the RN staffing requirements. Staffing will be reviewed every day to ensure compliance and that all shifts are covered. An audit will be completed to monitor and make sure we are recruiting. We will proactively review the following three days to go over past staffing as well as future to plan ahead for openings. Agency will be utilized as much as they are available. Bonuses are offered to staff to encourage them to pick up shifts. Completion date will be 1/27/2021.

********************* OAR 411-085-0310 Residents' Rights: Generally Refer to F550 and F552 ********************* 411-085-0360 Abuse Refer to F600, F609 and F610 ********************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F658, F677, F684 and F685 ********************* OAR 411-086-0370 Clinical Records Refer to F842 ******************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 *********************

Based on interview and record review it was determined the facility failed to ensure a resident was assisted with bathing for 1 of 3 sampled residents (#1) reviewed for grooming. This placed residents at risk for lack of hygiene. Findings include: Resident 1 was readmitted to the facility in 2020 with diagnoses including a leg amputation. A CAA dated 8/28/20 indicated the resident had impaired memory and required extensive assistance for bathing. The Care Plan initiated 6/4/20 indicated the resident was to be assisted with bathing twice a week. The November and December 2020 Documentation Survey Report revealed the resident had nine opportunities for bathing. The documentation indicated the resident received bathing on 11/14/20 and refused one bath on 12/2/20. The seven remaining days indicated "NA [not applicable]." On 8/17/21 at 11:51 PM Staff 9 (CNA) indicated if a resident refused a shower, the resident was re-approached at a later time and if the resident continued to refuse the nurse was notified. If a resident did not want a shower, a bed bath was given and was documented in the CNA charting system. If the resident continued to refuse it was documented as a refusal. On 8/17/21 at 11:50 AM Staff 8 (LPN) stated if a resident refused a shower the CNA re-approached the resident. If the resident did not want a shower a bed bath was offered. If the resident continued to refuse it was documented in the resident's record as a refusal. On 8/17/21 at 12:15 PM Staff 7 (RNCM) stated the CNAs documented if showers were provided in a resident's record and on a paper shower sheet. The sheets were shredded after approximately three months. Staff 7 acknowledged the resident was documented as "NA" for seven days. A request was made to Staff 7 to provide documentation to demonstrate showers were provided to Resident 1 or the resident refused. No additional information was provided.

Facility has assured that resident #1 is routinely being assisted with bathing. All residents that require assistance with bathing are at risk of this alleged deficient practice. An audit of bathing documentation for all current residents for the month of August 2021 will be conducted to see which residents have had missed bathing opportunities from refusal or documentation or lack of documentation. Bathing policy reviewed. Nursing staff education occurred on September 14, 2021, to reinforce documentation of bathing in Electronic Medical Record (EMR) system. Registered Nurse Manager (RNM) will report on the prior days baths in Morning Meeting to assure that all baths were completed. The Registered Nurse Manager (RNM) will also report in the weekly Risk Meeting that all baths have been documented for the week in the Electronic Medical Record (EMR) system. This information from the audits will be reported at both meetings for 2 months or until substantial compliance is met.

1.

Based on interview and record review it was determined the facility failed to ensure a resident's urine test and or results were communicated with the resident's physician in a timely manner for 1 of 3 sampled residents (#2) reviewed for change of condition. Resident 2 continued to show symptoms of an infection, was transferred to the emergency room to start antibiotics and was later admitted to the hospital and diagnosed with sepsis related to a UTI. Findings include: Resident 2 was admitted to the facility in 2020 with diagnoses including a stroke. The 2/16/20 CAA indicated the resident had a Foley catheter which placed the resident at increased risk for UTIs. Progress Notes revealed on 4/2/20 the resident had a fever of 100.4 F. The resident did not have respiratory symptoms, the provider was notified, an order was obtained to provide Tylenol (over the counter medication to treat fevers) and to obtain a urine specimen for a dip test (Thin plastic stick with chemical strips on it. Urine is placed on the strip and the strip changes color. It is used as a preliminary test to detect abnormalities including UTIs.) The resident's record did not have the results of the urine dip test. Progress notes revealed from 4/3/20 through 4/7/20 the resident's urine was, at times, noted to be cloudy and her/his temperatures ranged from 99.0 to 100.9 F. The resident was administered Tylenol PRN. The 4/7/20 Progress Note by Staff 3 (LPN) indicated Witness 13 (Physician) called the facility and reported she saw the resident's urine dip results and said "at this point by the time we get the C & S [Culture and Sensitivity] results for the ABX [antibiotic] [she]/he could be in much worse shape so you should send [her/]him out." The resident was transported to the local hospital and returned 4/8/20 at 12:20 AM on antibiotics. On 4/8/20 the resident's CBG was 473 and the physician was notified. Later the CBG was rechecked and was 476, the resident had a temperature of 102.5, was flushed, diaphoretic and more lethargic than baseline. The resident's physician was notified and the resident was sent to the hospital. The 4/9/20 hospital History and Physical indicated the resident was seen in the emergency room on 4/7/20, was started on antibiotics and was discharged back to the facility. The resident continued to have fevers and elevated blood sugars. The resident's urine culture was not responsive to the antibiotic started on 4/7/20 and the antibiotic was changed. The resident's diagnoses included "severe" sepsis (life threatening condition that arises when the body's response to infection causes injury to its own tissue and organs) from catheter related UTI. On 8/16/21 at 1:14 PM Staff 3 (LPN) indicated the resident had a history of UTIs and often had an increased CBG with infections. Staff 3 did not recall the specific information related to the urine dip test. The 8/16/21 e-mail from Staff 4 (DNS) indicated she was not able to find the 4/2/20 urine dip test results. On 8/20/21 at 2:47 PM Staff 4 verified she was not able to find the results of the urine dip test in the resident's chart. Staff 4 indicated the facility had the urine test strips in the facility, the resident had a Foley catheter and the test was easy to obtain. Staff 4 indicated she was not sure when the results were sent to the physician. Staff 4 acknowledged if the results were sent on 4/2/20 the staff should have tried to get a response from the physician before 4/7/20 and if the results were not sent until 4/7/21 there was a delay in obtaining the urine dip test. On 8/18/21 at 3:45 PM Witness 12 (Witness 13's Office Assistant) indicated Witness 13 reported she recalled the 4/2/20 incident with Resident 2's urine and indicated Witness 13 was not able to say whether or not the resident's sepsis would have been prevented if treated sooner. 2. Based on interview and record review it was determined the facility failed to remove staples after surgery for 1 of 2 sampled residents (#1) reviewed for surgical incisions and failed to request a change in treatment orders for 1 of 3 sampled residents (#1) reviewed for ulcers. This placed residents at risk for delayed care and delayed wound healing. Findings include: Resident 1 was readmitted to the facility 11/2020 with diagnoses including an above the knee amputation. a. Resident 1's 11/4/20 hospital Discharge Summary and orders indicated the resident had a leg amputation. The resident was to make a follow-up appointment with the surgeon "as soon as possible for a visit." The resident's record did not have documentation to indicate a surgical follow up appointment was scheduled. The resident's 11/24/20 Progress Note indicated the resident had 32 staples intact to the right amputation site and it was more than 30 days after the resident's surgery. On 8/12/21 at 9:13 AM Witness 7 (Complainant) reported Resident 1 went to a primary physician appointment and the resident's skin was found to have grown over the staples. The staples were removed in the office. On 8/16/21 at 10:15 AM Staff 7 (RNCM) stated after surgery Resident 1 was admitted to the skilled nursing unit. When the resident returned to the non-skilled unit the nurses identified the resident to still have staples. The physician was notified, an appointment was made and the staples were removed at the physician's office. On 8/19/21 at 11:34 AM Witness 6 (Surgeon's Medical Assistant) stated after a resident had surgery the post-hospital appointment was usually made two weeks after the procedure and staples were removed within that time frame. b. The 8/28/20 CAAs indicated Resident 1 had vascular surgery to the right leg to assist with circulation and wound healing. The surgery was not successful and the resident had a right partial foot amputation. The resident was admitted to the facility post-partial foot amputation. The Skin and Wound Evaluation sheets for the right partial foot amputation indicated the staff monitored the wounds weekly. On 8/3/20, first assessment after readmission, the resident's foot wound had 20 percent granulation (new tissue which is formed during wound healing) and 80 percent slough (dead tissue). The area of the wound was initially assessed to be 21 centimeters. The wound decreased in size but the amount of granulation tissue, slough and eschar (black dead tissue) varied each week. On 9/11/20 the wound had 30 percent granulation and 70 percent eschar, on 9/15/20 the wound was identified to have a faint odor after cleansing and on 9/22/20 the skin around the wound was assessed to have intense redness and moderate odor after cleansing. On 9/29/20 there was slight odor after cleansing but the wound had seropurulent (clear drainage tinged with milky drainage-potential sign of infection) drainage. On 10/13/20 the wound had 90 percent slough and purulent drainage (indicative of infection). The sheets did not indicate the physician was notified of the wound status including the development of eschar, intense redness and purulent drainage. The August, September and October 2020 TARs indicated the treatment was not changed to potentially assist with slough debridement (removal) or to culture the wound for infection. The 8/1/20 through 10/17/20 Progress Notes did not indicate the physician was updated on the resident's partial foot amputation when the wound developed eschar on 9/11/20, intense redness on 9/22/20, an odor or seropurulent drainage on 9/29/20 and purulent drainage on 10/13/20. On 10/16/20 the Progress Note indicated the resident's foot was red, warm to touch, had foul drainage to the wound bed and was covered with 80 percent slough. On 8/19/20 at 4:05 PM Staff 7 (RNCM) indicated if a wound did not show signs of improvement after two weeks, the physician was to be notified and a treatment change would possibly be implemented. Staff 7 indicated the resident's wound did not have granulation tissue prior to the 10/16/20 hospitalization and Staff 7 and Staff 4 (DNS) did not find documentation in the resident's record to indicate the facility contacted the resident's physician.

Resident #2 has discharged from the facility. Staples were removed from Res #1. Resident #1 no longer has a surgical wound that requires monitoring. All residents with orders for Urinalysis/Urine dip are at risk for the alleged deficient practice. An audit of all current residents with orders for a urinalysis/urine dip in the last 30 days will be conducted to assure that results were communicated timely to the ordering provider. All residents that admit with follow up appointments to be scheduled are at risk for this alleged deficient practice. An audit of all current residents that have admitted in the last 30 days will be conducted to assure that follow up appointments were scheduled timely. All residents with surgical wounds are at risk of the alleged deficient practice. An audit of current residents with surgical wounds will be conducted to assure that provider and responsible party have been notified if there has been a change of condition in a wound. Policy for Pressure Ulcer management has been reviewed and revised. Policy for Change of Condition has been reviewed. Policy for Lab and Diagnostic Test Results has been reviewed. Physician Order Processing policy has been reviewed and revised. Nursing staff education occurred on September 14, 2021, to include proper processing of lab orders including urine dipsticks, when to timely report lab results to Provider, notification of changes of conditions-including changes in wound management as outlined in the Pressure Ulcer management policy Registered Nurse Manager (RNM) will report orders for Urinalysis/urine dip daily in the morning meeting and follow up of the order(s). Registered Nurse Manager (RNM) will assure that follow up appointments have been made and report weekly in the Risk Meeting. Registered Nurse Manager (RNM) will report status of surgical wounds weekly in the Skin Meeting and if the wound has deteriorated that the Provider and Responsible Party has been notified. Reporting of these items will be to the Director of Nursing (DNS) or designee for 2 months or until substantial compliance is met

Based on interview and record review it was determined the facility failed to assess, document and obtain treatment orders for a resident's pressure ulcer for 1 of 3 sampled residents (#2) reviewed for pressure ulcers. This placed residents at risk for wound deterioration. Findings include: Resident 2 was admitted to the facility in 2020 with diagnoses including brain injury and dementia. The 6/23/21 CAAs indicated the resident had a history of stroke. The resident was placed on hospice services and, per family request, all nutrition including tube feeding was stopped. The resident had a history of pressure ulcers and continued to be at risk for the development of ulcers. Interventions included pressure reducing mattress, turn every two hours, heel lift cushion and a wedge was to be used for positioning off her/his back. On 8/14/21 at 11:00 AM and 1:20 PM Resident 2 was observed to be in bed with a pressure reducing mattress. The resident had a wedge behind her/his back when the resident was on her/his side and a wedge under her/his legs when on her/his back. On 8/17/21 at 10:05 AM with Staff 1 (CNA) and Staff 18 (LPN) Resident 2's coccyx was observed with a foam dressing. A date was not observed on the dressing. The dressing was removed and there were three pressure ulcers. There was one Stage II (partial thickness skin loss) which was one cm by one cm at the coccyx, one Stage II pressure ulcer on the left buttock region approximately two cm by one centimeter and one Pressure ulcer was not able to be staged by Staff 18 because the ulcer had a "scab" over part of the ulcer. The ulcer with a "scab" was approximately three cm by one cm. There was no drainage and no signs of infection to the ulcers or surrounding skin. Staff 18 indicated she was not aware the resident had a pressure ulcer and there were no ulcer treatments in the resident's record. Staff 1 indicated he had a few days off but heard last week the resident may have developed a skin issue. On 8/17/21 at 10:50 AM Staff 7 (RNCM) indicated she was the resident's interim RNCM and was not aware the resident had a current pressure ulcer. Staff 7 indicated if a resident developed a pressure ulcer staff were to initiate a skin event, fill out a Wound Assessment form, notify the family and physician and implement orders. Staff 7 reviewed the resident's record and indicated there were no skin assessments or physician orders for the pressure ulcers.

Resident #2 had treatment orders initiated on 08/17/21. Resident # 2 has discharged from the facility. All residents deemed at risk for skin breakdown are at risk for this alleged deficient practice. An audit using the Braden Scale numerical results and skin checks for unknown pressure injuries will be conducted on all current residents who are deemed at risk for skin breakdown and assure a corresponding treatment order is in place for pressure injuries. Pressure ulcer management policy reviewed and revised. Nursing staff was educated on policy and procedure on September 14, 2021. Education was given to Nursing staff regarding need for physician order for treatment of pressure injuries when an area is identified. Registered Nurse Manager (RNM) will audit 100% of weekly body checks for 4 weeks or until substantial compliance is met to assure that there is a treatment for any pressure injury that is identified on the body audit. Results of weekly body check audits will be reported to Director of Nursing (DNS) in the weekly Skin Meeting.

Based on interview and record review it was determined the facility failed to ensure a resident was assessed prior to an increase in antianxiety medication for 1 of 3 sampled residents (#7) reviewed for medication orders. Findings include: Resident 7 was admitted to the facility 12/2019 with diagnoses including kidney and liver failure. The hospital Discharge Summary indicated the resident was to be administered Ativan (antianxiety medication) 0.5 mg every eight hours PRN. The resident's December 2019 MAR indicated the resident was administered Ativan on five occasions. Three out of five times the Ativan administration was documented as effective, once it was documented as not effective and on one occasion the Ativan administration effectiveness was not evaluated. The December 2019 Progress Notes indicated the Ativan was effective to assist with the resident's anxiety. A 12/24/19 Progress Note by Staff 11 (RN) indicated the resident called out for help and staff provided nonpharmacological interventions. The resident requested Ativan and the note indicated it was effective for the resident's anxiety. The note also indicated the resident did not have additional Ativan refills and a refill request was sent to the physician. A 12/24/19 prescription indicated Resident 7 was to be administered two mg of Ativan three times a day PRN. The prescription comment indicated the medication was last filled on 3/22/19 (this was prior to Resident 7's admission to the facility). The resident's record did not have an assessment or rationale for the increase in dosage from 0.5 mg to 2.0 mg or a clarification from the physician to ensure the dose was correct. The December MAR indicated the resident received one dose of the 2.0 mg of Ativan on the morning of 12/26/19. The Progress Note dated 12/26/19 at 1:25 PM indicated the resident was agitated in the morning and the agitation decreased after the Ativan was administered. The resident was documented to refuse therapy and indicated she/he did not want to continue dialysis and wanted to die. The note indicated the physician and spouse were notified. The 12/26/21 at 3:07 PM Progress Note indicated the resident had a change in condition and was sent to the hospital for evaluation. On 8/17/21 at 11:31 AM Staff 11 did not recall Resident 7 and did not know the reason the resident's Ativan was increased. On 8/16/21 at 10:33 AM Witness 15 (Facility Contracted Pharmacist) indicated the pharmacist who received the 2.0 mg Ativan prescription acknowledged the pharmacy software warning which indicated Resident 7's 2.0 mg dose exceeded the recommended dosage for geriatrics. Witness 15 indicated the pharmacy system to review notes was currently not available but would call if there were notes related to the increase in dosage. No additional phone calls were received from Witness 15. On 8/17/21 at 11:10 AM Staff 4 (DNS) acknowledged Residents 7's Ativan was increased and she was not able to find an assessment or rational for the increased dose. The 1/26/20 hospital Discharge Summary indicated Resident 7 had diagnoses including end stage liver and kidney disease. The resident was admitted from he facility to the hospital with lethargy. The resident's mentation varied during hospitalization, was diagnosed with pneumonia and was placed on comfort care and was to be discharged home with family.

Resident #7 has discharged from the facility. All residents that receive increases in anti-anxiolytics are at risk for this alleged deficient practice. An audit of all current resident receive this medication class will be conducted to review for increases in the medication to assure an assessment was completed. Antipsychotic Medication Use policy has been reviewed and revised. Nursing staff was educated on September 14, 2021 regarding the need to review an increase in anti-anxiolytic medication to include completing the proper assessment. Social Services team to audit daily and report in morning meeting for increases in anti-anxiolytic medication orders and assessment is completed. Results of daily audits to be addressed with nursing staff and trends to be discussed at monthly Lifestyles meeting for 2 months or until substantial compliance is met.

OAR 411-086-0110 Nursing Services: Resident Care

Refer to F677 and Refer to F684 *************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686 *************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F758 ***************