Hillsboro Health And Rehabilitation

Resident 6 admitted 1/2025 with diagnoses including dementia. Resident 6's 6/9/25 MDS revealed Resident 6 had a BIMS of 5, which indicated a severe cognitive impairment. A 6/9/25 Sexual Capacity Evaluation indicated Resident 6 did not have sufficient memory and/or cognitive function to make the choice for sexual activity. Resident 10's 1/29/25 MDS revealed Resident 10 had a BIMS of 8, which indicated a moderate cognitive impairment. A 6/9/25 Sexual Capacity Evaluation indicated Resident 10 did not have sufficient memory and/or cognitive function to make the choice for sexual activity. On 8/11/25 at 1:04 PM, Staff 20 (CMA) stated she saw Resident 6 sitting on Resident 10GÇÖs bed on 6/9/25. She stated Resident 10 was touching Resident 6GÇÖs breasts and was offering Resident 6 money. She stated staff separated Resident 6 and Resident 10. On 8/11/25 at 1:07 PM, Resident 10 stated she/he did not remember the incident. Resident 6 was not able to be interviewed as she/he was no longer in the facility. On 8/12/25 at 10:17 AM, Staff 21 (RN) stated she saw Resident 6 go into Resident 10GÇÖs room and she observed them kissing on 6/9/25. She stated staff re-directed Resident 6 away from Resident 10. On 8/12/24 at 11:58 AM, Staff 3 (LPN Resident Care Manager) stated Resident 6 and Resident 10 were observed kissing on 6/8/25 and 6/9/25. He was made aware on 6/9/25 and completed the sexual consent evaluations for each resident and determined neither Resident 6 nor Resident 10 could consent to intimate activity.-á On 8/12/25 @ 12:30 PM, Staff 1 (Administrator) stated he was unable to locate any evidence the event was reported to the State Agency and that it was his responsibility to report to the State Agency.

POC F609 Reporting of Alleged Violations Resident 6 has been discharged from the facility Resident 10 has no recollection of the incident and there has been no further similar incident. There is no apparent psychosocial side effect on the resident from the incident. The care plan was reviewed to ensure there are interventions in place for inappropriate behaviors, particularly sexual behaviors. All other residents in the building reviewed for potential risks for similar situations occurring and none have been identified. Care plans were reviewed to ensure that behavior monitoring is in place for residents that may potentially display such behaviors. Training conducted to Staff about identifying reportable incidents such as alleged violations involving abuse, neglect, exploitation or mistreatment and misappropriation of property and that these violations need to be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. All incidents, grievances and nurses’ notes will be reviewed in daily clinical reviews to identify any events that may be reportable. Any identified incidents that fall under the category of allegations of abuse, neglect, exploitation or mistreatment and misappropriation of property will be reported immediately. These will be audited weekly for 4 weeks and then every 2 weeks until deemed no longer necessary. Results will be brought to QA meeting for further review and recommendations

Resident 6 admitted 1/2025 with diagnoses including dementia. Resident 6's 6/9/25 MDS revealed Resident 6 had a BIMS of 5, which indicated a severe cognitive impairment. A 6/9/25 Sexual Capacity Evaluation indicated Resident 6 did not have sufficient memory and/or cognitive function to make the choice for sexual activity. Resident 10's 1/29/25 MDS revealed Resident 10 had a BIMS of 8, which indicated a moderate cognitive impairment. A 6/9/25 Sexual Capacity Evaluation indicated Resident 10 did not have sufficient memory and/or cognitive function to make the choice for sexual activity. On 8/11/25 at 1:04 PM, Staff 20 (CMA) stated she saw Resident 6 sitting on Resident 10GÇÖs bed on 6/9/25. She stated Resident 10 was touching Resident 6GÇÖs breasts and was offering Resident 6 money. She stated staff separated Resident 6 and Resident 10. On 8/11/25 at 1:07 PM, Resident 10 stated she/he did not remember the incident. Resident 6 was not able to be interviewed as she/he was no longer in the facility. On 8/12/25 at 10:17 AM, Staff 21 (RN) stated she saw Resident 6 go into Resident 10GÇÖs room, and she observed them kissing on 6/9/25. She stated staff re-directed Resident 6 away from Resident 10. On 8/12/24 at 11:58 AM, Staff 3 (LPN Resident Care Manager) stated Resident 6 and Resident 10 were observed kissing on 6/8/25 and 6/9/25. He was made aware on 6/9/25 and completed the sexual consent evaluations for each resident and determined neither Resident 6 nor Resident 10 could consent to intimate activity.-á On 8/12/25 at 12:30 PM, Staff 1 (Administrator) stated he was unable to locate any evidence that the incident was investigated, and it was the AdministratorGÇÖs responsibility to complete the investigation.

POC F610 Investigate/Prevent/Correct Alleged Violation Resident 10 has been discharged from the facility. Resident 6 has no recollection of the incident and does not show any adverse psychosocial side effects related to the incident. Resident’s care plan was reviewed to ensure appropriate care plan interventions are in place for inappropriate behaviors, especially sexual in nature. All grievances and progress notes were reviewed to identify any other incidents that warrants an investigation. None were identified. The IDT Management team and staff were provided with re-training in identifying and reporting incidents that require an investigation. This includes allegations of abuse, neglect, exploitation, or mistreatment. All identified events/incidents will be reported to the administrator and DNS and investigations will be started immediately. Appropriate interventions will be initiated to mitigate further risk of the incident recurring or correct the alleged violation. The administrator/Designee will audit all investigations completed every week ensuring appropriate interventions were put in place and investigations were completed in a timely manner. This will be done weekly for 4 weeks and every two weeks there after until deemed no longer necessary. Results will be brought to QA meeting for further review and recommendations.

Resident 5 admitted in 7/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side. Resident 5GÇÖs 7/18/25 care plan indicated GÇ£Device: Seat belt-gait belt from homeGÇ¥ and GÇ£Mobility Device: Electric wheelchair, assist resident with seat belt.GÇ¥ A 7/20/25 progress note indicated Resident 5 was found on the floor, stated she/he GÇ£slid out of her wheelchairGÇ¥ and called emergency from her/his personal cell phone. Resident 5 had a laceration on her/his leg and was bleeding. Resident 5 was taken to the hospital for evaluation. On 8/8/25 at 12:28 PM, Staff 12 stated Resident 5 slipped out of her/his wheelchair and onto the floor. He further stated he could not get Resident 5GÇÖs seat belt around her/him because it was too small. He was unsure if use of the seat belt was in the care plan and stated he did not inform anyone the seat belt was too small because GÇ£it was known.GÇ¥ On 8/8/25 at 3:17 PM, Resident 5 reported she/he fell on the floor and her/his leg was bleeding. She/he yelled for help, but no one came. Resident 5 indicated she/he was scared and called 911 and was taken to the hospital.-á On 8/12/25 at 10:31 AM, Staff 22 (LPN) stated she saw Resident 5 during the morning medication pass. She did not know if Resident 5 was wearing a seat belt when she/he fell and was not sure if she/he was care-planned for its use. On 8/12/25 at 1:19 PM, Staff 1 (Administrator) stated he expected all staff to follow the care plan to prevent accidents.

POC F689 Free of Accident Hazards/Supervision/Devices Resident 5 has been discharged from the facility. DNS/RCMs will conduct an audit to ensure that care planned devices are in place and functional. Any devices identified missing or defective will be replaced or repaired. Care plans will be updated as needed. Nurses were re-trained in safety protocols which include identifying care planned devices and ensuring that they are in use. CNAs were also retrained in referring to the Kardex to know what safety devices are care planned for each resident. Everyone was reminded to let management or maintenance know if a safety device is not functioning properly so that this can be fixed. All the new admissions’ care plan will be reviewed to ensure the appropriate assistive devices specified in the care plan are in place. DNS/Designee will do audits of assistive devices every week for 4 weeks and then every 2 weeks thereafter unless otherwise deemed not necessary. The results will be brought to the QA meeting for further review and recommendations

Based on observation, interview and record review it was determined the facility failed to develop a resident centered care plan for 1 of 1 sampled resident (#1) reviewed for activities. This placed residents at risk for a lack of meaningful, purposeful and preferred activities and unmet psychosocial needs. Findings include: Resident 1 admitted to the facility in 12/2023 with diagnoses including dementia. The 3/1/25 Annual MDS assessed Resident 1 with a BIMS of three, which indicated severe cognitive impairment. The MDS Activity Preferences section indicated she/he found reading materials and the news somewhat important to her/him. Music, animals, going out in the fresh air and doing her/his favorite activities were very important. The 3/25/25 Activity Progress Note: Annual Review evaluation indicated Resident 1 was independent with activities and did not get out of bed. Resident 1 enjoyed The Daily Chronicle (flyer which provides reading, puzzles, coloring pages and other reading activities) and talking to family on the phone. The evaluation indicated Resident 1 was dependent for transportation on others and the problems indicated she/he did not get out of bed. Record review of Resident 1's Activity Participation from 4/23/25 tthrough 5/21/25 revealed the resident had not attended Bingo in the past 30 days. Resident 1 was documented to participate in the reading from the activity cart in her/his room frequently. A observation and interview on 5/19/25 at 1:07 PM revealed Resident 1 had no reading materials in reach of her/him. No music or television were on and the window blinds were open. Resident 1 stated she/he had not been busy for many years and would like to get out and do something which she/he liked to do. Resident 1 stated she/he enjoyed reading murder mystery, thriller and suspense books. The resident stated she/he did not recieve books to read. On 5/20/25 at 1:49 PM Resident 1 was observed in her/his bed with no lights on in the room, the blinds were slightly open and no reading material was within reach. No music or television was on and the curtain was pulled to not enable her/him to see into the hallway. Resident 1 smiled and stated she/he was not doing anything when asked. On 5/21/25 at 10:10 AM and 2:19 PM Resident 1 was observed in bed with no reading materials in reach, no music playing, and the blinds were open. At 2:19 PM the resident waved at the surveyor in the hallway and smiled. The 5/21/25 Care Plan indicated Activity Preferences documented in the ADL section. The intervention was "ACTIVITY PREFERENCES: (SPECIFY)." No other information was found in the care plan to direct staff to assist Resident 1 for her/his leisure, recreational, diversional or purposeful activities. Resident 1's 5/21/25 Kardex (a in room care plan) for Activity Participation directed staff to bring the resident to bingo. No additional activity preferences documented. On 5/22/25 at 11:27 AM Staff 22 (CNA) stated they obtained their information to care for the resident from the Kardex. When asked what activities Resident 1 enjoyed, Staff 22 stated Resident 1 preferred to stay in bed in her/his room. On 5/22/25 at 12:23 PM Staff 9 (CNA) stated they obtained their information to care for residents from the Kardex. Staff 9 stated Resident 1 liked to stay in bed and family was involved. On 5/23/25 at 9:09 AM Staff 23 (Activities Director) confirmed Resident 1 did not attend Bingo as directed in the Care Plan, no refusals to attend were documented and the resident preferred to stay in bed. Staff 23 acknowledged she had personally read The Daily Chronicle at bedside for Resident 1. Staff 23 stated Resident 1 was able to read printed reading material and sometimes used a magnifier glass. Staff 23 was aware Resident 1 enjoyed to read murder mystery type books but could not recall when the Resident was last provided a book to read or opportunity listen to a talking book. Staff 23 confirmed the Kardex and Care Plan did not direct staff to provide resident center leisure or diversional activity opportunities. On 5/23/25 at 11:08 AM Staff 1 (Executive Director) acknowledged he expected all residents to have a person-centered care plan for activities and all staff should be able to provide opportunities to assist residents in meaningful activities. Staff 1 confirmed he expected Resident 1 to have additional information in the Kardex and Care Plan for activities.

F656 Develop/Implement Comprehensive Care Plan 1) Resident 1s care plan was updated to reflect personalized plan for preferred activities. 2) All residents will be reviewed for a personalized care plan for activities. 3) Training will be provided to the activities director related to personalized activity care plans. Nursing staff will be provided training on incorporating activities in the residents care. 4) DNS/Administrator/Designee will audit all admissions moving forward for activity care plan completion every week for 4 weeks and every other week moving as deemed necessary. Results will be discussed in the monthly QAPI meeting.

Based on observation, interview and record review it was determined the facility failed to provide the necessary care and assistance to maintain good grooming and hygiene for 1 of 4 sampled resident (#43) reviewed for ADLs. This placed residents at risk for poor grooming. Findings include: Resident 43 was admitted to the facility in 3/2025 with diagnoses including nephrogenic diabetes insipidus (a medical disorder that occurs when your kidneys cannot properly balance bodily fluids) and ataxia (impaired muscle control that can affect walking, balance and the coordination of hand movements). A review of Resident 43's 5/3/25 admission MDS revealed she/he was cognitively intact and required supervision or touching assistance to complete personal hygiene tasks. Resident 43's care plan dated 4/28/25 revealed she/he received maximal/substantial assistance with showers on Sunday and Wednesday evenings and required supervision/touch assistance for grooming and personal hygiene. On 5/19/25 at 11:04 AM Resident 43 was observed to have a thick cluster of dark hairs growing from her/his chin. Resident 43 stated she/he was unable to shave independently because she/he could not control her/his hand movements. Resident 43 stated she/he was supposed to receive assistance to shave on her/his shower days and asked the CNAs to assist with shaving her/his shin hairs. On 5/22/25 at 2:13 PM Staff 18 (CNA) reported he worked with Resident 43 and should have offered to shave her/his chin because she/he was unable to shave independently. On 5/22/25 at 2:16 PM Staff 9 (LPN) stated he worked with Resident 43 regularly. Staff 9 stated Resident 43 was able to hold a razor but needed cueing to pick it up. Staff 9 stated he expected CNAs to help Resident 43 to shave herself/himself because she/he was unable to shave independently. On 5/22/25 at 2:42 PM Staff 19 (CNA) stated Resident 43 was unable to shave herself/himself because her/his hands were "shaky" and the resident was supposed to be shaved on her/his shower days. Staff 19 stated Resident 43 was not offered to be shaved this week. On 5/23/25 at 9:21 AM Staff 2 (DNS) stated she expected Resident 43 and other residents who required assistance with ADLs to receive assistance automatically. Staff 2 acknowledged Resident 43 was not provided appropriate ADL care and Resident 43 should not have to ask for assistance.

F677 ADL Care 1) Resident 43 was assisted in shaving facial hairs. 2) All residents were evaluated for facial hairs and offered a shave. Other aspects of care reviewed such as nails, hair and teeth. 3) CNAs were re-educated on providing complete ADL care. 4) DNS/SDC will do random audits of resident ADL care weekly for four weeks and every other week until deemed not necessary. Results will be discussed in the monthly QAPI meeting.

Based on interview and record review it was determined the facility failed to respond to a change of condition and provide respiratory interventions timely for 1 of 1 resident reviewed (# 41) for change of condition. This placed residents at risk for respiratory distress. Findings include: Resident 41 admitted to the facility in 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease and atrial fibrillation. The facility undated Standing Orders for oxygen indicated the goal of supplemental oxygen was to maintain saturations above 89% for residents with COPD. The orders indicated oxygen may go up to 2 liters before the provider was to be urgently notified. The 10/30/23 Care Plan directed staff to monitor Resident 41 for difficulties breathing and signs or symptoms of acute respiratory insufficiency. A Facility Report Incident indicated at 7:00 AM on 12/16/24, Resident 41 was found to have oxygen saturations of 64%. Resident 41's oxygen saturations were checked an additional two more times which were below 70%. Staff 5 (CNA) informed Staff 9 (LPN) several times as well as Staff 11 (Resident Care Manager/LPN) of Resident 41's low oxygen saturations. Staff 11 indicate he was busy, and took him time to address the concern. Staff 11 acknowledged oxygen was not given to the Resident 41. The resident was not sent out of the hospital until 2:00 PM and was diagnosed with hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions.) respiratory failure. The report concluded a lack of evaluation, treatment and urgency was found by the facility nurses. The report further indicated although the resident's condition may have not been prevented, an evaluation and initiation of oxygen may have provided relief and comfort to Resident 41. The 12/16/24 hospital noted indicated Resident 41 arrived at the hospital on 1 to 2 liters of oxygen. Resident 41 denied any shortness of breath, however, was found to have oxygen saturations in the low 70's at the nursing facility. During the resident's emergency department stay she/he was between 1 to 2 liters of oxygen and room air. On 5/19/25 at 9:47 AM Resident 41 stated she/he could not recall the incident on 12/16/24. Resident 41 stated she/he did not use oxygen. On 5/20/25 at 11:58 AM Staff 5 stated she was Resident 41's CNA on 12/16/24. Staff 5 stated on the morning of 12/16/24, Resident 41's oxygen saturations fluctuated between 64 to 68%. Staff 5 stated she told Staff 9 and Staff 11 of the resident's low oxygen saturations. Staff 5 stated the resident was not at her/his baseline and did not look well. Staff 5 stated Resident 41 was not given any oxygen and the resident was not sent out of the hospital until 2:00 PM. On 5/20/25 at 1:12 PM Staff 9 stated on 12/16/24, Staff 5 reported to him of Resident 41's low oxygen saturations. Staff 9 stated he checked the resident and was able to get her/his oxygen levels up by gravity and had the resident take deep breaths. Staff 9 stated Resident 41's oxygen saturations fluctuated between 80 to 90 percent. Staff 9 stated the first intervention should have been to provide oxygen to Resident 41, but he did not. Staff 9 stated oxygen saturations should be at 95 percent and below 90 percent was concerning. Staff 9 stated Resident 41 was not sent out to the hospital until the afternoon. On 5/21/25 at 9:51 AM Staff 11 stated on 12/16/24 he was not informed by Staff 5 of Resident 41's low oxygen saturations until 1:00 PM to 1:30 PM. Staff 11 stated he told Staff 9 to send the resident out to the hospital. Staff 11 further stated oxygen should be administetered for oxygen saturations below 92%. On 5/22/24 at 9:51 AM Staff 2 (DNS) stated when Resident 41's low saturations were reported to Staff 9, he should have reassessed Resident 41 and the first intervention should have been to provide the resident with oxygen. Staff 2 stated the standard of practice was to complete a full set of vitals, implement appropriate interventions, make a determination and either send the resident to the hospital or contact the physician if the resident was not in distress. Staff 2 acknowledged Resident 41 was not provide appropriate and timely respiratory interventions on 12/16/24.

F684 Quality of Care 1) Resident 41 was sent out to the ED as part of intervention for low saturations. No other resident was affected by this. 2) All residents vital signs are reviewed by clinical team every morning and throughout the day. Any abnormal vital signs were addressed right away. 3) CNAs and LNs were re-educated on normal ranges of vital signs, reporting abnormal vital signs as well as implementing appropriate interventions for any abnormal vital signs. 4) DNS/SDC/Designee will audit all vital signs weekly for 4 weeks for abnormal vital signs and interventions that were implemented and then every 2 weeks thereafter until deemed unnecessary. Results will be discussed in QAPI.

Based on interview and record review it was determined the facility failed to conduct weekly skin observations and evaluations to identify pressure ulcers and administer treatments timely treatment for 1 of 3 sampled resident (#359) reviewed for pressure ulcers. This placed residents at risk for complications related to unavoidable skin breakdown and not receiving care to treat pressure ulcers in a timely manner. Findings include: Resident 359 was admitted to the facility in 3/2024 with diagnoses including Alzheimer's disease (a progressive disorder which primarily affects the brain and leads to cognitive decline) and diabetes mellitus. A review of Resident 359's 3/18/24 admission MDS revealed she/he had severe cognitive impairment, had pressure ulcers, was at risk for the development of additional pressure ulcers and was dependent on staff for bed mobility. The Pressure Ulcer/Injury CAA indicated the facility provided Resident 359 with a pressure relieving mattress for her/his bed to minimize the pressure on her/his bony prominences while in bed. Resident 359's 3/22/24 care plan related to her/his pressure ulcers and risk for further skin breakdown indicated staff were to reposition her/him frequently, inspect her/his skin while providing cares and notify the nurse of any new skin conditions. A review of Resident 359's Weekly Skin Observations revealed no new skin impairments were identified on 8/7/24, 8/20/24, 8/30/24 or 9/13/24. The next reported Weekly Skin Observation was completed 35 days later on 10/17/24 and indicated Resident 359 developed an irregularly-shaped unstageable pressure ulcer (obscured full-thickness skin and tissue loss) 8 cm long and 10 cm wide on her/his coccyx (the last bone at the base of the spine). A hospice bath aide progress note dated 8/23/24 indicated Resident 359 had a new open sore on her/his "bottom." Staff 11 (Resident Care Manager/LPN) signed the note and indicated, "noted." A review of the facility's 10/16/24 investigation of Resident 359's open wound revealed the following: -A skin assessment completed on 10/15/24 indicated Resident 359 had an unstageable coccyx pressure injury with a dressing covering the area; -There was no previously written order for a dressing to be placed; -A coccyx pressure injury was noted on 8/26/24 in a hospice progress note and indicated "Will fax new wound care orders"; -The treatment order for the coccyx pressure injury was received on 9/20/24 but was implemented or followed up on; and -The facility determined there was a breakdown regarding the skin/wound management process and lack of nurse follow up regarding orders. A 10/18/24 progress note created by Staff 3 (RNCM) indicated Resident 359's coccyx pressure ulcer appeared to be a terminal ulcer. On 5/21/25 AT 4:18 PM Staff 3 stated the initial wound was discovered on 8/23/24 and a new wound dressing order was placed on 8/26/24 but was overlooked and not implemented. Staff 3 stated she first observed Resident 359's coccyx pressure wound on 10/18/24, noting it was a "larger wound" at the time and was then identified as a Kennedy pressure ulcer (a type of pressure ulcer that rapidly develops in the final stages of life, often appearing on the coccyx or other bony prominences). On 5/22/25 at 2:33 PM Staff 20 (LPN) stated Resident 359's hospice provider visited her/him twice each week, checked her/him for any changes and asked CNAs if there was "anything new." Staff 20 stated CNAs repositioned Resident 359 every two hours due to the resident's fragile skin. Staff 20 stated Resident 359's hospice caregiver discovered the new wound on resident 359's coccyx during a regular visit but he did not recall the date. On 5/22/25 at 2:48 PM Staff 19 (CNA) stated Resident 359 required assistance from two staff to reposition because her/his skin was fragile and she/he was "limp" and unable to help the CNAs with the repositioning process. Staff 19 stated she was aware of Resident 359's multiple pressure ulcers but was unaware of any new pressure ulcers to the resident's bottom. On 5/22/25 at 4:33 PM Staff 11 stated on 8/23/24 Resident 359's hospice provider observed a new open wound on the resident's "bottom" which was not previously observed or charted by staff in Weekly Skin Observations. Staff 11 stated hospice staff left him a handwritten note regarding the new wound. Staff 11 stated he did not act on the note because he had been out of the facility for more than a week, he did not ensure the information was provided to the oncoming nurse and instead assumed a nurse would see the note. On 5/23/25 at 8:53 AM Staff 21 (Former Administrator) stated Resident 359's hospice provider stated they faxed orders to treat the new pressure wound identified on 8/23/24 but the orders were not received and the resident was not provided care for the new wound when. Staff 21 stated the wound on 8/23/24 was blanchable (a type of pressure injury characterized by intact skin with a localized area of redness that turns white when pressed with a finger). On 5/23/25 at 9:29 AM, Staff 2 (DNS) stated she worked as the Regional Support Nurse during Resident 359's stay. Staff 2 stated staff were required to complete Weekly Skin Observations, which would trigger weekly skin evaluations for any new wounds. Staff 2 stated staff were expected to obtain and implement treatment orders for new skin impairments, maintain consistent wound care documentation, and follow facility protocols. She acknowledged staff's failure to document Resident 359's skin condition and follow up on orders, which led to inadequate evaluation and delayed treatment. Staff 2 stated Resident 359's pressure ulcer was discovered by hospice on 8/23/24, before facility staff identified the wound. Staff 2 further stated regular observations and documentation should have identified the new skin impairment to enable timely treatment and prevent wound deterioration.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer 1) Resident 359 is not in the facility anymore. 2) A skin sweep was completed on all residents. New skin impairments were prescribed treatments and were monitored. Weekly skin audits were assigned to all residents, and these were monitored for completion. 3) Nurses were re-educated on the importance of completing skin audits weekly for all residents. CNAs were re-educated in reporting any new skin impairment to the charge nurse. RCMs were re-educated in ensuring that skin audits were completed as well as monitoring major skin impairments through the weekly skin evaluation. 4) DNS or designee will audit that weekly skin audits and weekly skin evaluations are completed every week for 4 weeks and then every other week until deemed no longer necessary. Findings will be presented and discussed in QAPI meeting.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 5 of 7 days reviewed for RN staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include: A review of the facility's DCSDRs on 5/1/25, 5/5/25, 5/6/25, 5/7/25, 5/12/25, 5/13/25 and 5/14/25 revealed the postings inaccurately reflected the facility's RN coverage on the following days: -5/5, 5/6, 5/12, 5/13 and 5/14. On 5/22/25 at 12:15 PM, Staff 14 (Staffing Coordinator) confirmed the facility's DCSDRs inaccurately reflected RN coverage on 5/5/25, 5/6/25, 5/12/25, 5/13/25 and 5/14/25.

F732 Posted Nurse Staffing Information 1) The Direct Care Staff Daily Report that had inaccurate information did not directly affect any resident. 2) The specified dates that were identified with inaccurate DCSDR were reviewed for possible adverse outcomes to resident related and none were identified. 3) Staffing coordinator was educated on the state regulation on staffing and posting accurate staffing information. 4) ED or designee will audit the DCSDR for accuracy every week for 4 weeks and every other week until deemed no longer necessary. This information will be brough to QAPI meeting.

Based on interview and record review it was determined the facility failed to provide appropriate dosing of opioid medications for 1 of 6 sampled residents (#45) reviewed for medications. This placed residents at risk for complications related to narcotic medications. Findings include: Resident 45 was admitted in 3/2025 with diagnoses included alcoholic cirrhosis of the liver (severe liver disease) with ascites (abnormal build-up of fluid in the space between the organs and the lining of the abdomen). Resident 45's 4/17/25 physician order indicated the resident was to be administered two tablets of oxycodone (opioid pain medication) every four hours as needed for pain levels of eight to 10 out of 10. Resident 45's 5/2025 MAR indicated the resident was administered two tablets of oxycodone when her/his pain levels were less than eight as follows: -5/1: for pain levels of 6 and 7. -5/2: for pain levels of 5 and 6. -5/3: for pain levels of 4 and 5. -5/4: for pain levels of 5 and 6. -5/5: for a pain level of 6. -5/8: for pain levels of 4 and 5. -5/7: for a pain level of 7. -5/8: for pain levels of 4 and 5. -5/9: for a pain level of 7. -5/10: for a pain level of 6. -5/11: for a pain level of 7. -5/12: for a pain level of 5. -5/14: for pain levels of 6 and 7. -5/16: for a pain level of 6. -5/18: for a pain level of 5. -5/19: for a pain level of 3. -5/20: for a pain level of 7. -5/21: for a pain level of 7. On 5/19/25 at 9:20 AM, Resident 45 stated she/he had back pain and "they keep putting me on opioids" when the muscle rub worked better. Resident 45 stated staff were "more strict" with the muscle cream than the opioid medication. On 5/21/25 at 2:27 PM, Staff 9 (LPN) reviewed Resident 45's MAR and stated on 5/9/25 and 5/16/25 he did not ask Resident 45 her/his pain level because the resident would "just" state "10" if asked so he always dispensed two oxycodone pills to the resident. Staff 9 stated he just recorded a number in the pain level section and should have recorded an eight. On 5/21/25 at 2:34 PM, Staff 17 (RN) reviewed Resident 45's MAR and stated on 5/11/25 she mistakenly administered two oxycodone pills when she/he should have administered one pill. On 5/22/25 at 8:15 AM, Staff 8 (LPN) stated Resident 45 usually experienced pain and was clear in communicating if she/he was painful. Staff 8 reviewed Resident 45's MAR and stated on 5/3/25, 5/4/25, 5/5/25 and 5/8/25, she administered two oxycodone pills when only one oxycodone should have been administered. On 5/22/25 at 8:27 AM, Staff 3 (RNCM) reviewed Resident 45's MAR and confirmed the resident was administered two oxycodone pills when she/he should have received one pill on the identified days. On 5/22/25 at 8:44 AM, Staff 2 (DNS) stated physician orders should be implemented and followed. Staff 2 acknowledged staff did not follow the parameters for the administration of Resident 45's oxycodone.

F757 Drug Regimen is free from unnecessary drugs 1) Resident 45s medication was reviewed for appropriateness of dosing. Adjustment made as necessary based on residents pain management needs as prescribed by physician. 2) All residents pain regimen will be reviewed for unnecessary dosing. Adjustments will be made as unnecessary doses are identified. 3) All nurses and medication aides will be education on administering medication according to the specified dose based on the parameters prescribed. 4) DNS or designee will audit pain medication administrations related to appropriate doses administered every week for 4 weeks and then every other week until deemed no longer necessary. Findings will be brought to QAPI meeting.

Based on interview and record review it was determined the facility failed to maintain appropriate RN coverage for at least eight consecutive hours between the start of day shift and the end of evening shift for 5 of 7 days reviewed for RN staffing. This placed residents at risk for unmet assessments and care needs. Findings include: A review of the facility's DCSDRs (Direct Care Staff Daily Reports) and RN time sheets for 5/1/25, 5/5/25, 5/6/25, 5/7/25, 5/12/25, 5/13/25 and 5/14/25 revealed the following days without appropriate RN coverage. -5/5/25, 5/6/25, 5/12/25, 5/13/25 and 5/14/25. On 5/21/25 at 1:09 PM and 5/22/25 at 12:44 PM, Witness 2 (Anonymous Reporter) stated the facility frequently had no RNs working as a charge nurse during day or evening shift despite the DCSDRs indicating an RN was on shift, and stated this practice had been going on for at least the past two months. On 5/22/25 at 12:15 PM, Staff 14 (Staffing Coordinator) confirmed the facility was without appropriate RN coverage on 5/5/25, 5/6/25, 5/12/25, 5/13/25 and 5/14/25. On 5/22/25 at 2:25 PM, Staff 2 (DNS) stated she was not aware an RN was required to be scheduled as a charge nurse for eight hours from the start of day shift to the end of evening shift.

M182 Nursing Services 1) Reviewed state regulation of not meeting eight hours of RN charge nurse coverage between day and eve shifts. RN charge coverage didnt negatively affect residents or care. 2) Staffing coordinator will be educated on the state regulation on ensuring RN charge nurse coverage of eight hours between day and eve shift. 3) Daily recruiting efforts will be made to hire RN charge nurses at a competitive wage and will be posted to appropriate recruiting platforms. 4) DNS/Administrator/Designee will audit all applications/resumes received. Ensure interviews are set to appropriate applicants, interviews and offers tracked every week for four weeks or until deemed no longer necessary. Finding will be brought to QAPI meeting to be discussed.

******************** 411-086-0060 Comprehensive Resident Centered Care Plans Refer to F656 ******************** 411-086-0110 Quality of Life: Nursing Services: Resident Care Refer to F677 ******************** 411-086-0110 Quality of Care: Nursing Services: Resident Care Refer to F684 ******************** 411-086-0140 Quality of Care: Nursing Services: Problem Resolution and Preventive Care Refer to F686 ******************** 411-086-0100 Nursing Services: Staffing Refer to F732 ******************** 411-086-0140 Pharmacy Services: Nursing Services: Problem Resolution and Preventive Care Refer to F757 ********************

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications prior to leaving medications unattended at the resident's bedside for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for unsafe medication administration. Findings include: The facility's 9/2017 Self-Administration of Medication Policy & Procedure indicated a self-administration medication evaluation was completed before the resident was able to self-administer medications. If a resident was determined to safely self-administer medications, the nurse obtained a physician order for self-administration of the specific medication, a self-administration care plan was initiated and proper safety mechanisms were initiated to ensure medications were safely stored. Resident 36 was admitted to the facility in 7/2023 with diagnoses including diabetes mellitus type 2. Resident 36's 1/17/24 Quarterly MDS indicated the resident was cognitively intact and received medication for diabetes mellitus type 2. On 2/5/24 at 9:24 AM a medicine cup, which contained five various shaped pills, was on Resident 36's overbed table. Resident 36 stated the pills were "what was left" of her/his morning medications and stated staff left the pills with her/him. Resident 36 was unable to identify the medications which remained in the medication cup and stated, "I suppose I should take these now." Resident 36's health record revealed no evaluations, no physician orders, no care plan updates and no safety mechanisms related to medication self-administration. On 2/5/24 at 10:52 AM Staff 19 (LPN) stated he passed medications to the residents on the 300 hall where Resident 36 resided. Staff 19 stated the facility's procedure related to medication administration included to watch residents take their pills and not leave the pills at the residents' bedside. On 2/8/24 at 1:16 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 stated medications were not to be left at a resident's bedside unattended and she expected staff to ensure the resident took the medications.

F 554  Resident self-admin Meds-Clinically Apprpo CFR(s): 483.10(c)(7) Resident Specific: The identified residents issue was resolved: Resident 36 was promptly assessed by DNS for the ability to self-administer their medications and it was determined that they did not meet the criteria to do so. Other Residents: The Director of Nursing (DNS) and/or designee has reviewed and determined that no resident is clinically appropriate for self-administration of medication. Facility Systems: Facility clinical staff have been re-educated on policies and procedures for self-administration of medication and the five rights of medication administration. Monitor: The DNS and/or designee (IDT member or person of management team) will be auditing for medications left at bedside and reporting to DNS and included in ECR rounds three times weekly for 4 weeks, then weekly for three months until substantial compliance is met and maintained. The initial audit sweep will be completed by 02/29/2024. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Director of Nursing and/or designee.

Based on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for homelike environment. This placed residents at risk for adverse health conditions and an unclean environment. Findings include: Observations of the facility's general environment and residents' rooms from 2/5/24 through 2/9/24 identified the following issues: -Dirty floor vents inside the beauty shop, outside the beauty shop, outside of Rooms 109 and 220. -Four dime sized holes on the wall next to the timeclock. -One brown water stained ceiling tile in the main dining area near the kitchen entrance, two brown water stained ceiling tiles outside Room 106. -Gouged/damaged walls with paint missing behind resident beds in Rooms 109, 114-1, 114-2, 208-2, 312 and 315. -Lights not working on Hall 100 outside Rooms 102 and 111, Hall 200 outside Rooms 206 and 221, and Hall 300 outside the therapy room. -Room 107's door had missing pieces of wood leaving sharp/jagged edges on the doorframe. -Room 114's door had missing pieces of wood resulting in sharp/jagged edges. -Room 216's doorframe corner guard was lifted and pulled away from the doorframe. -Rooms 102 and 107 had unaccessable overbed light cords that were approximately 2 inches in length. On 2/9/24 at 10:22 AM Staff 1 (Interim Executive Director) and Staff 7 (Maintenance Director) acknowledged the identified issues and stated the repairs were needed.

F 584  Safe / Clean / Comfortable / Homelike Environment CFR(s): 483.10(i)(1)-(7) Resident Specific: Residents are at risk for failed practice of not having a safe/clean/comfortable environment. Other Residents: Residents are at risk for failed practice of not having a safe/clean/comfortable environment. Facility Systems: Dirty floor vents outside beauty shop, and rooms 109, 220 were cleaned, dime size holes next to time clock repaired, brown water stained tile outside room 106 replaced, damaged walls behind beds in rooms 109, 114, 208, 312, and 315 were repaired and painted, lights on 100 hall and 200 hall and 300 hall were repaired/replaced, sharp/jagged edges on the noted doorframe in room 114, 216 repaired, missing pieces of door edge room 114 was repaired of jagged edges, doorframe corner guard in room 216 repaired, light cords replaced in rooms 102 and 107. The Maintenance Director was educated and in serviced on keeping the facility in good repair with residents able to enjoy a safe, clean and comfortable homelike environment. Initial sweep of building was performed on 02/28/2024 and immediate repairs are in progress and education provided. Monitor: Vents, walls, ceilings lights resident door frames and over the beds light cords will be inspected monthly until substantial compliance is met and shown to be maintained. Date of Compliance: Date of compliance is March 15st 2024 Person Responsible: Executive Director or designee

Based on interview and record review it was determined the facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission for 1 of 2 sampled residents (#36) reviewed for care planning. This placed residents at risk for being uninformed about their plan of care. Findings include: Resident 36 was admitted to the facility in 7/2023 with diagnoses including diabetes mellitus type 2. Resident 36's 1/17/24 Quarterly MDS indicated the resident was cognitively intact. On 2/5/24 at 9:24 AM Resident 36 was unable to recall if the facility reviewed and provided her/him with a baseline care plan. Resident 36's health record revealed no evidence a baseline care plan was reviewed and provided to the resident within 48 hours. On 2/8/24 at 1:40 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 stated the facility was not consistent with review and provision of baseline care plans within 48 hours as required.

F 655 Baseline Plan of Care CFR(s): 483.21(a)(1)-(3) Resident Specific: The identified residents issues were resolved: DNS promptly verified that Resident 36 has had a documented comprehensive care plan 1/4/24 and participated in the care conference where the care plan was reviewed. Resident has been discharged from this facility on 2/29/24. Other Residents: The Director of Nursing (DNS) and/or designee will complete an initial audit sweep on residents admitting in the past 30 days to ensure that baseline plans of care were reviewed, a copy was provided, and was documented By March 1st 2024. Facility Systems: Education has been provided to licensed nursing staff and IDT members regarding completion and review of baseline plan of care within 48 hours of admission. Monitor: The DNS and/or designee will be auditing new admissions daily during morning clinical review to ensure that a baseline plan of care has been reviewed with the resident or responsible party, that a copy has been provided, and documented in medical records. The facility MOD will review on Sundays admissions that occurred Friday. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Director of Nursing and/or designee.

Based on observation, interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 3 of 8 sampled residents (#s 2, 36 and 42) reviewed for care plans, medications and accidents. This placed residents at risk for unmet needs. Findings include: The facility's 5/2023 Care Directive Policy & Procedure specified the ISP (individual service plan) was part of the care planning process and updates and revisions were completed as appropriate. 1. Resident 36 was admitted to the facility in 7/2023 with diagnoses including type 2 diabetes mellitus. Resident 36's current Care Plan indicated the following: - Monitor adverse side effects and/or toxic symptoms of trazodone (antidepressant). Resident 36's health record indicated the trazodone order was discontinued on 10/22/23. On 2/8/24 at 1:36 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation and acknowledged Resident 36's care plan was not updated to reflect the resident's current medications. 2. Resident 42 was admitted to the facility in 12/2023 with diagnoses including fracture of the arm. Resident 42's current ISP indicted the resident was on isolation precautions related to shingles (viral skin infection which causes blisters and rash). On 2/5/24 at 11:55 AM Resident 42's doorway or room entrance did not have infection control signage or PPE supplies to indicate the resident was on transmission-based precautions for an infection. On 2/8/24 at 10:35 AM Staff 18 (CNA) stated she relied on Resident 42's ISP for information related to the resident's care needs. Staff 18 reviewed Resident 42's ISP and stated it was confusing because Resident 42 did not currently have shingles and was not on isolation precautions. Staff 42 stated the ISP should be updated to reflect the resident's current status so staff who were not familiar with the resident's care were not confused. On 2/8/24 at 1:44 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) acknowledged Resident 42's ISP was not updated to reflect the resident no longer had shingles and did not require isolation precautions. , 3. Resident 2 admitted to the facility in 10/2021 with diagnoses including senile degeneration of the brain (memory loss). Review of Resident 2's 5/29/21 care plan revealed the resident was to have a unilateral mobility bar on the right side of her/his bed and a cushioned mat on the floor at her/his bedside to prevent injury from falls. On 2/5/24 at 10:43 AM Resident 2 was observed in bed without a unilateral mobility bar on the right side of her/his bed or a cushioned mat on the floor at her/his bedside. Review of Resident 2's 8/2023 TAR revealed the fall mat precaution had been discontinued on 8/27/23. Review of Resident 2's 12/6/23 Quarterly Nursing Review Progress Note revealed the resident was no longer utilizing bilateral mobility bars. On 2/8/24 at 8:11 AM Staff 15 (CNA) stated the resident used to have a fall mat next to her/his bed but they did not think the resident needed it any longer. On 2/8/24 at 8:22 AM Staff 13 (RN) stated Resident 2's bed was to be in low position and the resident was to have frequent checks for falls and was unaware if other fall preventions were in place. On 2/8/24 at 8:29 AM Staff 2 (DNS) stated Resident 2's order for the unilateral mobility bar and fall mat had been removed since the resident no longer got out of bed on her/his own. Staff 2 stated it was her expectation care plans were updated with new orders.

F 657 Care Plan Timing and Revision CFR(s): 483.21(b)(2) (i)-(iii) Resident Specific: The identified residents issues were resolved: care plan was promptly reviewed by DNS and the monitor for adverse side effect and/or toxic symptoms of trazadone (antidepressant) was removed from the care plan. care plan was promptly reviewed by DNS and the isolation precautions were removed from care plan and ISP, care plan was prompltly reviewed by DNS and the unilateral mobility bar and the fall mat were removed from the care plan. Other Residents: The Director of Nursing (DNS) and/or designee will complete an initial audit sweep on residents currently using antidepressant medication, isolation precautions, mobility bars, and floor mats to ensure plans of care accurately reflect resident needs by March 4th 2024 Facility Systems: Education was provided to licensed nursing staff and IDT members regarding care plan revision reflecting residents current needs and the care planning process. Monitor: The DNS and/or designee will audit revisions to accurately reflect the needs of the residents for monitoring adverse side effects and or toxic symptoms of antidepressant medications, isolation precautions, mobility bar use, and floor mat use. Audits will occur daily at the clinical meeting for new orders, resident change of condition, and updates to care plans. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Director of Nursing and/or designee.

Based on observation, interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 8 sampled residents (#s 32, 34, 36 and 42) reviewed for choices, care plans and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 36 was admitted to the facility in 7/2023 with diagnoses including type 2 diabetes mellitus, GERD (acid reflux), hypertension (high blood pressure) and chronic congestive heart failure (heart condition which can result in rapid weight gain from fluid build-up). a. Resident 36's 1/17/24 Quarterly MDS indicated the resident was cognitively intact. On 2/5/24 at 9:24 AM Resident 36 stated she/he received her/his Rybelsus (diabetic medication) late everyday. Resident 36 stated the medication was supposed to be taken before breakfast and staff brought it with the rest of her/his medications after breakfast. Resident 36's 2/2024 Physician Orders included Rybelsus 7 mg everyday for diabetes mellitus 2. The order included the following instructions: - "Must be given 30 minutes before first food/beverage/other medications with plain water." On 2/6/24 at 7:58 AM Resident 36 was observed with her/his breakfast meal partially consumed. Resident 36 stated she/he did not receive any of her/his medications yet. On 2/6/24 at 8:24 AM Staff 19 (LPN) was observed to administer Resident 36's Rybelsus medication. On 2/6/24 at 8:34 AM Staff 19 reviewed Resident 36's Rybelsus order and acknowledged the order indicated the medication was to be administered with plain water before any other food, beverages and medications. Staff 19 stated it was not always possible to administer "everyone's" medications on time and confirmed Rybelsus was not administered 30 minutes before the resident's first food, beverage and other medications. On 2/8/24 at 1:17 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 acknowledged Resident 36's physician order for Rybelsus was not followed and the medication was not administered before food, beverages and other medications. Staff 2 stated she expected staff to follow physician orders and administer medications as ordered. b. Resident 36's 2/2024 Physician Orders included omeprazole 20 mg, twice daily before meals. On 2/6/24 at 7:58 AM Resident 36 was observed with her/his breakfast meal partially consumed. Resident 36 stated she did not receive any of her/his medications yet. On 2/6/24 at 8:33 AM Staff 19 (LPN) was observed to administer Resident 36's omeprazole medication. On 2/6/24 at 8:34 AM Staff 19 reviewed Resident 36's omeprazole order and acknowledged the order indicated the medication was ordered to be administered before meals. Staff 19 stated it was not always possible to administer "everyone's" medications on time and confirmed Resident 36's omeprazole was not administered before breakfast as ordered. On 2/8/24 at 1:17 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 acknowledged Resident 36's physician order for omeprazole was not followed and stated she expected staff to follow physician orders and administer medications before meals when indicated. c. Resident 36's 1/2024 Physician Orders included Milk of Magnesia Suspension (MOM), give 30 ml by mouth as needed for constipation. If resident does not have a bowel movement for three days, administer milk of magnesia per physician order on day four. Resident 36's 1/2024 Bowel Movement Flowsheet revealed the resident did not have a bowel movement for four days on 1/28/24, 1/29/24, 1/30/24 and 1/31/24. Resident 36's 1/2024 MAR revealed MOM was not administered as ordered for bowel care. On 2/8/24 at 1:31 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 stated Resident 36 should have received MOM for bowel care on 1/31/24 and acknowledged the MOM Physician Orders were not followed. d. Resident 36's 1/2024 Physician Orders included the following: - obtain daily weight: notify the provider for clinical signs or symptoms of fluid overload or for weight gain of greater than five pounds in one week related to congestive heart failure. Resident 36's 1/2024 TAR revealed the resident's weight was not obtained on the following 13 dates: - 1/2/24, 1/3/24, 1/4/24, 1/5/24, 1/6/24, 1/12/24, 1/14/24, 1/16/24, 1/20/24, 1/25/24, 1/26/24, 1/27/24 and 1/31/24. On 2/8/24 at 1:35 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 stated she expected physician orders to be followed and staff should have obtained Resident 36's daily weights as ordered. e. Resident 36's 2/2024 Physician Orders included the following: - Humulin R (insulin), inject three units subcutaneously before meals related to type 2 diabetes mellitus. On 2/6/24 at 12:30 PM Staff 21 (RN) entered Resident 36's room and told the resident she needed to administer her/his insulin. Resident 36's lunch meal was observed on her/his table and no food remained on the plate. Resident 36 stated "You're late, I just ate my whole lunch." Staff 21 acknowledged she was "running behind" and administered Resident 36's insulin. On 2/8/24 at 1:18 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation and acknowledged staff did not follow the insulin order. f. Resident 36's 1/2024 Physician Orders included the following: - metoprolol succinate extended release (medication for high blood pressure), give 100 mg two times a day related to hypertension. Hold for systolic blood pressure lower than 110 or heart rate less than 55. Resident 36's 1/2024 MAR revealed the following dates and times when resident's systolic blood pressure was lower than 110 and the resident received metoprolol succinate: - 1/1/24 at 6:00 PM; - 1/7/24 at 8:00 AM and 6:00 PM; - 1/18/24 at 8:00 AM. On 2/8/24 at 1:20 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 stated staff should not have administered the metoprolol when Resident 36's systolic blood pressure was outside the ordered parameters and acknowledged the physician orders were not followed. 2. Resident 32 was admitted to the facility in 7/2023 with diagnoses including depression. On 2/5/24 at 1:13 PM Resident 32 stated in 9/2023 she/he did not receive her/his antidepressant medication for several days. Resident 32 stated she/he did not recall if she/he experienced negative side effects as a result of the missed medications. Resident 32's 9/2023 Physician Orders included escitalopram oxalate (antidepressant) 20 mg one time a day for depression. Resident 32's 9/2023 MAR revealed escitalopram was marked "00" and not administered on the following eight days: - 9/3/23, 9/4/23, 9/5/23, 9/6/23, 9/7/23, 9/8/23, 9/9/23 and 9/10/23. On 2/9/24 at 9:42 AM Staff 9 (RNCM) reviewed Resident 32's 9/2023 MAR and acknowledged it was marked with "00" which indicated the medication was not available and not administered. Staff 9 stated she was unsure why Resident 32's escitalopram was not administered as ordered and she was unable to provide rationale for why the medication was marked as unavailable as it was available in the facility's supply kit. 3. Resident 42 was admitted to the facility in 12/2023 with diagnoses including fracture of the arm. Resident 42's 12/14/23 Admission MDS indicated the resident was cognitively intact. Resident 42's 12/5/23 Hospital Discharge Summary indicated the following: - follow up with orthopedics for [arm] fracture. Resident 42's 1/15/24 Physician Order included "please schedule follow-up with orthopedics per the discharge summary if not already done" and "repeat right humerus 2-view" (x-ray of right upper arm). Review of Resident 42's health record revealed no orthopedic appointment was scheduled and no x-ray of the resident's right arm was obtained. On 2/5/24 at 11:55 AM Resident 42 stated she/he broke her/his right arm, used a sling and was unable to bear weight or use her/his right arm since her/his admission to the facility. Resident 42 stated there was no follow-up appointment with orthopedics or communication from staff regarding the use or weight-bearing status of her/his arm since she/he admitted to the facility. On 2/8/24 at 11:34 AM Staff 22 (LPN Resident Care Manager) stated it was her responsibility to respond to physician orders and schedule follow-up appointments. Staff 22 stated she worked in the facility for just a few weeks and thought Staff 2 (DNS) took care of Resident 42's orthopedic appointment and right arm x-ray. On 2/8/24 at 1:44 PM Staff 2 and Staff 20 (Divisional Director of Clinical Operations) reviewed the 12/5/23 Hospital Discharge Summary and the 1/15/24 Physician Order. Staff 2 stated she thought Staff 22 made the orthopedic appointment and scheduled the x-ray tests. Staff 2 acknowledged Resident 42's Physician Orders were not followed. , 4. Resident 34 was admitted to the facillity in 1/2024 with diagnoses including hypertension (high blood pressure). Resident 34's 1/16/24 physician order instructed staff to provide amlodipine beslyate once a day for hypertension, but to not administer if Resident 34's systolic blood pressure (SBP [upper blood pressure number]) was less than 110 and heart rate was less than 60 beats per minute. Review of the 1/2024 MAR revealed Resident 34 received amlodipine beslyate from 1/17/23 through 1/23/23 with no record of her/his blood pressure or heart rate being assessed upon medication administration. Review of Resident 34's 1/2024 MAR also revealed Resident 34 received amlodipine beslyate on 1/24/23 with her/his heart rate recorded at 55 beats per minute at the time of medication administration. Resident 34 also received amlodipine beslyate on 1/27/23 and her/his SPB was recorded at 103 at the time of medication administration. On 2/9/24 at 8:54 AM Staff 2 (DNS) confirmed Resident 34's blood pressure and heart rate were not recorded upon administration of amlodipine beslyate from 1/17/23 through 1/23/23 and Resident 34 received this medication outside of the ordered parameters on 1/24/23 and 1/27/23.

F 684 Quality of Care CFR(s): 483.25 Resident Specific: The identified residents issues were resolved: medications were reviewed and orders were prompltly updated to ensure medication administration is timely and physician orders were followed. Medication availability was promptly reviewed to ensure timely administration. Appointment orders and x-ray orders were reviewed and resolved to ensure timely follow-up. Other Residents: Residents receiving medication to be administered before food, as needed bowel care medications, daily weight orders, Insulin, antihypertensive medications with blood pressure parameters, antidepressants, orthopedic appointments, and x-rays orders, have the potential to be affected. Initial audit including medication administration observations on three separate medication passes will be completed by March 1st, 2024 Facility Systems: Education was provided to licensed nursing staff regarding the administration of medication in a timely manner. This included assigning a specific time for medications, the 5 rights of medication administration including giving medication at the appropriate time, following physician orders, appointment and x-ray orders, and follow up on medications not currently available. Monitor: The DNS and/or designee will perform (random) medication administration observation audits weekly for four weeks then monthly for 3 months until substantial compliance has been met and maintained. Additionally, DNS or designee will complete audits daily during clinical meeting on medications not administered, residents having no bowel movements, and clinical alerts to ensure follow up. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Director of Nursing and/or designee.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were completed for 21 out of 67 sampled days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: A review of the Direct Care Staff Daily Reports dated 12/1/23 through 2/5/24 revealed 21 out of 67 days the Resident census, CNA and/or RN hours were blank for one or more shifts for the following days: -12/1/23 -12/2/23 -12/5/23 -12/6/23 -12/7/23 -12/8/23 -12/9/23 -12/10/23 -12/12/23 -12/14/23 -12/15/23 -12/16/23 -12/19/23 -12/20/23 -12/21/23 -12/22/23 -12/23/23 -12/24/23 -1/6/24 -2/1/24 -2/2/24 On 2/8/24 at 10:59 AM Staff 6 (Activities Director/Staffing Coordinator) acknowledged the incomplete Resident census and CNA and/or RN hours for the days identified.

F 732 Posted Nurse Staffing Information CFR(s): 483.35 (g)(1)-(4) Resident Specific: No residents in this facility have the potential to be affected. Other Residents: No other residents have the potential to be affected. Facility Systems: Education was promplty provided to licensed nursing staff and staffing coordinator on accurately completing the nursing staffing data at the beginning of each shift. An initial audit will be completed by February 29th 2024 on current days staffing form and past 7 days. Monitor: The DNS and/or designee will perform daily auditing of the Nursing Staffing information form to ensure accuracy and completion. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Director of Nursing and/or designee.

Based on interview and record review it was determined the facility failed to obtain and provide routine medications for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for not receiving prescribed medications. Findings include: Resident 36 was admitted to the facility in 7/2023 with diagnoses including diabetes mellitus type 2. Resident 36's 12/2/23 Physician Orders included the following: - calcitonin nasal solution 200 unit/ACT, one spray alternating nostrils one time a day for osteoporosis (bone brittleness and weakness). Resident 36's 12/2023 MAR revealed "00" was marked on the following 21 days: - 12/5/23, 12/6/23, 12/7/23, 12/8/23, 12/9/23, 12/10/23, 12/11/23, 12/15/23, 12/16/23, 12/17/23, 12/18/23, 12/19/23, 12/20/23, 12/21/23, 12/25/23, 12/28/23, 12/29/23, 12/30/23 and 12/31/23. Resident 36's 1/2024 Physician Orders included the following: - calcitonin nasal solution 200 unit/ACT, one spray alternating nostrils one time a day for osteoporosis. Resident 36's 1/2024 MAR revealed "00" was marked on the following five days: - 1/1/24, 1/2/24, 1/3/24, 1/4/24 and 1/7/24. On 2/8/24 at 1:28 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) reviewed Resident 36's 12/2023 and 1/2024 MARs and stated "00" indicated the calcitonin nasal spray was unavailable and the resident did not receive the medication. Staff 2 stated if a medication was not available, she expected staff to call the pharmacy right away to get the medication delivered and to notify the physician.

F 755 Pharmacy Srvcs / Procedures / Pharmacist / Records CFR(s): 483.45 (a)(b)(1)-(3) Resident Specific: The identified residents issues were resolved: DNS promptly verified that the resident currently has available and receives medications as per physicians orders. Other Residents: Residents with medications On Order have the potential to be affected. Facility Systems: Education was promptly provided to licensed nursing staff regarding follow-up procedures on medications not currently available. This education also included the five rights of medication administration and following physician orders. Monitor: The DNS and/or designee will perform three random medication administration audits weekly for 4 weeks then monthly for three months until substantial compliance has been met and maintained. In addition, DNS or designee will perform daily audits of medications not administered during daily clinical meetings. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th, 2024 Person Responsible: Director of Nursing and/or designee.

Based on interview and record review it was determined the facility failed to follow-up on pharmacist recommendations for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for medication errors. Findings include: The facility's 3/2019 Medication Regimen Review (MRR) Policy & Procedure specified the procedure as follows: - A pharmacist completes the monthly MRR, the pharmacist sends an email report of any irregularities and the facility and attending physician respond to the recommendations within two weeks. Resident 36 was admitted to the facility in 7/2023 with diagnoses including diabetes mellitus type 2. Resident 36's 9/16/23 Consultant Pharmacist MRR revealed the following recommendation: - "Resident has an order for calcitonin nasal spray. Be sure to add right alternating left nostril [every day]. The MAR [indicates] we are giving it into the right nostril every day." Resident 36's 9/2023 MAR revealed calcitonin spray was not administered in alternating nostrils and the Consultant Pharmacist MRR recommendation was not implemented. Resident 36's 10/16/23 Consultant Pharmacist MRR revealed the following recommendation: - "Resident has an order for calcitonin nasal spray. Be sure to set up in the system add right alternating left nostril [every day]. The MAR [indicates] we are giving it into the left nostril every day with occasional right nostril." Resident 36's health records revealed no 11/2023 Consultant Pharmacist MRR. Resident 36's 10/2023 and 11/2023 MARs revealed calcitonin spray was not administered in alternating nostrils consistently and the Consultant Pharmacist MRR recommendation was not implemented. On 2/8/24 at 1:26 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) reviewed Resident 36's 9/2023 and 10/2023 Consultant Pharmacist MRR recommendations and the resident's 9/2023, 10/2023 and 11/2023 MARs. Staff 2 acknowledged the calcitonin nasal spray was not administered in alternating nostrils as recommended and stated the recommendations should have been implemented.

F 756 Drug Regimen Review, Report Irregular, Act on CFR(s): 483.45(c)(1)(2)(4)(5) Resident Specific: The identified resident issues were resolved: DNS promptly verified that pharmacy recommendations are implemented, and order verified that calcitonin is administered in alternating nostrils. Other Residents: Residents with pharmacy recommendations have the potential to be affected. Initial audit sweeps of pharmacy recommendation for the current month will be completed by March 1, 2024. Facility Systems: Education provided to licensed nursing staff and pertinent IDT members on follow up and implementation of pharmacy recommendations in a timely manner. Monitor: The DNS and/or designee will perform audits weekly for 4 weeks then monthly for 3 months until substantial compliance has been met and maintained. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Director of Nursing and/or designee.

Based on interview and record review it was determined the facility failed to ensure antibiotics were administered as ordered for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for receiving unnecessary medications, experiencing adverse medication effects and developing antibiotic resistance. Findings include: The CDC Core Elements of Antibiotic Stewardship (https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html) dated 8/2021 indicated Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Resident 36 was admitted to the facility in 7/2023 with diagnoses including major depressive disorder. Resident 36's health record included a 12/26/23 prescription for cephalexin (antibiotic) 500 mg capsules, take one capsule four times a day, 20 capsules, no refill. Resident 36's 12/2023 MAR indicated the cephalexin start date was 12/26/23 and the discontinue date was 1/8/24, a total of 14 days and not five days as ordered. The 12/2023 MAR revealed cephalexin 500 mg was initiated and administered on 12/26/23 at 6:00 PM and the resident received cephalexin four times daily from 12/27/23 through 12/31/23. Resident 36's 1/2024 MAR revealed cephalexin 500 mg was administered four times on 1/1/24, two times on 1/2/24, one time on 1/3/24, four times on 1/4/24, two times on 1/5/24, one time on 1/6/24, one time on 1/7/24 and one time on 1/8/24. On 2/8/24 at 1:21 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) reviewed Resident 36's 12/26/23 cephalexin prescription. Staff 2 stated the prescription specified a total of 20 capsules dispensed. Staff 2 stated the cephalixin should have been administered over the course of five days, four times a day and discontinued upon completion. Staff 2 acknowledged Resident 36 received the antibiotic for 14 days which exceeded the prescribed dose and duration.

F 757 Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6) Resident Specific: The identified residents issue was resolved the DNS promptly verified that the identified resident is not currently receiving antibiotics and does not have current orders for antibiotics. Other Residents: Residents receiving antibiotics in this facility have the potential to be affected Initial audit of pharmacy recommendation for the current month will be completed by March 1, 2024. Facility Systems: Education provided promptly to licensed nursing staff on ensuring orders (including antibiotics) are carried out accurately and discontinued as prescribed. Nursing staff education included that orders are to be followed per prescribed dose, frequency, and duration. An initial audit sweep for the current month for accuracy of antibiotic orders will be completed by March 1, 2024. Monitor: The DNS and/or designee will complete audits daily in the clinical meeting for accuracy and completion of new antibiotic orders until substantial compliance has been met and maintained. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Director of Nursing and/or designee.

Based on interview and record review it was determined the facility failed to ensure residents were comprehensively assessed for the use of psychotropic medications and failed to ensure GDR (gradual dose reduction) was attempted for 1 of 5 sampled residents (# 36) reviewed for medications. This placed residents at risk for receiving unnecessary medications. Findings include: Resident 36 was admitted to the facility in 7/2023 with diagnoses including major depressive disorder. Resident 36's 7/24/23 Admission MDS revealed the resident used an antidepressant medication to treat her/his depression, had no behaviors and scored 0 on the PHQ-9 assessment (used to detect the presence and severity of depression; high score indicates symptoms of depression). The MDS Psychotropic Drug Use CAA indicated the facility worked in "concert" with the resident's physician and the pharmacy consultant to attempt a GDR of the antidepressant medications when appropriate. Resident 36's 1/17/24 Quarterly MDS revealed the resident used an antidepressant, had no behaviors and scored 0 on the PHQ-9 assessment. Resident 36's 7/2023, 8/2023, 9/2023, 10/2023, 11/2023, 12/2023, 1/2024 and 2/2024 Physician Orders included duloxetine (antidepressant) 30 mg, take 90 mg every day for major depressive disorder. Resident 36's 7/2023, 8/2023, 9/2023, 10/2023, 11/2023, 12/2023, 1/2024 and 2/2024 MARs revealed the resident received duloxetine 90 mg daily. Review of Resident 36's health record revealed no behavior monitor flowsheet to track potential signs and symptoms of depression such as tearfulness, sadness, mood changes, increased fatigue, loss of interest or pleasure in daily activities and sleep disturbances. Resident 36's 7/28/23 Care Plan identified the resident used an antidepressant. The interventions included to monitor for effectiveness via monthly review with the facility's pharmacy consultant. Resident 36's 10/2023, 11/2023, 12/2023 and 1/2024 Psychotropic Drug and Behavior Monthly Review revealed Staff 24 (Pharmacist), Staff 23 (Executive Director), Staff 2 (DNS), Staff 8 (MDS Coordinator) and Staff 5 (Social Services Director) were present at the meetings. The Reviews revealed Resident 36 was prescribed duloxetine 90 mg daily for major depressive disorder. The 10/2023, 11/2023, 12/2023 and 1/2024 Psychotropic Drug and Behavior Monthly Reviews, sections titled, "Describe how medication is assisting the resident in reaching highest functional level" revealed the following documentation: - "The medications are assisting the resident to not be teary and isolate in bed or be depressed. Resident is spending more time up in [her/his] chair and visiting and smiling." The 10/2023, 11/2023, 12/2023 and 1/2024 Psychotropic Drug and Behavior Monthly Reviews, sections titled, "Target Behaviors summary/trend since last review" revealed the following documentation: - "None." The 10/2023, 11/2023, 12/2023 and 1/2024 Psychotropic Drug and Behavior Monthly Reviews, sections titled, "Non drug interventions" revealed the following documentation: - "Reposition, redirection, breathing techniques, relaxation techniques and medication." The 10/2023, 11/2023, 12/2023 and 1/2024 Reviews, sections titled, "Team recommendations" revealed the following documentation: - "The medications are assisting the resident to not be teary and isolate in bed or be depressed. Resident is spending more time up in [her/his] chair and visiting and smiling. Team recommends no changes at this time." No other documentation was found in Resident 36's health record or within the Reviews to indicate the resident participated in the medication review process and communicated potential changes in her/his depression symptoms. No evidence was found to indicate the resident was comprehensively assessed with a person-centered approach and adequately monitored and evaluated for therapeutic response to the antidepressant medication. The Reviews revealed no previous or new targeted behaviors and lacked unique, person-centered non-pharmacological interventions for Resident 36's depression. The Reviews lacked rationale to support the current dose and duration of duloxetine and lacked documentation a GDR was attempted or contraindicated. On 2/8/24 at 1:37 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 reviewed Resident 36's Psychotropic Drug and Behavior Monthly Reviews, acknowledged the Reviews were not comprehensive, the resident was not assessed with a person-centered approach and a GDR was not documented as attempted or contraindicated.

F 758 Free from Unnecessary Psychotropic Meds / PRN Use. CFR(s): 483.45(c)(3)(e)(1)-(5) Resident Specific: The identified residents issue was resolved: DNS ensured per GDR via pharmacy recommendation issued in the month of February 2024, when the antidepressant dose was reduced. Other Residents: Residents in this facility receiving antidepressant medications have the potential to be affected. Facility Systems: Education was provided to licensed nursing staff and IDT members on psychotropic drugs (including antidepressants) and the psychotropic IDT review guidelines. An initial antidepressant medication audit will be completed by March 1, 2024. Monitor: The DNS and/or designee will complete psychotropic drug and behavior monthly reviews each month to ensure that the reviews are comprehensive with a person-centered approach. The DNS or designee will perform audits monthly to ensure that the documentation supports a gradual dose reduction or if it is contraindicated. This will include monthly monitoring of documented behaviors and inclusion of resident feedback and participation in psychotropic reviews until substantial compliance has been met and maintained. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Director of Nursing and/or designee.

Based on observation, interview and record review it was determined the facility failed to ensure a medication administration error rate of less than 5%. There were seven errors in 29 opportunities resulting in a 24.14% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: 1. Resident 36 was admitted to the facility in 7/2023 with diagnoses including type 2 diabetes mellitus. Resident 36's 2/2024 Physician Orders included: - Rybelsus (diabetic medication) 7 mg everyday for type 2 diabetes mellitus, must be given 30 minutes before first food/beverage/other medications with plain water. - omeprazole (stomach acid reducer) oral capsule delayed release, 20 mg two times a day before meals. - Humulin R (short-acting insulin), inject three units before meals. On 2/6/24 at 7:58 AM Resident 36 was observed with her/his breakfast meal partially consumed. Resident 36 stated she/he did not receive any of her/his medications yet. On 2/6/24 from 8:09 AM until 8:34 AM Staff 19 (LPN) was observed for Resident 36's medication administration. At 8:24 AM Staff 19 administered the Rybelsus to Resident 36 and at 8:33 AM Staff 19 administered the omeprazole to Resident 36. On 2/6/24 at 8:34 AM Staff 19 reviewed Resident 36's Rybelsus order and acknowledged the medication was ordered to be administered with plain water before any other food, beverages and medications. Staff 19 stated it was not always possible to administer "everyone's" medications on time and confirmed Rybelsus was not administered 30 minutes before the resident's first food, beverage and other medications. Staff 19 reviewed Resident 36's omeprazole order and acknowledged the medication was ordered to be administered before meals. Staff 19 confirmed Resident 36's breakfast meal was consumed and he did not administer the resident's omeprazole as ordered before meals. On 2/6/24 from 11:59 AM to 12:30 PM Staff 21 (RN) was observed for insulin administration. At 12:24 PM Staff 21 prepared three units of Resident 36's Humulin R and entered the resident's room. Resident 36 was observed in bed with her/his lunch completely consumed. Staff 21 told Resident 36 she had her/his insulin to administer. Resident 36 stated, "I already ate my whole [lunch]." Staff 21 acknowledged she was late with the insulin, administered the insulin and left the room. On 2/7/24 at 8:25 AM Staff 22 (LPN Resident Care Manager), Staff 25 (Agency RN) and Staff 26 (Agency RN) were observed to prepare Resident 36's insulin. Staff 22 handed a vial of insulin aspart (rapid-acting insulin) to Staff 25 who drew up three units into a needle. Staff 25 showed the needle with insulin to Staff 22 and Staff 26 who verbally acknowledged the needle contained three units of insulin. The RN State Surveyor stopped Staff 25 prior to entering Resident 36's room and asked Staff 25 to review the resident's insulin order. Staff 25 read the order aloud and acknowledged she had drawn up three units of insulin aspart which was the incorrect insulin, and not Humulin R insulin as ordered. On 2/8/24 at 1:08 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the medication and insulin errors and acknowledged the medications and insulin were not administered timely and as ordered. 2. Resident 104 was admitted to the facility in 1/2024 with diagnoses including type 2 diabetes mellitus. Resident 104's 2/2024 Physician Orders included Humalog (insulin lispro), inject per sliding scale. On 2/6/24 at 12:08 PM Staff 21 (RN) was observed for Resident 104's insulin administration. Staff 21 knocked and entered Resident 104's room and explained she was there to administer two units of insulin. Staff 21 retrieved a vial of insulin lispro from the medication cart and drew up two units into the needle. The RN State Surveyor visualized the vial of insulin lispro and observed the vial to be labeled with Resident 38's name. The RN State Surveyor asked Staff 21 to visualize the vial and Staff 21 confirmed the insulin lispro vial did not belong to Resident 104. On 2/8/24 at 1:08 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the insulin lispro error and acknowledged the incorrect resident's insulin vial was used to obtain Resident 104's insulin. 3. Resident 26 was admitted to the facility in 1/2024 with diagnoses including type 2 diabetes mellitus. Resident 26's 2/2024 Physician Orders included insulin lispro injection solution, inject per sliding scale. On 2/6/24 at 12:35 PM Staff 21 (RN) was observed for Resident 26's insulin administration. Staff 21 knocked and entered Resident 26's room and explained she needed to obtain the resident's blood sugar and administer insulin. Resident 26 stated she/he already ate her/his entire lunch. Staff 21 retrieved a vial of insulin lispro from the medication cart, drew up seven units into a needle and administered the insulin to Resident 26. Staff 21 acknowledged she obtained Resident 26's blood sugar after the meal and administered the resident's insulin late and after she/he consumed the lunch meal. On 2/8/24 at 1:08 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified about Resident 26's late insulin administration. Staff 2 stated she expected staff to request help from other staff when they were late on medications and insulin. 4. Resident 38 was admitted to the facility in 10/2023 with diagnoses including type 1 diabetes mellitus. Resident 38's 2/2024 Physician Orders included the following: - Humalog (insulin), inject four units before meals. - Humalog, inject four units before meals for blood sugar between 201-250. - Insulin Glargine (long acting insulin), inject 13 units one time a day. On 2/7/24 from 7:55 AM to 8:22 AM Staff 26 (Agency RN) was observed for Resident 38's blood sugar and insulin administration. Staff 26 obtained Resident 38's blood sugar and it was 220. Staff 26 retrieved the vial of Glargine, drew up 13 units into the needle and verbally verified the insulin with the RN State Surveyor. Staff 26 then retrieved another needle, drew up eight units of Glargine and verbally verified the insulin. The RN State Surveyor stopped Staff 26 and requested he review the resident's insulin orders. Staff 26 acknowledged he drew up Glargine in two separate needles and did not draw up the Humalog as ordered. Staff 26 stated he was "overwhelmed" and was running behind on tasks. On 2/8/24 at 1:08 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified about Staff 26's insulin error. Staff 2 stated she expected staff to request help from other staff when they were late on medications and insulin.

F 759 Free of Medication Error Rts 5 Prcnt or More. CFR(s): 483.45(f)(1) Resident Specific: The identified residents issues were resolved: Resident medication timing including insulin was promptly verified by DNS and updated as indicated to facilitate timely administration and ensure that physicians orders are followed.. Education was promptly provided to licensed nursing staff on administration of medication timely and following physicians orders. Other Residents: Residents receiving time sensitive medications including insulin have the potential to be affected. Facility Systems: Education was provided to licensed nursing staff on administration of medication including insulin in a timely manner including assigning a specific time for administration and following physicians orders. This education included the 5 rights of medication administration, giving medications at the appropriate time, following physician orders, and follow up on medications not currently available. Monitor: The DNS and/or designee will complete 3 random medication administration observation audits weekly for four weeks then monthly for 3 months until substantial compliance has been met and maintained and findings will be brought to the Quality Assurance Performance meeting. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Director of Nursing and/or designee.

Based on observation, interview and record review it was determined the facility failed to handle and prepare food in a sanitary manner for 1 of 1 kitchen reviewed for sanitary practices and to ensure resident personal refrigerators were free of expired and/or unlabeled foods for 1 of 3 residential halls reviewed for food safety. This placed residents at risk for foodborne illness. Findings include: 1. On 2/5/24 at 10:58 AM Resident 38's personal refrigerator was observed to have two expired strawberry yogurts dated 12/6/23, an unidentifiable 8 ounce drink not labeled or dated, and an unidentifiable 32 ounce drink not labeled or dated. On 2/5/24 at 11:47 AM Staff 11 (CNA) stated the items should have been dated or thrown away. 2. On 2/5/24 at 11:14 AM Resident 36's personal refrigerator was observed to have what appeared to be cheese and broccoli soup in a small plastic container not labeled or dated, a small Starbucks coffee cup not labeled or dated, one opened four ounce container of strawberry yogurt dated 9/18/23, and two small containers of unopened fruit not labeled or dated. On 2/5/24 at 11:47 AM Staff 11 (CNA) stated the items should have been dated or thrown away. On 2/5/24 at 12:41 PM Staff 1 (Interim Executive Director) stated the refrigerators should have been checked on a regular schedule and foods thrown away within a reasonable time period. , 3. On 2/7/24 at 12:05 PM Staff 16 (Cook) was observed working at the kitchen's steam table preparing and plating food for the lunch meal. She was observed touching the food with utensils and her gloved hands. She then stepped away from the steam table to retrieve a salad from the refrigerator adjacent to the food preparation area. She was observed to open the refrigerator with her gloved hand, retrieve a salad that was covered in cling film and close the refrigerator door with her gloved hand. Without changing her gloves or completing hand hygiene, she returned to the steam table, removed the cling film from the prepared salad, placed it on a tray for delivery to a resident and continued to handle food using utensils and her gloved hands. On 2/7/24 at 12:07 PM when asked when it was appropriate change her gloves, Staff 16 pointed to a stack of gloves on tray table and stated, "I do it all the time during tray line. That's why I keep the stack of gloves right there." When asked why she did not change her gloves after touching the refrigerator door handle, she stated, "I should have changed my gloves." On 2/7/24 at 12:11 PM Staff 17 (Dietary Manager) stated she expected staff to change gloves whenever they touch potentially contaminated surfaces in order to minimize risk of cross contamination. On 2/9/24 at 11:45 AM Staff 1 (Interim Executive Director) acknowledged the absence of appropriate glove use and hand hygiene and stated, "I expect kitchen staff to follow our hand-hygiene policies all the time because of the risk lapses pose to our residents."

F 812 Food Procurement, Store / Prepare / serve-Sanitary CFR(s): 483.60(i)(1)(2) Resident Specific: The identified residents issues were resolved when expired or unlabeled food was removed from personal refrigerators, and cook was promptly educated on hand hygiene and changing gloves. Other Residents: Residents with personal refrigerators in this facility have the potential to be affected. Resident personal refrigerators were promptly checked for expired and unlabeled foods. Facility Systems: Education was provided to staff on hand hygiene, glove use policy, and facility policy on personal refrigerators. Monitor: Audits will be completely weekly to ensure food in resident refrigerators is labeled and discarded by expiration date and ensure proper hand hygiene with glove use weekly x4 and monthly x2 or until adequate compliance has been determined. Results brought monthly to QAPI for review and potential further action. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the ED and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: March 15th 2024 Person Responsible: Executive Director and/or designee.

******************** 411-086-0260 Pharmaceutical Services Refer to F-554 ******************** 411-087-0100 Physical Environment: Generally Refer to F-584 ******************** 411-086-0040 Admission of Residents Refer to F-655 ******************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F-657 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F-684 ******************** 411-086-0100 Nursing Services: Staffing Refer to F-732 ******************** 411-086-0260 Pharmaceutical Services Refer to F-755 and F-756 ******************** 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F-757 and F-758 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F-759 ******************** 411-086-0250 Dietary Services Refer to F-812 ********************

Based on interview and record review it was determined the facility failed to ensure resident narcotic medications were not misappropriated for 1 of 1 resident (# 9) reviewed for anti-anxiety medications. This placed residents at risk for loss of property. Findings include: Resident 9 was admitted to the facility in 2017 with diagnoses including Alzheimer's and Heart Disease. Resident 2/17/22 Admission MDS identified Resident 9 with severe cognitive impairment. Resident 9 10/20/22 Care Plan revised on 5/15/22 indicated the resident used anti-anxiety medications Lorazepam, related to comfort measures for end-of-life care. A 5/12/23 Facility Risk Management Report identified a 24 ml bottle of liquid Lorazepam used to treat Resident 9 for end-of-life care went missing on 5/7/23 at 1:00 AM. A facility wide comprehensive medication reconciliation was conducted by the facility on all narcotic medications from 5/7/23 to 5/9/23. According to the facility report, care staff and management were unable to locate the missing bottle of Lorazepam. On 8/30/23 at 2:50 PM Staff 10 (LPN) indicated she discovered the medication went missing and reported it to the facility. Staff 10 stated the facility conducted a facility wide reconciliation but confirmed the facility was unable to locate the bottle of the Lorazepam after several days. On 8/31/23 at 10:01 AM Staff 1 (Administrator) confirmed the facility was unable to locate the missing 24 ml bottle of Lorazepam.

F602- Free from Misappropriation/Exploitation Resident #9 is no longer in the facility. All residents admitted to the facility have the potential of being affected. All current residents that has orders for narcotic medications were reviewed and ensured that everything is accounted for and not misappropriated. Education will be provided to licensed nursing staff regarding misappropriaprion of resident’s narcotic medication and will review facility policies and procedures on reconciling narcotic medication. DNS or designee will be auditing residents with narcotic medications 3 times weekly for the next 4 weeks then monthly x 3 months, until substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance: September 29, 2023.

*********************** OAR 411-085-0360 Abuse Refer to F 602

Based on observation, interview and record review it was determined the facility failed to ensure staff implemented appropriate environmental cleaning and disinfection practices for 1 of 3 shared resident shower rooms and 1 of 2 nursing stations reviewed for infection control during an active COVID-19 outbreak. This placed residents at risk for infection. Findings include: 1. On 4/24/23 Oregon Health Authority consulted with the facility and provided the following recommendations related to infection control: if unable to dedicate a shared shower room for COVID-19 positive residents, ensure that a terminal disinfection is happening after every resident use. On 4/26/23 at 11:15 AM Staff 1 (Administrator) stated the facility was currently in an active COVID-19 outbreak including both staff and residents. On 4/27/23 at 9:40 AM Staff 12 (Housekeeping) stated she cleaned the resident shared shower rooms once a day at the beginning of each shift and the CNAs were supposed to clean the shower rooms after each resident's shower. On 4/27/23 at 10:40 AM Staff 6 (CNA) was observed exiting Room 112. A sign was posted on the door indicating contact precautions. Staff 6 entered the shared shower room across the hall to assist Resident 4 with her/his shower. Staff 6 stepped out of the shower room and confirmed Resident 4 was on contact precautions because she/he tested positive for COVID-19. Staff 6 stated Resident 4 frequently requested to take a shower and the resident also had a shower yesterday. Staff 6 further stated the CNAs did not clean the shower rooms and that they were supposed to notify housekeeping when shower rooms needed to be cleaned. On 4/27/23 at 10:59 AM Staff 8 (Housekeeping) stated she normally worked on the weekends but was told another housekeeper recently tested positive for COVID-19 so she was asked to work. Staff 8 further stated once a day at the beginning of each shift housekeeping cleaned the shared shower rooms, and then CNAs were supposed to clean the shower rooms after they gave residents showers. On 4/27/23 at 11:10 AM Staff 11 (CNA) stated the facility had three shared shower rooms and the CNAs were supposed to clean the shower room after each shower. Staff 11 opened the 300-hall shower room and looked for cleaning supplies, but no supplies were in the room. Staff 11 further stated sometimes it was difficult to know if the shower room was cleaned. On 4/27/23 at 11:19 AM Resident 4 exited the 100-hall shower room. The shower room did not contain any cleaning supplies. 2. On 4/27/23 at 11:05 AM Staff 10 (LPN/Charge Nurse), Staff 11 (CNA) and Staff 13 (Occupational Therapy Assistant) were observed standing at the nurse's station on the 300-hall next to two used COVID-19 test swab kits sitting directly on the counter. Staff 11 and Staff 13 confirmed they used the COVID-19 test swab kits earlier and had to wait 15 minutes for the results. Staff 11 and Staff 13 acknowledged the facility was in a current COVID-19 outbreak and they should not have left the swab kits directly on the counter. On 4/27/23 at 11:06 AM Staff 10 (LPN/Charge Nurse) stated it was not best practice for staff to test at the nurse's station especially during an active COVID-19 outbreak and staff should always sanitize and disinfect work areas. On 4/27/23 at 12:00 PM Staff 2 (DNS) acknowledged staff failed to implement and maintain appropriate environmental cleaning and disinfection practices during an active COVID-19 outbreak.

1.Thorough proper sanitation of the shower rooms and nurses station was completed when the deficiency was identified. Immediate education was provided to all facility staff regarding the proper cleaning and disinfection practices for resident shower rooms and nurse's stations. 2.All residents have the potential to be affected. Facility audited and ensured that all shower rooms are being properly sanitized after each use, nurse’s stations are sanitized throughout the day, and proper disinfecting products are readily available for staff. The facility implemented procedures to ensure that proper disinfecting products are consistently stocked in all shower rooms and nurse's stations. Additionally, a step-by-step process for effectively disinfecting the shower rooms after each resident use is now prominently displayed in each of the shower rooms. 3.In-service on proper disinfection of shower rooms and nurse’s stations was Completed with staff and added to the facility “Agency Binder”. Furthermore, the facility will ensure that all staff receive training on "Sparkling Surfaces", “Clean Hands” and "Keep Covid-19 Out" protocols and “Lessons on PPE “ by the compliance date. 4.DNS and/or designee will conduct audits to verify compliance with proper sanitation practices in shower rooms and nurse's stations. These audits will be conducted three times a week/4 weeks, followed by weekly audits for the subsequent two months, until substantial compliance is achieved and sustained. Any concerns identified during the audits will be promptly addressed. Immediate action will be taken, including providing additional education and counseling if deemed necessary. The audit findings will be presented and reviewed at the monthly Quality Assurance Performance Improvement meeting. 5.Person/s Responsible: DNS or Designee 6.Compliance Date: June 07th, 2023 Root Cause Analysis: After conducting a comprehensive root cause analysis, several factors were identified as potential causes of the listed deficiencies. These factors include: Why? Infection control complacency Why? Failure to restock sanitizing products in the shower room as they were depleted. Why? Staff being unaware of the facility protocols related to sanitation. Why? Lack of understanding regarding the potential serious complications resulting from improper sanitation processes. Why? Education on proper disinfection was not provided.

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 01/16/2023 and 01/22/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review it was determined the facility failed to ensure resident assessments were accurate for 1 of 1 sampled resident (#26) reviewed for contractures. This placed residents at risk for unmet needs. Findings include: Resident 26 was admitted to the facility in 5/2020 with diagnoses including dementia. During multiple random observations from 10/31/22 through 11/4/22 between the hours of 9:00 AM and 4:00 PM, Resident 26 was observed with contractures of all fingers on both hands and both wrists that curved into a C-shape. A 5/8/20 Admission-Readmission Nursing Evaluation revealed Resident 26 had contractures of both hands upon admission. Resident 26's MDS assessments indicated the resident had no upper extremity contractures on the following annual and quarterly assessments: 11/16/21, 2/16/22, 5/17/22 and 8/17/22. On 11/2/22 at 12:19 PM Staff 11 (LPN Care Manager) stated Resident 26 had contractures of her/his fingers and wrists on both hands which were present upon admission. On 11/2/22 at 2:20 PM Staff 10 (MDS Coordinator) confirmed all of Resident 26's MDS assessments were inaccurate. The resident's upper extremity contractures were not assessed or identified.

F641- MDS Assessments Immediate education was provided to MDS coordinator to ensure accurate resident assessments are completed to capture any limitations in range of motion that interfere with daily functioning. Residents with limitations in range of motion have the potential of being affected. Review of all residents were completed to ensure all identified limitation in range of motion are accurately captured in the MDS assessments. DNS or designee will be auditing all MDS assessments due to be completed weekly X 4 weeks and a sample of 10 random MDSs, monthly X 3 months until substantial compliance is met and maintained. Findings will be brought to Quality assurance performance improvement meeting. Date of compliance- 12/13/2022

Based on interview and record review it was determined the facility failed to ensure comprehensive, person-centered care plans for vision were developed for 1 of 1 sampled resident (#29) reviewed for vision and hearing. This placed residents at risk for unmet care needs. Findings include: Resident 29 was admitted to the facility in 12/2021 with diagnoses including multiple sclerosis (an autoimmune disease that impacts the brain, spinal cord, and optic nerves), diabetic retinopathy (a complication of diabetes that affects the eyes), and cataract. The Vision CAA from Resident 29's 12/2021 Admission MDS noted Resident 29 had a visual field deficit and decreased visual acuity. The CAA further indicated the need for a care plan in order to minimize risks related to her/his impaired visual function and for staff to approach from the left side or the front if possible. A review of Resident 29's comprehensive care plan (last revised 10/20/22) revealed no problem statements, goals or interventions related to vision. On 11/3/22 at 11:42 AM Staff 11 (LPN Care Manager) confirmed a vision care plan for Resident 29 was indicated but not completed. On 11/4/22 at 9:05 AM Staff 4 (SSD) stated she was responsible for initiating and updating all care plans related to vision. Staff 4 acknowledged a vision care plan was indicated for Resident 29 at the time of her/his admission MDS in 12/2021 but was not completed.

F656- Development/Implementation of Care plan. Immediate education was provided to SSD to ensure that all vision deficits are identified and care planned appropriately. Residents with any vision deficits have the potential of being affected. Review of all residents were completed to identify any vision deficits. Facility ensured all identified deficits had a comprehensive, person centered care plans for vision. All new admissions will be reviewed for vision deficits and any identified will be care planned appropriately. ED or designee will be auditing all care plans for vision deficits to ensure that any identified vision deficits have a person centered care plan developed appropriately. Audits will be conducted weekly X 4 weeks and monthly X 3 months until substantial compliance is met and maintained. Findings will be brought to Quality assurance performance improvement meeting. Date of compliance- 12/13/2022

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 2 of 5 sampled residents (#s 29 and 34) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 34 was admitted to the facility in 3/2022 with diagnoses including heart failure and hypertension. a. A 3/24/22 physician order indicated Resident 34 was prescribed amlodipine (a medication used to treat high blood pressure and heart conditions) one time a day at bedtime; hold for systolic blood pressure (SBP) less than 110 or heart rate (HR) less than 60. A review of Resident 34's 9/2022 and 10/2022 MARs indicated the resident received amlodipine on all days during both months; however, there was no evidence in Resident 34's clinical record staff were monitoring SBP or HR prior to administering the resident's amlodipine except on the following days: 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 10/1, 10/3, 10/10, 10/22 and 10/31. Resident 34's 10/2022 MAR indicated staff monitored SBP and HR on 10/1, 10/3 and 10/10 and the resident received amlodipine outside of the established parameters on the following days: -10/1/22 amlodipine was administered with a heart rate of 52; -10/3/22 amlodipine was administered with a heart rate of 56; -10/10/22 amlodipine was administered with a heart rate of 56. On 11/3/22 at 9:55 AM and 1:17 PM Staff 2 (DNS) reviewed Resident 34's 9/2022 and 10/2022 MARs. Staff 2 confirmed nursing staff did not consistently monitor SBP and HR for amlodipine as directed and on the identified days when monitoring for SBP and HR occurred, staff administered amlodipine in error. b. A 3/27/22 physician order indicated Resident 34 was prescribed carvedilol two times a day, hold for SBP less than 105 and HR less than 55. A review of Resident 34's 9/2022 and 10/2022 MARs indicated the resident received carvedilol outside of the established parameters on the following days: -9/4/22 carvedilol was administered with a heart rate of 54; -9/14/22 carvedilol was administered with a heart rate of 51; -10/1/22 carvedilol was administered with a heart rate of 52; -10/3/22 carvedilol was administered with a heart rate of 50; -10/4/22 carvedilol was administered with a heart rate of 50; -10/13/22 carvedilol was administered with a heart rate of 52. On 11/3/22 at 9:55 AM Staff 2 (DNS) confirmed Resident 34's carvedilol was administered in error on the identified dates. , 2. Resident 29 was readmitted to the facility in 4/2022 with diagnoses including hypertension and diabetes. The resident's 9/2022 and 10/2022 physician orders instructed staff to administer the following: -insulin glargine solution inject 22 units subcutaneously (applied under the skin) one time a day with breakfast, hold if CBG was less than 110. -lisinopril tablet one time a day, hold for systolic blood pressure (SBP) less than 110. -metoprolol succinate extended release tablet two times a day, hold for SBP less than 110. The resident's 9/2022 MAR and Injection Administration Record revealed the following: -lisinopril was administered on 9/6/22 when the resident's SBP was 108. -metoprolol succinate was administered on 9/6/22 when the resident's SBP was 108 and on 9/14/22 when her/his SBP was 109. -insulin glargine was administered on the following dates when CBGs were less than 110 * 9/1/22 with CBG of 101; * 9/8/22 with CBG of 104. The resident's 10/2022 MAR and Injection Administration Record revealed the following: -insulin glargine was administered on the following dates when CBGs were less than 110 * 10/14/22 with CBG of 92; * 10/17/22 with CBG of 99; * 10/21/22 with CBG of 106; * 10/22/22 with CBG of 109; * 10/23/22 with CBG of 109; * 10/24/22 with CBG 79. On 11/4/22 at 12:54 PM Staff 2 (DNS) stated she could not find any information regarding why the resident's lisinopril, metropolol and insulin were administered outside of the physician ordered parameters. She confirmed the medications were not held.

F684- Quality of Care Education was provided to all licensed nurses and Medication aides regarding following mediation orders accurately adhering to parameters and protocols written by physicians. All residents taking medications that have parameters listed, have the potential to be affected. DNS or designee will be auditing medication orders to ensure medication orders are followed accurately adhering to parameters and protocols. Audits will be completed 2 X week for the first 4 weeks and monthly for the next 3 months until substantial compliance is met and maintained. Findings will be brought to Quality assurance performance improvement meeting. Date of compliance- 12/13/2022

Based on interview and record review it was determined the facility failed to ensure residents received restorative services for 1 of 1 sampled resident (#34) reviewed for restorative services. This placed residents at risk for decreased mobility. Findings include: Resident 34 was admitted to the facility in 3/2022 with diagnoses including injuries from a motor vehicle accident. Resident 34's 10/1/22 MDS indicated she/he required two people for assistance with transfers, toileting, personal hygiene and Resident 34 did not walk. Resident 34's 9/26/22 Restorative Program indicated the resident was to receive restorative services two to three times a week to maintain bilateral lower extremity ROM and strength. Resident 34's program consisted of the following: -transfers using a sliding board; -active ROM of both legs; -hip exercises; -stretching exercises; -passive ROM to both ankles. Resident 34's 10/2022 restorative treatment record indicated the resident received restorative services as follows: -10/10 through 10/16: Resident 34 received restorative treatment one time; -10/24 through 10/30: Resident 34 received restorative treatment one time. On 10/31/22 at 10:05 AM and 10:59 AM Resident 34 stated she/he did not receive much therapy for the past "couple of months." Resident 34 indicated without therapy her/his legs were losing mobility. On 11/2/22 at 9:14 AM and 10:39 AM Staff 6 (RA/CNA) stated Resident 34 started restorative services at the end of 9/2022. She stated she was not able to cover all of the treatment sessions as ordered due to providing CNA coverage, accompanying residents to appointments or being off due to illness and no staff were assigned to cover for her. On 11/3/22 at 11:53 AM and 12:00 PM Staff 9 (CNA) and Staff 8 (CNA) reported CNA staff did not provide any restorative treatment services. On 11/4/22 at 10:20 AM Staff 1 (Executive Director) was informed of the findings of this investigation. She stated the facility needed to work on their restorative program to ensure residents received restorative services as ordered.

F688- Increase/Prevent decrease in ROM/Mobility. Facility assigned two new staff members to take over the facility RA responsibilities to ensure all residents needing restorative services, receive them as identified in their person centered restorative program. These two staff members were also provided with education on importance of adhering and completing restorative services to the frequency listed in each of the residents restorative program. All residents needing restorative services to maintain or improve mobility with the maximum practicable independence, unless a reduction in mobility is demonstrated unavoidable, have the potential to be affected. DNS or designee will be auditing restorative program to ensure all residents that has a restorative program will be receiving their services as identified. Audits will be completed weekly for 4 weeks and monthly for 3 months until substantial compliance is met and maintained. Findings will be brought to Quality assurance performance improvement meeting. Date of compliance- 12/13/2022

Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 2 of 5 sampled residents (#s 29 and 34) reviewed for unnecessary medications. This placed residents at risk for inaccurate clinical records. Findings include: 1. Resident 34 was admitted to the facility in 3/2022 with diagnoses including heart failure and hypertension. A 3/24/22 physician order indicated Resident 34 was prescribed Ramelteon one time a day. A 3/25/22 Notice of Insurance Non-Payment indicated Ramelteon was not covered by insurance and a new order was provided to begin melatonin at bedtime instead. A review of Resident 34's 9/2022 and 10/2022 MARs revealed most dates were marked "OO" indicating Ramelteon was on order from the pharmacy. On 9/1, 9/11, 9/18, 9/24, 9/28 10/1, and 10/22 the MARs were marked with a check mark indicating Ramelteon was given. On 11/3/22 at 1:17 PM Staff 2 (DNS) stated the facility never received Ramelteon because it was not covered by insurance and it was replaced with an order for melatonin. Staff 2 stated nursing staff did not write a discontinue order for Ramelteon so it continued to show on Resident 34's 9/2022 and 10/2022 MARs. Staff 2 stated the nurses who marked the medication as given were from a temporary staffing agency and no longer worked at the facility and the medication was marked in error. , 2. Resident 29 was readmitted to the facility in 4/2022 with diagnoses including hypertension and diabetes. A review of Resident 29's 9/2022 and 10/2022 MAR and TAR revealed the following: -weekly weight on 9/18/22, 10/9/22 and 10/16/22 were blank; -10/9/22 all evening medications and treatments were blank. There was no evidence in the resident's health record indicating weights were taken and her/his medications and treatments were administered on the dates mentioned above. On 11/4/22 at 12:54 PM Staff 2 (DNS) stated the nurse responsible for administering medications and treatments on 10/9/22 administered them but did not document they were completed. She confirmed there should not have been any blanks on the MAR and TAR.

F842- Resident Records- Identifiable information. Education was provided to all licensed nursing staff to ensure all residents records will be kept complete and accurate, to avoid unnecessary orders being listed. All residents have the potential to be affected. DNS or designee will be auditing residents clinical records to ensure records are kept accurate/complete and unnecessary medication will not be listed. Audits will be completed weekly for 4 weeks and monthly for 3 months until substantial compliance is met and maintained. Findings will be brought to Quality assurance performance improvement meeting. Date of compliance- 12/13/2022

******************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F-641 and F656 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F-684 ******************** 411-086-0150 Nursing Services: Restorative Care Refer to F-688 ******************** 411-085-0370 Confidentiality Refer to F-842 ********************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/04/2022 and 07/10/2022, 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 follow physician orders for 1 of 3 sampled residents (#1) reviewed for medications. This placed residents at risk for incorrect medication dosing. Findings include: Resident 1 was admitted to the facility in 2/2021 with diagnoses including multiple sclerosis and major depressive disorder. The facility policy Non-Controlled Medication Order Documentation, Procedure B, effective 8/2018, indicated "any dose or order that appears inappropriate considering the resident's age, condition, allergies or diagnosis is verified by nursing with the attending physician." Resident 1's 7/20/21 physician order written by Witness 3 (Nurse Practitioner) instructed staff to decrease the resident's sertraline (anti-depressant) from 200 mg to 150 mg. On 7/20/21 at 3:11 PM, Staff 14 (Former RNCM) discontinued Resident 1's sertraline 150 mg order written by Witness 3. Resident 1's 7/20/21 TAR indicated Resident 1 received the previously ordered dose of sertraline 200 mg instead of the new dose of 150 mg. The medication was provided according to Witness 3's order on 7/21/21. On 5/10/22 at 10:31 AM, Witness 3 stated on 7/20/21, he discontinued some medications and wrote new medication orders for Resident 1. Witness 3 stated he specifically recalled that he wrote an order to decrease sertraline in an attempt to reduce the medication over time. Witness 3 stated when he checked the chart later in the day, the order was deleted. Witness 3 stated he spoke with Staff 14 who reported no other provider discontinued the medication and he followed up with the facility and corporate management regarding Staff 14's discontinuation of his order without his consent. On 5/11/22 at 4:05 PM and 5/12/22 at 9:06 AM, Staff 14 reported she discontinued and implemented all medication orders written by Witness 3 on 7/20/21 except the order for sertraline. Witness 14 stated she discontinued the sertraline 150 mg order without Witness 3's consent. Staff 14 stated the next morning, she was instructed by Staff 1 (Administrator) to implement all of Witness 3's medication orders written on 7/20/21, which she did. On 5/12/22 at 10:56 AM, Staff 1 confirmed Staff 14 discontinued Resident 1's sertraline 150 mg order written on 7/20/21 without the consent of Witness 3 or any other medical provider.

F-684 Quality of Care Staff member that was directly involved with discontinuing orders written by the provider was terminated and was also reported to the Oregon State Board of Nursing, by the facility at that time. Residents in center have the potential of being affected. Re-education will be provided to all LN staff regarding following orders prescribed by providers to ensure that all residents receive treatment and care in accordance with professional standards of practice. DNS or designee will audit any struck out/discontinued orders weekly x 4 weeks then monthly x 3 months to validate substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance June 30th, 2022.

Based on interview and record review it was determined the facility failed to screen residents for eligibility of pneumococcal vaccines and failed to administer pneumococcal vaccines in accordance with Center for Disease Control (CDC) recommendations for 4 of 5 sampled residents (#s 1, 2, 3 and 5) reviewed for immunizations. This placed residents at risk for illness. Findings include: The 2/16/22 CDC Pneumococcal Vaccine Timing for Adults indicated the previous pneumococcal recommendations remain in effect pending further evaluation and two pneumococcal vaccines are recommended for adults: * 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar13) * 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23) Resident 1 was admitted to the facility in 11/2019 with diagnoses including multiple sclerosis. Resident 1's health record indicated the resident received the PCV13 in 2015. An 11/18/19 pneumococcal vaccine informed consent declination, signed by Resident 1 was found in the resident's health record. The declination indicated Resident 1 was offered the PCV13 and PPSV23 on 11/18/19. The resident declined both vaccines due to "personal choice." No documentation was found to indicate Resident 1 was offered the PPSV23 after 11/18/19 as recommended by CDC. On 5/16/22 at 10:34 AM Staff 2 (DNS) stated Resident 1 was eligible for the PPSV23 and was unsure if the vaccine was offered to the resident. Resident 2 was admitted to the facility in 4/2021 with diagnoses including spinal stenosis. A 4/29/21 pneumococcal vaccine informed consent declination, signed by Resident 2 was found in the resident's health record. No documentation was found to indicate Resident 2 was offered the PCV13 or PPSV23 after 4/29/21 as recommended by CDC. On 5/16/22 at 10:42 AM Staff 2 acknowledged the 4/29/21 declination and did not provide documentation to indicate Resident 2 was offered the pneumococcal vaccine since 4/29/21. When asked about the facility's process to monitor for residents' immunization eligibility, Staff 2 was unable to articulate a clear system to monitor for residents' eligibility. Resident 3 was admitted to the facility in 4/2018 with diagnoses including emphysema. Resident 3's health record indicated the resident received the PCV13 on 1/4/19. No documentation was found to indicate Resident 2 was offered the PPSV23 as recommended by CDC. On 5/16/22 at 10:48 AM Staff 2 stated the documentation was incomplete and could not find additional information to indicate the resident was offered PCV13 or PPSV23 as recommended by CDC. Resident 5 was admitted to the facility in 12/2018 with diagnoses including traumatic brain injury. Resident 5's health record indicated the resident received the PCV13 on 4/12/19. No documentation was found to indicate Resident 5 was screened for eligibility and offered the PPSV23 as recommended by CDC. On 5/16/22 at 10:57 AM Staff 2 stated she could not find documentation to indicate the resident was screened and offered the PPSV23 and would need to look into it. On 5/17/22 at 3:05 PM Staff 1 (Administrator) and Staff 2 were notified of the findings of this investigation. No additional information was provided.

F-883 Influenza and Pneumococcal Immunizations Residents in center have the potential of being affected. Immediate review of all residents for pneumococcal vaccine eligibility was completed. All eligible residents will be offered the Prevnar 20 vaccine. Any declinations will be documented in facility EHR. Facility will also be offering the Pneumococcal vaccine for any eligible residents upon admission. Any declinations will be reviewed and re-offered again yearly. DNS or designee will audit pneumococcal vaccine admisinitration weekly x 4 weeks then monthly x 3 months to validate substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance June 30th, 2022.

OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684 ***************************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F883 *****************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/22/2021 and 11/28/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to provide a written summary of the baseline care plan for 3 of 3 sampled residents (#s 135, 136 and 138) reviewed for new admission. This placed residents at risk for being uninformed and not included in their plan of care. Findings include: 1. Resident 135 was admitted to the facility in 11/2021 with diagnoses including cerebral infarction (stroke) with left-sided hemiparesis (weakness). Resident 135's Admission MDS was incomplete at the time of survey. On 11/08/21 at 9:12 AM Resident 135 stated she/he did not remember if staff discussed her/his plan of care and did not believe she/he was provided a summary of the plan of care. An 11/3/21 admission progress note written by Staff 2 (DNS) revealed the following: "[Resident alert and oriented], oriented to room, call light, routine, meals, TV remote. Called and spoke with [spouse] and explained therapy routines and reassurance of resident comfort." The admission progress note did not indicate staff provided Resident 135 with a summary of the plan of care including the resident's initial goals, medications and dietary instructions. Resident 135's health record revealed no documented evidence the resident's plan of care was reviewed with the resident and she/he was provided a written summary of the plan of care. On 11/15/21 at 9:59 AM Staff 14 (RNCM) stated she provided a written copy of the baseline care plan to every resident upon admit. Staff 14 stated she tried to document when the baseline care plan was provided, she didn't always remember to do that and it was probably not documented in most of the residents' health records. On 11/15/21 at 11:37 AM Staff 2 (DNS) stated the baseline care plans were not printed and residents were not provided a written summary consistently. Staff 2 stated it was a technology issue and a progress note was made instead. Staff 2 acknowledged the 11/3/21 admission progress note was not a good example and did not provide evidence the plan of care was reviewed and provided to Resident 135. 2. Resident 136 was admitted to the facility with diagnoses including cellulitis (skin infection). The 11/4/21 Admission MDS Section C: Cognition assessed Resident 136 cognitively intact with a BIMS score of 15. On 11/07/21 at 2:48 PM Resident 136 stated the facility only discussed insurance coverage with her/him, there was no discussion related to how long she/he would be on antibiotics and no written summary was provided. A 10/28/21 progress note written by Staff 14 (RNCM) revealed the following: "Education on plan of care, medications, therapy and room orientation were provided." Resident 136's health record revealed no documented evidence the resident was provided with a written summary of the baseline plan of care. On 11/15/21 at 9:59 AM Staff 14 (RNCM) stated she provided a written copy of the baseline care plan to every resident upon admit. Staff 14 stated she tried to document when the baseline care plan was provided, she didn't always remember to do that and it was probably not documented in most of the residents' health records. On 11/15/21 at 11:37 AM Staff 2 (DNS) stated the baseline care plans were not printed and residents were not provided a written summary consistently. 3. Resident 138 was admitted to the facility in 10/2021 with diagnoses including cerebral infarction (stroke) with left-sided hemiplegia (paralysis). The 10/31/21 Admission MDS Section C: Cognition indicated Resident 138 with BIMS score of 6, severe cognitive impairment. On 11/08/21 at 10:25 AM Resident 138 was unable to provide information about her/his plan of care. Resident 138's health record revealed no documentation to indicate the resident or the resident's representative was provided with a written summary of the baseline plan of care. On 11/15/21 at 9:59 AM Staff 14 (RNCM) stated she provided a written copy of the baseline care plan to every resident upon admit. Staff 14 stated she tried to document when the baseline care plan was provided, she didn't always remember to do that and it was probably not documented in most of the residents' health records. On 11/15/21 at 11:37 AM Staff 2 (DNS) stated the baseline care plans were not printed and residents were not provided a written summary consistently.

Education was provided to Licensed Nursing staff on importance of completing baseline care plans with residents, have resident or responsible party sign and provide a copy to resident and/or responsible party. Residents identified are no longer in the facility. Residents admitted to facility are at risk of being affected. Review of residents admitted within past 30 days done to validate baseline plan of care is complete and copy given to resident/responsible party. Follow up done as indicated. New admissions will be reviewed the following day during clinical meeting for completion of baseline care plans have been reviewed with resident and/or responsible party and signed. A copy of signed baseline care plan will be provided to resident and/or responsible party. Further education will be provided to Licensed Nurses on reviewing and providing a copy of signed baseline care plan to the resident and/or responsible party within 48hours of admission to the facility. Review of admissions and baseline care plans will be done during morning clinical meeting for completion and corrected if warranted. Weekly audits will be conducted to validate base line care plan is done and copy provided as required for new admissions by DNS or designee weekly x 4 weeks monthly x 3 months until substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance January 7, 2022.

Based on observation, interview and record review it was determined the facility failed to provide oral care to 1 of 2 sampled residents (#135) reviewed for ADLs. This placed residents at risk for poor oral hygiene. Findings include: Resident 135 was admitted to the facility in 11/2021 with diagnoses including cerebral infarction (stroke) with left-sided hemiparesis (weakness). Resident 135's 11/3/21 care plan indicated she/he had upper and lower dentures and required extensive assistance with grooming tasks. On 11/7/21 at 11:13 AM Resident 135 was observed with upper and lower dentures in her/his mouth. Food debris was visible on the upper dentures. An unused denture soaking container was observed out of Resident 135's reach on her/his bedside table. On 11/7/21 at 11:13 AM, 11/8/21 at 9:02 AM and 11/9/21 at 11:51 AM Resident 135 stated staff did not provide assistance with oral care and her/his dentures were not cleaned throughout the day and after meals and staff did not remove the dentures to soak overnight. On 11/8/21 at 2:51 PM Staff 13 (CNA) stated he was Resident 135's CNA for the day shift. Staff 13 stated he did not recall if Resident 135 had dentures and did not provide denture care to Resident 135. On 11/9/21 at 1:49 PM Staff 9 (CNA) stated she was Resident 135's CNA for the day shift. Staff 9 stated Resident 135 did not have dentures. Resident 135's health record revealed no documented evidence of denture care. On 11/9/21 at 2:18 PM Staff 14 (RNCM) stated Resident 135 admitted with dentures and she expected CNAs to provide her/his denture care. On 11/15/21 at 11:54 AM Staff 2 (DNS) was notified of the findings of this investigation. Staff 2 stated routine oral care was a standard of care for every resident and dentures should be cleaned based on the resident's preferences.

Resident # 135 is no longer in the facility. Residents will be reviewed to determine what residents are dependent for oral/ADL care to validate they are provided care as their needs require. Residents identified will have their care plans reviewed and updated if warranted. Education will be provided to staff who provide ADL care, regarding assisting residents with oral care, and reporting refusals to the charge nurse. Education will be provided to licensed nurses on importance of documentation of oral status on baseline care plan to ensure C.N.As are aware of dental status. DNS or designee will be auditing residents for visible food debris and oral care during rounds. Any concerns will be brought to daily morning clinical meeting for follow ups. Audits will be conducted weekly x 4 weeks then monthly x 3 months until substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance January 7, 2022

Based on observation, interview and record review the facility failed to provide treatment and care to address the resident's positioning needs in accordance with the person-centered care plan for 1 of 1 sampled resident (#25) reviewed for positioning. This placed residents at risk for worsening contractures (condition of shortening or hardening of muscle) and unmet needs. Findings include: Resident 25 admitted to the facility in 12/2018 with diagnoses including traumatic brain injury, contracture of the hand, wrist, arm, ankle, and foot. The 10/2021 MDS Section C: Cognition indicated Resident 25 with BIMS score of 8, severe cognitive impairment and Section G: Functional Status as extensive two person assistance with bed mobility and positioning. Resident 25's 6/19/21 care plan, revised on 11/10/21, directed staff to apply soft blue boots to feet for comfort. The care plan and the Bedside Individual Service Plan directed staff to reposition Resident 25 "often using lots of pillows to keep comfortable. Use a wedge cushion and one pillow under right leg to alleviate pressure" due to contractures. Resident 25 was observed on the following dates and times to not have the care plan interventions of the wedge, blue boots for feet or extra pillows or pillow under right leg in place: - 11/9/21 at 9:03 AM, 12:55 PM, and 4:31 PM; - 11/10/21 at 10:35 AM and 12:56 PM; - 11/12/21 at 9:50 AM; - on 11/12/21 at 2:02 PM a pillow was observed under right knee and pillow under left heel, no blue boots or wedge. On 11/15/21 at 11:14 AM Staff 6 (RN) stated he expected CNAs to follow the care plan and confirmed Resident 25 did not have interventions in place and should have a wedge, pillows, and blue boots on feet per care plan. On 11/15/21 at 2:11 PM Staff 2 (DNS) acknowledged she expected care plans to be followed and interventions in place as directed.

Immediate education was provided to staff regarding resident 25, on ensuring positioning devices are in place according to the care plan. Residents that require positioning devices have the potential of being affected. Residents were reviewed to determine if positioning devices are in place per their individual needs if indicated. Care plans were reviewed to ensure they reflect the residents needs accurately. Education will be provided to staff related to positioning devices and importance of following care plan. All new admissions will be reviewed during clinical meeting to identify if a positioning device is ordered or needed. Care plans will be updated and reviewed to ensure positioning devices are in place. During rounds managers will audit for positioning devices in place for residents. Any concerns will be brought to morning clinical for follow up. DNS or designee will audit weekly x 4 weeks then monthly x 3 months to validate that required positioning devices are in place as care planned until substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance January 7, 2022

Based on observation, interview and record review it was determined the facility failed to ensure smoking materials were assessed, care planned and securely stored for 1 of 2 sampled residents (#6) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 6 admitted to the facility in 8/2021 with diagnoses including nicotine dependence, cannabis dependence, weakness, and repeated falls. The 8/2021 Admission MDS Section C: Cognition indicated Resident 6 with BIMS of 15, cognitively intact. On 11/7/21 at 10:12 AM, Resident 6 was observed to leave the facility from the front door and stated she/he was going to smoke. During the 11/7/21 lunch service between 12:00 PM to 12:46 PM two staff were overheard to converse about not being able to pass Resident 6 her/his meal tray due to Resident 6 being outside to smoke. On 11/7/21 at 2:52 PM, Resident 6 stated she/he was told upon admission not to smoke in the facility, and she/he needed to be off campus to smoke. Resident 6 stated the facility staff did not keep her/his lighter or cigarettes secured, and she/he kept a good eye on them. Resident 6 stated she/he kept the lighter and cigarettes, so she/he did not have to bother staff when she/he wanted to go out. Resident 6 stated she/he was not offered a lock box to keep the items in her/his room locked and secured. Record review for Resident 6 revealed no smoking assessment, no smoking care plan or other information related to how the smoking materials were to be kept safe while in the facility. On 11/12/21 at 8:56 AM, Resident 6 was observed in her/his room to pack her/his belongings for discharge. Two lighters and a pack of cigarettes were observed on Residents 6's bedside table. On 11/15/21 at 2:32 PM, Staff 2 (DNS) confirmed Resident 6 did not have a smoking assessment or smoking care plan to ensure the items were secured while in the facility. Staff 2 acknowledged the facility was a nonsmoking facility and she and staff were aware Resident 6 smoked while at the facility.

Resident #6 no longer in the facility. Immediate education was provided to staff on smoking materials needing to be locked up in med room. Residents in center have the potential of being affected. Residents admitted in past 30 days will be reviewed to validate they have been informed of facility smoking policy and any smoking materials they brought in are secured by staff until discharge. Education will be provided to new residents that the facility is a non-smoking facility and any smoking materials will need to be sent home with family or locked up in med room. Education will be provided to licensed nurses on smoking assessment and smoking policy. If a resident chooses to smoke off property, an assessment will be completed. Care plan will reflect residents desire to smoke and ability to do so off of facility property. Admission Coordinator will discuss with potential new admissions that facility is a non-smoking facility. New admissions will be reviewed at daily clinical meeting to identify if resident is a smoker and if there is a need for medications to assist with cessation. If resident has smoking materials, they will be locked up in the med room until discharge. Admissions will be audited during clinical meeting to identify if a resident is a smoker. DNS or designee will audit weekly x 4 weeks then monthly x 3 months to validate that new admissions have been informed of smoking policy and reviewed for any smoking materials, need for cessation medications, etc or until substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance January 7, 2022

Based on observation, interview, and record review it was determined the facility failed to provide sufficient nursing staff to ensure residents attained their highest practicable physical, mental, and psychosocial well-being for 2 of 3 halls reviewed for dining. This placed residents at risk for unmet needs. Findings include: The 672 Report (identified care needs) dated 11/7/21, revealed the facility identified nine residents who required the assistance of one to two staff for eating and three residents were dependent for eating needs. A review of the Direct Care Staff Daily Reports from 10/1/21 through 11/9/21 revealed the following days when state minimum CNA staffing ratios at the temporary numbers were not met on 6 of the 40 days reviewed. Four of those days there were three CNAs staffed for evening shift, who typically would have served the dinner meal. On 11/7/21 the following observations were made of the lunch meal service: - 12:02 PM, the meal cart for the 300 hall was pushed out of the kitchen; - 12:22 PM, meal cart from 100 hall pushed into the dining room; - 12:24 PM, meal cart for 200 hall and the dining room was pushed out of the kitchen. Additional administrative staff were observed to help CNAs with meal service; - 1:12 PM, meal tray from cart was delivered to Resident 25 in her/his room with assistance to eat. Resident Council Meeting Minutes were reviewed for 7/2021, 8/2021, and 10/2021. In the 7/8/21 Resident Council meeting, concern was expressed for timely meal tray delivery and mentioned CNAs were doing better with meal tray pick up. In the 8/12/21 Resident Council meeting, concern was expressed about late dinner service. The 10/30/21 Resident Council meeting minutes mentioned the residents expressed concerns relsted to understaffed nursing. During a Resident Council meeting on 11/10/21 at 10:30 AM, the following staffing concerns for meal service were expressed: - during meal service it can take anywhere from a half hour to up to an hour to get assistance for call lights; - staff will say they are too busy, need to finish what they are doing (deliver meal trays) before helping; - sometimes it takes over a hour after start of meal service to get food and it happens on a regular basis; - due to lack of staff, residents who required assistance (which includes meal tray delivery) with meals have to wait up to 30 minutes to an hour for staff assistance after the beginning of the meals; - food is often cold when delivered but residents felt staff were too busy to reheat the food and; - not enough staff and they are spread too thin at meal times, especially in the evening. Interviews from 11/7/21 to 11/12/21 with multiple facility staff indicated the following staffing concerns: - when passing meal trays, at times residents waited for care until meal trays were passed; - residents were left unattended in rooms during meals due to staff leaving the hall area to pass meal trays in another hall; - typically only the CNAs passed meal trays to residents and provided residents assistance to eat; - one resident on 200 hall takes at least one hour assistance to eat, which took away from ability to assist other residents who need assistance; - meal service for the evening shift was especially difficult to deliver meal trays and assist timely as needed; - sometimes the charge nurse would help pass trays or answer call lights but often was too busy and stopped their duties (medication administration and treatments) and often fell behind in order to assist the CNAs. On 11/12/21 02:14 PM, Staff 1 (Executive Director) acknowledged the residents expressed concerns with timely meal service and the facility was working on improving the meal service for the residents. In an interview on 11/15/21 at 2:11 PM, Staff 2 (DNS) acknowledged the staffing concerns and stated the facility attempted to hire more staff to fill the positions and the facility was actively recruiting staff. Staff 2 stated the facility was aware and continued to work on the needed improvements for timely meal service for residents.

Residents in center have the potential of being affected. Education was provided to managers to assist during meal times to support line staff. Admissions will be reviewed at daily clinical meeting to determine residents who need assistance with meals. Facility will provide education to staff on importance of meal times and getting the meals out to the residents promptly. Kitchen staff will be educated to ensure the meal carts are out on time. Non clinical staff will be utilized to assist with passing trays to assist floor staff. Facility will continue to recruit and retain staff to maintain sufficient staffing. Facility will continue to reach out to agencies to fill in open shifts to maintain sufficient staffing. DNS or designee will conduct audits during meal times weekly x 4 weeks and monthly x 3 months to ensure residents are getting their meals timely and those residents needing assistance are being assisted. Results will be taken to QAPI to determine compliance and if continued auditing is warranted. Date of Compliance January 7, 2022.

Based on observation, interview and record review it was determined the facility failed to properly secure medications and ensure medications were stored under proper temperature controls for 1 of 2 medication storage rooms and failed to properly secure medications for 2 of 2 treatment carts. This placed residents at risk for unauthorized access to medications and reduced vaccine efficacy. Findings include: 1. The Centers for Disease Control (CDC) Vaccine Storage and Handling Guidelines specified the following: -Exposure of vaccines to temperatures outside the recommended ranges can decrease their potency and reduce the effectiveness and protection they provide; -Temperature monitoring of the storage unit at least two times each workday; -Recording temperature readings on a log; -Store routinely recommended vaccines in a refrigerator between 35 degrees F and 46 degrees F. The undated facility Medication Storage In The Facility policy and procedure outlined the following: - "Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications." - "Medication rooms, carts, and medication supplies are locked and attended by persons with authorized access." On 11/10/21 at 11:51 AM the facility medication room was reviewed with Staff 11 (LPN). The medication room was located in the facility common area next to the nursing station and contained various medications, supplies and an unlocked refrigerator. The contents of the refrigerator included a thermometer and medications including insulin, vaccinations and lorazepam (a schedule IV controlled substance). The thermometer temperature was visualized with Staff 11 and the temperature was confirmed 32 degrees F, three degrees F lower than the recommended range. The 11/2021 Facility Temperature Log for Refrigerator and Freezer was observed taped to the front of the medication refrigerator and Staff 11 stated this was used to monitor refrigerator temperatures twice daily. The Temperature Log was incomplete and lacked evidence the temperatures were monitored twice a day. On 11/10/21 at 12:28 PM the refrigerator thermometer was visualized with Staff 11 and the temperature was confirmed at 48 degrees F, two degrees F higher than the recommended range. On 11/15/21 at 8:29 AM the refrigerator thermometer was visualized with Staff 1 (Executive Director) and the temperature was confirmed at 50 degrees F, four degrees F higher than the recommended range. On 11/15/21 from 8:03 AM until 8:29 AM the facility medication room door was wide-open, propped with a door stop to prevent closure and the room was unattended by authorized staff. During this time, Staff 1 (Executive Director), Staff 4 (SSD), Staff 8 (CNA), Staff 12 (LPN), Staff 15 (CNA), Staff 16 (CNA), Staff 17 (Business office), Staff 18 (RN Nurse Consultant), an unidentified housekeeping staff and two unidentified ambulatory residents walked in direct proximity to the open medication room. On 11/15/21 at 8:29 AM Staff 1 noticed the open medication room and closed the door. Staff 1 was notified the medication room door was propped wide-open and unattended from 8:03 AM until 8:29 AM, a total of 26 minutes. On 11/15/21 at 8:39 AM and 11:28 AM Staff 2 (DNS) stated the acceptable temperature range for the medication room refrigerator was 36 degrees F to 46 degrees F, especially when vaccines were stored, and the temperature should be monitored twice daily. Staff 2 stated the medication room should remain locked when authorized staff were not actively using it. 2. On 11/15/21 from 8:03 AM through 8:29 AM two medication carts were observed to be unattended and unlocked in the facility's common area next to the nursing station. During this time, Staff 1 (Executive Director), Staff 4 (SSD), Staff 8 (CNA), Staff 12 (LPN), Staff 15 (CNA), Staff 16 (CNA), Staff 17 (Business office), Staff 18 (RN Nurse Consultant), an unidentified housekeeping staff and two unidentified ambulatory residents walked in direct proximity to the unlocked medication carts. On 11/15/21 at 8:33 AM the medication carts were reviewed with Staff 12 and contained insulin, medicated creams, medicated powders and insulin administration supplies such as needles. Staff 12 confirmed the two medication carts were unlocked and unattended and stated the carts should be locked if unattended by the nurse. On 11/15/21 at 8:39 AM and 11:28 AM Staff 2 (DNS) Staff 2 stated the medication carts should remain locked when the nurse was not actively using them.

No resident identified Residents in center have potential to be affected Immediate education was provided to all LN staff on the importance of Med room door being closed when its not being utilized. Further education will be provided to licensed staff on policy and procedures related to drug storage, including fridge temperature check frequencies and ranges. DNS or designee will audit medication room to ensure door is shut and Fridge temps are in within required range. Medication/Treatment cars will also be audited to ensure they are locked when licensed nurse is not present. DNS or designee will complete audits weekly x 4 weeks then monthly x 3 months until substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance January 7, 2022

Based on observation, interview and record review it was determined the facility failed to ensure food was appropriately stored in 1 of 1 kitchens reviewed for the intial tour of the kitchen. This placed residents at risk for food-borne illness. Findings include: The 2021 U.S. Food and Drug Administration's (FDA) Food Code and the 2021 Centers for Disease Control and Prevention's (CDC) food safety guidance indicated as national standards to store and distribute food in long term care facilities in a safe and sanitary manner. On 11/7/21 at 10:24 AM, observations in the kitchen of the third refrigerator from the left revealed the following: - an egg salad sandwich, lettuce and tomato plate dated 11/5; - a silver container with 10 hardboiled eggs, uncovered; - unknown contents on a plastic white and blue wrapper with crumbled foil exposed to the air. On 11/7/21 at 10:37 AM, Staff 17 (Cook) did not provide an explanation for the uncovered eggs, but she covered the eggs immediately. The sandwich and the unknown package were removed. On 11/10/21 07:31 AM, Staff 5 (Dietary Manager) stated the eggs should have been covered, items wrapped and stored properly and the date on the food items marked as last date to be served. Staff 5 confirmed the sandwich dated "11/5" should have been thrown out by 11/7/21.

No resident identified. Identified items were discarded in the trash and immediate education was provided to all staff involved. Residents in center have the potential to be affected Education will be provided to all kitchen staff related to dating, covering foods per policy, and discarding outdated items in fridges and freezers. Audits will be conducted by Dietary Manager or designee weekly x 4 weeks then monthly x 3 months until substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance January 7, 2022

Based on observation, interview and record review it was determined the facility failed to appropriately disinfect a common use glucometer (device used to obtain blood) between resident use for 1 of 2 staff (#6) observed during point-of-care testing and failed to ensure catheter bag, tubing and urine were not on the floor for 1 of 3 residents (#6) reviewed for urinary catheter/UTI. This placed residents at risk for the spread of infection. Findings include: 1. The Centers for Disease Control and Prevention (CDC) Injection Safety; Blood Glucose Monitoring indicated the following: - The disinfection solvent should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Note that 70% ethanol solutions are not effective against viral bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device. The 2/2017 Disinfecting Glucometer facility policy and procedure directed the following: - Multi-resident use glucometers are cleaned/disinfected with appropriate bleach product following product recommendations between residents. On 11/9/21 at 11:58 AM Staff 6 (RN) used a common use glucometer to perform a CBG test for two residents. Upon completion of each CBG, Staff 6 cleaned the glucometer with a Spectrum Hand Sanitizing Wipe. The Spectrum Hand Sanitizing Wipe's only active ingredient was Ethyl Alcohol, 70%. Staff 6 stated the alcohol product was used to disinfect the glucometer between residents as part of infection control. On 11/15/21 at 11:32 AM Staff 2 (DNS) was notified of the findings of this investigation. Staff 2 stated the common use glucometers should be disinfected between each resident with the appropriate bleach wipe. Staff 2 stated the Spectrum Hand Sanitizing Wipes were to be used for residents' and staff hands and not appropriate for disinfecting the glucometer. , 2. Resident 6 admitted to the facility in 8/2021 with diagnoses including kidney disease and obstructive uropathy (flow of urine blocked). The 8/2021 MDS Section C: Cognition indicated Resident 6 with BIMS score of 15, cognitively intact and Section G: Functional Status for toileting as supervision with one person assist. On 11/7/21 at 2:12 PM and 11/10/21 at 2:27 PM, Resident 6 was observed in her/his room to lie on her/his bed with a urine catheter bag hung from right side of the bed toward the doorway. The catheter bag and tubing were touching the floor and a large pool of urine ran from the bag towards the wall which was across the entryway of the room. On 11/12/21 at 1:17 PM, Resident 6 was observed in her/his room to lie on her/his bed with a urine catheter bag hung from right side of the bed toward the doorway. A large pool of urine ran from the bag towards the wall which was across the entryway of the room. The 8/26/21 care plan directed the catheter bag and tubing for Resident 6 was hung below the level of the bladder, away from the door, check for tubing kinks each shift and monitor intake. On 11/15/21 at 2:32 PM, Staff 2 (DNS) confirmed she expected Resident 6's urine catheter bag and tube to not touch the floor and the urine should be emptied.

Resident # 6 is no longer in the facility Residents in center that require CBG checks and have indwelling catheters have potential to be affected. Residents reviewed to identify these residents and validate they have their own CBG machine and catheter bags/tubing are stored appropriately and not touching the floor. Immediate education was provided to staff related to proper storage of catheter bag and tubing for residents, and provide a privacy bag, ensuring not touching the floor. Admissions will be reviewed during clinical meeting to identify diabetic residents and residents with catheters. Further education will be provided to staff on infection control practices related to catheters. Education will be provided to licensed staff related to glucometer cleaning and use of individual glucometers for each diabetic resident. DNS/Designee will audit for glucometer usage and cleaning weekly x 4 weeks then monthly x 3 months. Identified concerns will be corrected immediately. DNS/Designee will audit for catheters and proper storage, weekly x 4 weeks then monthly x 3 months. Identified concerns will be corrected immediately. Results will be taken to the QAPi meeting to determine compliance and if continued auditing is warranted. Date of Compliance January 7, 2022.

Based on interview and record review it was determined the facility failed to ensure state temporary minimum CNA staffing ratios were maintained for 6 of 40 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: The NF (Nursing Facility)-21-045 Provider Alert, dated 8/24/21, temporary revision of the Oregon Administrative Rule related to revising the CNA staffing ratio reflected the minimum number of CNAs required to care for residents to ensure health and safety. A review of the Direct Care Staff Daily Reports from 10/1/21 through 11/9/21 revealed the following days when state minimum CNA staffing ratios at the temporary numbers were not met: - 10/27/21 night shift staffed two CNAs and three were required; - 10/29/21 night shift staffed two CNAs and three were required; - 10/31/21 evening shift staffed three CNAs and four were required; - 11/1/21 evening shift staffed three CNAs and four were required; - 11/3/21 evening shift staffed three CNAs and four were required; night shift staffed two CNAs and three were required; - 11/5/21 evening shift staffed three CNAs and four were required. On 11/15/21 at 2:11 PM Staff 2 (DNS) acknowledged the failure to meet state minimum temporary CNA staffing ratios.

No resident identified. Residents in center have the potential of being affected. Immediate review of staffing schedules was completed to identify open positions. Contacted current contracted agencies for open shifts needing to be filled. Staffing Coordinator re-educated on sufficient staffing requirements by DNS/Designee. Facility will expand agency usage by contacting other agencies and obtaining contracts with multiple agencies to expedite shifts needing filled. Facility will continue to advertise for open positions available on multiple platforms Facility will also contact CNA training programs to inquire about CNAS graduating and looking for positions Facility will utilize non-clinical staff to assist with non-clinical tasks to assist when there is a last minute call out or if facility is unable to fill a position Daily review of staffing will be completed by DNS/ED or designee to identify if all staff are present. ED/DNS or designee will conduct weekly review of schedule with staffing director to identify shift needs and validate sufficient staffing. Audits will be conducted weekly x 4 weeks, then monthly x 3 months until substantial compliance is met and maintained. Findings will be brought to Quality Assurance Performance improvement meeting. Date of Compliance January 7, 2022

OAR 411-086-0040 Admission of Residents

Refer to F655 **************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677 ***************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ***************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 **************************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 **************************************** OAR 411-086-0260 Pharmacy Services: Pharmaceutical Services Refer to F761 **************************************** OAR 411-086-0250 Dietary Services Refer to F812 **************************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ****************************************

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

Based on observation, interview and record review it was determined the facility failed to ensure appropriate and adequate hand hygiene during meal delivery for 1 of 4 staff (#3) observed during dining. This placed residents at risk for exposure to the COVID-19 virus and other infectious disease. Findings include: Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 2/23/21 indicated the following: 1. Hand Hygiene A. HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protective equipment (PPE), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. B. HCP should perform hand hygiene by using alcohol based hand sanitizer (ABHS) with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS. The facility's 3/2018 Handwashing/Hand Hygiene Policy & Procedure directed the following: (7) Use an alcohol-based hand rub or soap and water for the following situations: - Before and after direct contact with resident; - Before and after entering isolation precaution settings; - Before and after assisting a resident with meals. (8) Hand hygiene is the final step after removing and disposing of personal protective equipment. On 7/27/21 between 6:08 PM and 6:23 PM, the following sequence of events were observed: - Staff 3 (CNA) provided feeding assistance to Resident 1 in Resident 1's room and was observed to be in direct contact with the resident and the resident's immediate environment. - Staff 3 exited Resident 1's room, placed the meal tray on top of the 100-hall food cart and retrieved another resident's meal tray. - Staff 3 placed the meal tray on a table outside room 112 (a transmission-based precaution room of a resident under observation for COVID-19), donned an isolation gown and face shield and entered the room. Staff 3 did not don gloves prior to entering the resident's room. - Staff 3 exited room 112 with the gown and face shield donned and placed the meal tray on the adjacent table outside the room. With bare hands, Staff 3 doffed the face shield and gown, stuffed the gown inside a trash receptacle, picked up the meal tray and placed it into the meal cart. - Staff 3 walked to the hall meal cart on hall 200, retrieved another resident's meal tray and entered the main dining room. - Staff 3 removed the plate of food, beverages and utensils from the tray and placed the items on the dining table in front of Resident 2. - Staff 3 walked over to the sink in the dining room and washed her hands for five seconds. Staff 3 did not appropriately perform hand hygiene after direct contact with Resident 1 and Resident 1's immediate environment, before and after assisting Resident 1 with her/his meal, before and after entering and exiting an isolation room and before donning PPE and after doffing potentially contaminated PPE. Staff 3 did not adequately perform hand hygiene for at least 20 seconds to effectively remove pathogens that may have been transferred to her bare hands. On 7/27/21 at 6:53 PM Staff 3 stated hand hygiene should be completed "all the time, before and after care and every time you turn around" and stated she preferred not to wash her hands in the isolation room. On 7/27/21 at 7:02 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 18 (Director of Clinical Operations) were notified of the inappropriate and inadequate hand hygiene incidents. Staff 2 stated hand hygiene should be performed between every resident contact, in and out of every resident room, between each meal tray delivery and after doffing PPE. Staff 1 and Staff 18 acknowledged the findings of this investigation.

Hillsboro F880 Resident: Resident #1 has been assessed and tested for any signs or symptoms of infection related to deficient practice; no evidence of infection has been found. Other residents: The DNS and/or designee has reviewed/assessed other residents to ensure the facility staff practice proper hand hygiene during cares in order to avoid placing residents at increased risk for infection. Facility Systems: Facility staff have been re-educated on proper hand hygiene using the Clean Hands Video followed by return demonstration of technique. As the root cause analysis revealed infection control complacency we are also training using the Keep Covid 19 Out! Video to remind staff of importance of infection control. Monitor: After thorough root cause analysis by the IDT team it has been determined that infection control complacency, nervousness around surveyor and lack of comprehension around potential serious complications of improper hand hygiene. Based on this the DNS and/or designee will monitor staff hand hygiene to ensure that residents are not placed at increased risk for infection. Validation of compliance using audit tools will occur a minimum of 3 times/week for 4 weeks then monthly for three months. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the Director of Nursing and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team

OAR 411-086-0330 - Infection Control and Universal Precautions

Refer to F880 ******************************