Nehalem Valley Care Center

Based on observation and interview it was determined that the facility failed to ensure a dignified dining experience for 2 of 5 sample residents (#s 8 and 20) reviewed for dining. This placed residents at risk for decreased quality of life. Findings include:

On 6/23/25 at 12:39 PM two meal trays were observed in the dining room with black plastic garbage bags over the trays. Each tray had the main meal served in a disposable clamshell container, the fruit was served in a disposable paper soup cup and there were plastic utensils for residents to utilize. Staff 22 (CNA) provided the meal trays to Residents 8 and 20 who were sitting at a communal table with three other residents.

On 6/24/25 at 11:42 AM Staff 27 (Cook) stated the plastic covered trays with disposable containers and utensils were for "people on precautions."

On 6/25/25 at 03:17 PM Staff 3 (Regional Nurse) stated the plastic bag covering the tray and the use of the clamshell, disposable soup cups and utensils were not part of the protocol for residents on contact precautions.

On 6/26/25 at 11:33 AM Resident 20 stated she/he preferred to have a normal tray if the disposable tray was not required for safety.

On 6/26/25 at 11:37 AM Resident 8 stated she/he wanted to be like everyone else and have the same tray.

Based on observation, interview and record review it was determined the facility failed to ensure residents with diagnoses of dementia were free from unnecessary use of antipschotic medication for 1 of 5 sampled residents (#7) reviewed for medications. This placed residents at risk for adverse side effects of antipsychotic medication. Findings include:

Resident 7 was admitted to the facility in 11/2023 with diagnoses including a stage four pressure ulcer and dementia.

The following psychoactive medications were ordered on Resident 7's 6/2025 MAR:
·        
quetiapine (an antipsychotic)
·        
trazodone (an antidepressant)
·        
venlafaxine (an antidepressant and antianxiety agent)
·        
Namenda (an anti-Alzheimer ' s agent)
·        
hydroxyzine (an antianxiety agent)

On 5/15/24 Resident 7's Abnormal Involuntary Movement Scale (AIMS) total score was 7 indicating the symptoms/side effects of psychoactive medication use were present.

On 2/4/25 the facility notified Resident 7's physician that she/he was experiencing symptoms including sweating, and involuntary smiling and grimacing. The physician ordered a reduction of Resident 7's venlafaxine dose, but did not address the resident's use of quetiapine.

The 3/31/25 Psychotropic Committee Meeting Review form indicated no additional GDRs were ordered, and there was nothing to indicate Resident 7's use of antipsychotic medication despite the presenece of adverse side effects was assessed.

On 4/24/25 Resident 7's AIMS total score was 9 indicating worsening symptoms/side effects of antipsychotic medication were present.

A review of the resident's clinical record from 5/2025 through 6/2025 indicated staff were to monitor for calling out behaviors. The document indicated the behavior did not occur.

On 6/22/25 at 12:28 PM, 6/24/25 at 12:48 PM, and 6/25/25 at 10:31 AM Resident 7 was observed in her/his room and interacted with staff with no negative behaviors or signs of distress noted.

On 6/24/25 at 12:30 PM Staff 4 (LPN) stated Resident 7's calling out behaviors lessened in the past several months and she/he was able to express her/his wants and needs.

On 6/24/25 at 2:56 PM Staff 29 (NA) stated Resident 7 was able to express her/his needs and did call out for things like a pillow or pain medication, but denied the resident exhibited signs of distress.

On 6/25/25 at 3:15 PM Staff 6 (LPN Resident Care Manager) stated the facility did not assess Resident 7 for antipsychotic medication use, but rather they relied on the pharmacist reviews and recommendations.

On 6/26/25 at 10:30 AM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged antipsychotic medication was prescribed to address Resident 7's calling out behaviors that were disturbing to those around her/him, but did not seem to cause distress to the resident. Staff 3 further acknowledged a comprehensive risk/benefit assessment should have been completed to determine if continued use of the medication was appropriate despite the presence of adverse side effects.

Based on interview and record review it was determined the facility failed to ensure sufficient nursing staff to meet resident care needs in a timely manner for 3 of 3 resident halls reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet care needs. Findings include:

Resident Council Notes indicated the following:
-3/25/25: Showers were not being done.
-4/30/25: CNAs were not getting residents to activities in a timely manner and meal service was late.

A review of the facility's Direct Care Staff Daily Reports from 2/11/25 through 2/18/25 and 5/23/25 through 6/23/25 revealed the facility had insufficient CNA staff, according to state minimum staffing requirements, for one or more shifts on the following dates:
-5/30/25
-6/2/25
-6/7/25
-6/9/25
-6/11/25
-6/19/25

Interviews with residents revealed the following concerns:
-On 6/22/25 at 11:59 PM Resident 28 stated on 6/22/25 at 8:20 PM she/he pushed her/his call light and staff did not answer her/his light until 9:15 PM.

-On 6/22/25 at 12:12 PM Resident 231 stated at night it took up to an hour for the call light to be answered.

-On 6/22/25 at 12:34 PM Resident 21 stated she/he received late showers related to the facility's staffing issues.

-On 6/22/25 at 12:54 PM Resident 15 stated call lights took up to 45 minutes to be answered and meals were delivered late.

-On 6/22/25 at 2:40 PM Resident 9 stated it took up to an hour for staff to answer her/his call-light and at times she/he had to go into the hall to find help and often nobody was around.

Interviews with staff revealed the following concerns:
-On 6/23/25 at 9:30 AM Staff 25 (Agency CNA) stated the facility was short staffed and she was often rushed to complete her basic tasks which included resident showers and answering call lights.

-On 6/24/25 at 9:40 AM Staff 16 (CNA) stated all shifts, both weekdays and weekends, had staffing
issues. Staff 16 stated she was usually assigned to 8-12 residents which made it hard to answer call-lights and provide resident care timely.

-On 6/24/25 at 10:55 AM Staff 24 (CNA) stated it was often hard to get basic tasks done timely and she often felt rushed.

-On 6/24/25 at 11:25 AM Staff 15 (CNA) stated it was normal for staff to be rushed and not have enough time to provide showers. Staff 15 stated answering call lights timely was a constant challenge.

-On 6/25/25 at 11:25 AM Staff 26 (Agency CNA) stated the facility was always short staffed and it was common for residents to wait over 20 minutes for call lights to be answered.

On 6/26/25 at 11:27 AM Staff 1 (Administrator) acknowledged the staffing concerns related to timely assistance and confirmed the staffing shortages.

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours per day for 3 of 43 days reviewed for staffing. This placed residents at risk for unassessed needs and lack of care. Findings include:

Review of the Direct Care Staff Daily Reports from 2/11/25 through 2/18/25 and 5/23/25 through 6/23/25 indicated there was no RN coverage for eight consecutive hours on 2/13/25, 2/15/25, and 6/20/25.

On 6/26/22 at 10:17 PM Staff 1 (Administrator) and Staff 3 (Regional Nurse) acknowledged the facility lacked RN coverage on the identified days.

Based on observation, interview, and record review it was determined the facility failed to ensure pureed foods were prepared using methods that conserved nutritive value and flavor for 2 of 2 meals served to residents requiring pureed diets. This placed residents at risk for consuming unpalatable, nutritionally compromised food. Findings include:

The facility's dining menu on 6/25/25 indicated the entrée for the lunch meal was roasted salmon.

The facility's recipe for preparation of pureed food indicated to add hot cooking liquid and/or hot broth and food thickener to the roasted salmon while it was being processed to the puree texture.

On 6/25/25 at 11:58 AM Staff 28 (Cook) was observed adding approximately 6-8 ounces of clear liquid to the salmon puree as it was being processed. Staff 28 stated he was preparing the salmon for one resident tray. Staff 28 confirmed the clear liquid was water.

On 06/25/25 at 02:47 PM Staff 7 (Dietary Manager) stated water was not be used to prepare a pureed meal. Instead, a liquid with more nutritional value was to be added.

Based on observation, interview and record review the facility failed to ensure proper hand hygiene during meals and failed to use proper PPE for contact-based precautions for 1 of 1 dining room and 2 of 2 of sampled residents (#s 8 and 12) reviewed for dining and infection control. This placed residents at risk for cross contamination. Findings include:

According to the Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html):
·        
Use Contact Precautions for patients with known or suspected infections that present an increased risk for contact transmission.
·        
Use personal protective equipment (PPE) appropriately including gloves and gown.
·        
Wear a gown and gloves for all interactions that may involve contact with the patient or patient's environment.
·        
Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.
·        
If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.

The facility's Standard Precautions policy revised September 2022 stated the following:
·        
Hand hygiene is performed with Alcohol-Based Hand Rub (ABHR) or soap and water: before and after contact with the resident.
·        
Gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact.
·        
Reusable equipment is not to be used for the care of more than one resident until it has been appropriately cleaned and reprocessed.

1. On 6/23/25 at 9:10 AM Staff 22 (CNA) entered Resident 12's room who was on Contact Precautions. Prior to entering the room, Staff 22 did not don PPE. Staff 22 exited the resident's room without performing hand hygiene. A CDC Contact Precautions sign was prominently displayed on the room door.

On 6/23/25 at 9:20 AM Staff 22 returned to Resident 12's room with a cup of coffee and again entered without donning PPE. No hand hygiene was observed upon exiting the room.

On 6/23/25 at 9:23 AM Staff 22 acknowledged the resident was on Contact Precautions, and that she/he did not don PPE upon entering the room or perform hand hygiene upon exiting.

On 6/25/25 at 2:22 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged staff were to use appropriate PPE for residents on Contact Precautions. Staff 2 and Staff 3 indicated some staff were confused about the difference between Enhanced Barrier Precautions and Contact Precautions.

2. On 6/23/25 at 9:24 AM Staff 23 (LPN) entered Resident 8's room who was on Contact Precautions. Staff 23 did not don PPE and used a reusable blood pressure device to take a reading on the resident. Staff 23 exited the resident's room and placed the blood pressure device on top of a medication cart without putting down a barrier first. Staff 23 returned to the resident's room to administer medications and did not don PPE before she/he entered. A CDC Contact Precautions sign was prominently displayed on the room door.

On 6/23/25 at 9:29 AM Staff 23 acknowledged the resident was on Contact Precautions and that she/he did not don PPE before entering the resident's room. Staff 23 acknowledged she did not clean the reusable blood pressure cuff after using it on the resident.

On 6/25/25 at 2:22 PM Staff 2 (DNS) and Staff 3 (Regional RN) acknowledged staff were to use appropriate PPE for residents on Contact Precautions. Staff 2 and Staff 3 indicated some staff were confused about the difference between Enhanced Barrier Precautions and Contact Precautions.
, Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was implemented during meals and failed to use proper PPE for contact-based precautions for 1 of 1 dining room and 2 of 2 of sampled residents (#s 8 and 12) reviewed for dining and infection control. This placed residents at risk for cross contamination. Findings include:

On 6/23/25 from 12:22 PM to 12:42 PM, Staff 22 was observed assisting residents to dine in the main dining room wearing the same gloves and without hand hygiene. Staff 22 was observed to:

On 6/23/25 at 12:22 PM Staff 22 (CNA) was observed wearing gloves while serving a resident her/his meal tray in the main dining room. Staff 22 took off plastic wrap from resident's fruit bowl using gloves while touching every surface of the bowl including the fruit, this was repeated with at least three residents.

On 6/23/25 at 12:39 PM Staff 22 (CNA) was observed handling his phone with the same gloves on, he then provided beverages to residents with the same gloves on. Staff 22 (CNA) then assisted a resident with getting food and uncovering the food with the same gloves. Staff 22 (CNA) poured more beverages for residents with the same gloves on.

On 6/23/25 at 12:42 PM Staff 22 (CNA) pushed a resident closer to the table with the same gloves on, then poured more beverages and opened creamers to put into coffee with the same gloves on. Staff 22 then finally removed the soiled gloves, but did not perform hand hygiene.

On 6/23/25 at 12:56 PM Staff 22 (CNA) stated he usually performed hand hygiene and glove changes only twice during meal service. When Staff 22 was asked about glove changes after touching his phone he noted he took the gloves off right away but "should have" performed hand hygiene.

On 6/26/25 at 11:20 AM Staff 3 (Regional RN) stated staff were expected to perform hand hygiene in between helping residents in the dining room.

OAR 411-085-0310 Residents' Rights: Generally Civil Rights

Refer to F550
************
OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care

Refer to F605
************
OAR 411-086-0100 Nursing Services: Staffing

Refer to F725 and F727
************
OAR 411-086-0250 Dietary Services

Refer to F804
************
OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880

Based on interview and record review it was determined the facility failed to use the services of a registered nurse for at least eight consecutive hours a day for 41 out of 99 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include:

1. A review of the Direct Care Staff Daily Reports dated 8/1/24 through 11/7/24 revealed there were 41 days without eight consecutive hours of registered nurse coverage in a 24-hour period. The identified dates included:

- 8/12/24, 8/19/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/26/24, 8/27/24, 8/28/24.
- 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/8/24, 9/13/24, 9/14/24, 9/16/24, 9/17/24, 9/18/24, 9/25/24, 9/26/24, 9/27/24.
- 10/7/24, 10/9/24, 10/10/24, 10/11/24, 10/15/24, 10/17/24, 10/18/24, 10/19/24, 10/20/24, 10/21/24, 10/25/24, 10/26/24, 10/27/24, 10/28/24, 10/31/24.
- 11/1/24, 11/3/24, 11/5/24.

On 10/29/24 at 10:03 AM Staff 1 (Administrator) confirmed the identified days were missing RN coverage.

2. Based on observation and interview it was determined the facility failed to designate a registered nurse to serve as the director of nursing on a full time basis for 1 of 1 facility reviewed for nurse staffing. This placed residents at risk for lack of nursing oversight. Findings include:

During the survey conducted from 11/7/24 through 11/12/24, no DNS was observed in the facility.

On 11/7/24 at 9:15 AM Staff 2 (CNA) stated it had been 2-3 months since the last DNS was in the building. Staff 2 stated everything felt more "chaotic".

On 11/7/24 at 9:25 AM Staff 3 (CNA) stated it had been 3-4 months since the last DNS was in the building. Staff 3 stated it was difficult to know who was in charge and staff didn't have a "higher up" to go to when there was a problem.

During interviews with Staff 2 (CNA), Staff 3 (CNA), Staff 4 (CNA), Staff 5 (CNA), Staff 7 (LPN), Staff 8 (CNA), and Staff 9 (CNA) from 11/7/24 through 11/12/24 the staff reported the previous DNS left in October of 2024 and there was no full-time DNS in the facility since that time. The staff reported Staff 10 (RN Consultant) was designated as the DNS, but she did not work in the facility. Staff 8 stated it was "rough" not having a DNS. Staff 4 stated there was no one to go to for clinical questions.

On 11/12/24 at 11:00 AM Staff 12 (Therapy Staff Member) stated the facility struggled with higher level recommendations for clinical needs and concerns. Staff 12 stated resident information was provided to the charge nurses, but it was clear they didn't always know what to do with the information.

On 11/12/24 at 11:35 AM Staff 1 (Administrator) confirmed Staff 10 was working remotely as the DNS. Staff 1 confirmed there was no full time RN serving as Director of Nursing in the facility.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained for 21 of 99 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

A review of the Direct Care Staff Daily Reports from 8/1/24 through 11/7/24 revealed the facility did not have sufficient CNA staff to meet the minimum CNA to resident staffing requirements on the following days:

- 8/7/24, 8/11/24, 8/25/24, 8/27/24, 8/29/24.
- 9/1/24, 9/4/24, 9/6/24, 9/7/24, 9/9/24, 9/10/24, 9/16/24, 9/17/24.
- 10/2/24, 10/15/24, 10/17/24, 10/22/24, 10/24/24, 10/29/24.
- 11/3/24, 11/5/24.

On 11/12/24 at 11:35 AM Staff 1 (Administrator) confirmed the CNA staffing ratios were not met for the identified dates.

*********************
OAR 411-086-0100 Nursing Services: Staffing

Refer to F727
*********************

Based on interview and record review the facility failed to provide required liability notices, including when the resident's financial liability would start for 1 of 1 sampled residents who remained in the facility (R) (R10) and reviewed for beneficiary notice. The facility did not issue a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-10055; and instead used a different CMS form which did not document the start date of the resident's financial liability. This failure increased the residents' risk for not having adequate information to make financial decisions.

Findings include:

Review of CMS Fee for Services Skilled Nursing Facility Advance Beneficiary Notice (FFS SNF ABN) located at https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-snf-abn, date last modified 9/6/23, accessed on 4/26/24/24, showed "Skilled Nursing Facilities (SNFs) must issue a notice to Original Medicare (fee for service - FFS) beneficiaries in order to transfer potential financial liability before the SNF provides *an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or *custodial care."


Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-10055, is issued by the facility if the beneficiary intends to continue services and the facility believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. The ABN form allows the facility to enter the date the resident would start paying out of pocket for the care, the item or service deemed no longer meeting coverage requirements, the reason the item or service was not meeting coverage requirements, the estimated cost of the item or service and then asked the resident to choose one of three options based on this information.


Review of facility policy, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised date September 2022, documented, "Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) ...c. Termination-In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care or services are terminated. 3. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare, and assume financial responsibility."


Review of R10's records showed an ABN was issued for ICF (intermediate care facility) care-nursing facility placement because Medicare does not cover non therapy stay. The estimated daily cost was shown. The form did not show the start date of the resident's financial liability. The facility used Form CMS-R-131 and not Form CMS-10055.

During an interview on 4/23/24 at 2:15 PM Social Services Director (SSD) confirmed that R10 had Medicare A benefit days left and remained in the facility. During concurrent review of ABN form issued to R10, SSD was asked to point to the location on the form showing the start date of the resident's financial liability. SSD reviewed form and stated that there was no dates on the form and the form did not show the start date of the resident's financial liability. SSD further stated that the ABN and Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) was always completed together which is why the effective date when payment starts was likely missed. SSD also stated form (CMS R-131) has been in use for the past two years after being downloaded from the CMS website.

During an interview on 4/26/24 at 11:58 AM Director of Nursing (DON) was informed that CMS form 10055 was not used and therefore the start date of financial liability was not communicated. DON nodded head and did not provide any further information.

Based on interview and record review, the facility did not ensure an abuse allegation was reported within the mandated timeframe to the State Survey agency for one of two sampled residents (Resident [R] 4) reviewed for abuse reporting.

This failure had the potential for not identifying abuse incidents timely and may result in provision of inappropriate corrective action and protection of vulnerable residents.

Findings:

Review of Facesheet indicated R4 was admitted with diagnoses including major depressive disorder (mood disorder that causes a persistent feeling of sadness) and anxiety (a feeling of fear, dread, and uneasiness).

Review of R4's Minimum Data Set (MDS, an assessment tool) with Assessment Reference Date (ARD) of 03/04/24 indicated a Brief Interview for Mental Status (BIMS) score of 15 which means R4 was cognitively intact.

During an interview on 04/22/24, at 03:40 PM, R4 stated, "An Aide (facility staff) told me I was stupid." According to R4, the incident happened on 04/21/24 and stated that she did not report the incident to anyone.

On 04/22/24, at 04:45 PM, the Director of Nursing (DON) was made aware of R4 allegation. The DON stated she will check because there is a grievance that was filed yesterday (04/21/24) with the Administrator.

During an interview on 04/23/24, at 12:40 PM, the DON stated that she talked to R4 and the facility initiated the five day investigation of R4's allegation. Per DON, she reported the incident to the "State" and stated, "I did it a bit late, well it's not within 2 hrs."

Review of Nursing Facility Reported Incident (FRI) Form, R4's allegation was reported to Oregon Department of Human Services (DHS) on 04/22/24 at 08:21 PM.

Review of facility policy titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating" dated September 2022 indicated, "1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility...3."Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury..."

Based on interview and record review, the facility failed to have documented evidence that a thorough investigations was completed of alleged abuse for 1 of 2 sampled resident (R10) reviewed for abuse investigations. The failure to conduct thorough investigations created the potential risk of not identifying all contributing factors related to the incident and identify root causes of abuse, which placed residents at risk for unidentified abuse, inappropriate corrective actions being implemented, and recurrent incidents with the potential for continuing abuse or other incidents.

Findings include:

Review of Resident 10's (R10) record indicated the facility admitted the resident in November 2023 with diagnoses including depression, diabetes, and dementia. R10's Minimum Data Set (MDS-assessment tool) dated 3/24/24 documented resident's brief interview for mental status was 13, indicating resident was cognitively intact.

During an interview on 4/22/24 at 2:05 PM with R10 and R10's family member, both stated that resident's left hand was smacked by a staff member in resident's room. Staff then wheeled resident into the dining room and pushed resident's wheelchair into the dining room table smashing resident's left hand between the wheelchair and the table. R10 stated "I don't know what I did to make her so upset at me, I think she just having a bad day." R10 and family member further stated that R10 had a large bruise on her left and right hand. R10 stated "my whole hand was bruises" pointing to left hand, "I couldn't hide it from anyone." R10's family member described staff member but couldn't recall her name and stated staff was fired on the spot.

Review of Facility policy, Abuse, Neglect and Exploitation-Reporting and Investigating, revised date September 2022, documented "All investigations are thoroughly investigated ...the individual conducting the investigation as a minimum: .....interviews other residents to whom the accused employee provides care and services ..."

Review of Facility's Reported Incident (FRI) form for R10, dated 1/22/24 documented on 1/22/24 facility became aware of incident where resident reported "she slapped my hand real hard ....she wasn't mad, she just smacked it pretty hard. It doesn't take much to bruise me" when nurse inquired about a bruise noted to resident's left hand and right middle finger. Resident could not recall date, time, location of incident or staff member's name but described staff member's physical appearance.

Review of Occurrence Investigation Final Summary, event date 1/19/24, documented, "On Monday, 1/22/24, the RCM (Resident Care Manager) was given a grievance filed by a CNA (Certified Nursing Aide) staff member informing that another resident (R20) was signaling her to the table, pointed to R10. When approached the table, R10 informed her that a CNA slapped her hand very hard and threw my right hand on the table causing a bruise." The summary report documented the investigation including gathering witness statements and statements from staff for this unwitnessed event, with the conclusion that "abuse or neglect are not able to be substantiated or unsubstantiated." The summary report did not include documented evidence that other residents who received care from accused staff were interviewed; other residents who received care from alleged staff were not interviewed to assess if rough care or adverse interactions were experienced by other residents.

During an interview on 4/22/24 at 4:45 PM Director of Nursing (DON) stated that the staff involved in the allegation was an agency CNA and that staff no longer was used by the facility. DON further stated that the abuse allegation could not be substantiate because the resident has dementia and of course the CNA denied it.

During an interview on 4/24/24 between 3:00 PM and 3:30 PM DON stated that alleged staff abuse investigation includes random interviews with other residents who receive care from that staff. When informed that this type of documentation was not present in the documents received, DON stated that she would check her files.

During an interview on 4/26/24 at 11:58 AM DON stated that she did not have any further documentation to provide to surveyor and could not locate other resident interviews.

Based on interview, record review, and facility policy review, the facility failed to ensure written notice was sent to the resident and/or the resident's representative (RR) after an emergent transfer from the facility to the hospital for one resident (Resident (R) 21) of one resident reviewed for hospitalizations. This failure had the potential to affect the resident and their RR by not having the knowledge of where and why the resident was transferred.

Findings include:

Review of a policy provided by the facility titled, "Transfer Agreement," dated 03/2017 indicated, "Our transfer agreement is in writing and authorized by individuals who are permitted to execute such an agreement ...Ensures that residents are transferred from the facility to the hospital and admitted in a timely manner when appropriate (as determined by the attending physician) ...facilitates the exchange of medical and other information necessary or useful in the care and treatment of residents transferred between the institutions ...Specifies the responsibilities assumed by both the discharging and receiving institutions for: Prompt notification of the impending transfer of the resident; the exchange of pertinent clinical information; arranging appropriate and safe transportation and care of the resident during transfer; and the transfer of personal effects, particularly money and valuables, and of information related to such items ..."

Review of R21's electronic medical record (EMR) "Profile" located under the "Profile" tab indicated the resident was admitted to the facility on 01/25/23.

Review of R21's "Progress Notes," located under the "Progress Notes" tab in the EMR and dated 02/29/24, indicated the resident departed to the Hospital via ambulance at 1:16 PM due to shakiness and overall, not feeling well.

Review of the "Progress Notes" and "Documents" tab in the EMR revealed there was no evidence that a written notice, with all required information, was provided to the resident and the RR, regarding the transfer to the hospital.

Interview on 04/23/24 at 2:36 PM with License Practical Nurse (LPN) 1 revealed "I sent the resident out to the hospital for confusion. The transfer/discharge paperwork was sent with the resident to the hospital. The resident was not in his right mind to sign paperwork and I did not document any paperwork in the EMR."

Interview on 04/26/24 at 11:06 AM with the Director of Nursing (DON) revealed "All paperwork should be sent, explained, and signed. Documentation should be completed in the EMR."

Based on interview, record review, and review of the facility policy, the facility failed to ensure one (Resident (R) 21) out of one resident who was transferred to the hospital, was provided a written bed hold notice at the time of transfer to the local hospital. This had the potential to limit the amount of information on the facility's bed payment policy, which would possibly affect the resident's right to return to the same room after a hospitalization.

Findings include:

Review of a document provided the facility titled "Bed Holds and Returns" dated 10/2022 indicated ...All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave) ...The written bed-hod notice provided to the resident/representative explain in detail: the duration of the state bed-hold policy; the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed or to hold a bed beyond the state bed-hold period; the facility return policy ...Residents who seek to return to the facility within the bed-hold period are allowed to return to their previous room, if available ..."

Review of R21's electronic medical record (EMR) "Profile" located under the "Profile" tab indicated the resident was admitted to the facility on 01/25/23.

Review of R21's "Progress Notes," located under the "Progress Notes" tab in the EMR and dated 02/29/24, indicated the resident departed to the hospital via ambulance at 1:16 PM due to shakiness and overall, not feeling well.

Review of the "Progress Notes" and "Documents" tab in the EMR revealed there was no evidence that a bed-hold policy was given to the resident.

Interview on 04/23/24 at 2:36 PM with License Practical Nurse (LPN) 1 revealed "I sent the resident out to the hospital for confusion. The bed-hold policy was sent with the resident in a packet. The resident was not in his right mind to sign paperwork and I did not document any paperwork in the EMR."

Interview on 04/26/24 at 11:06 AM with the Director of Nursing (DON) revealed "All paperwork should be sent, explained, and signed. Documentation should be completed in the EMR."

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-assessment tool) data for pressure injury/ulcer including pressure injury/ulcer staging was accurate for 1 of 1 sampled resident (R) (R9) reviewed for pressure injury. This failure increased resident risk for not receiving an individualized plan of care based on the resident's specific needs.

Findings include:


During concurrent observation and interview on 4/22/24 at 2:36 PM a large dressing was observed on R9's right hip. Licensed Nurse (LN)1 stated R9 was admitted with a large pressure ulcer on her right hip that had about 4 to 5 centimeters (cm) of tunneling.

Observation on 4/24/24 at 1:00 PM showed LN1 with two student nurses present removing resident's right hip dressing that was saturated with drainage. With sterile gloves, LN1 placed a cotton tip covered long stick into the right hip wound and stated that it was 4 cm deep. The wound had tunneling. The wound bed was fully visible with pink granulated tissue about 2 cm x 1 cm. There was no eschar or slough present.

Review of Resident 9's (R9) record indicated the facility admitted the resident in November 2023 with diagnoses including depression, diabetes, and dementia. R9's Minimum Data Set (MDS-assessment tool) dated 2/11/24 documented resident's brief interview for mental status was 10, indicating moderate cognitive impairment. Admission MDS, dated 11/16/23, and Quarterly MDS, dated 2/11/24, both documented resident did not have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device but later the MDS assessment documented resident had one unstageable pressure ulcers/injuries due to non-removable dressing/device.

Review of the Long-Term Facility Resident Assessment Instrument 3.0 User's Manual v1.18.11 dated October 2023 under Section M0100: Determination of Pressure Ulcer/Injury Risk directed to check A if resident has a Stage 1 or greater pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device by reviewing descriptions of pressure ulcers/injuries and information obtained during physical examination and medical record review. Section M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage directed to determine deepest anatomical stage at admission and code based on findings from the first skin assessment that is conducted on or after and as close to the admission as possible. Do not reverse or back stage. It further documented that if a pressure ulcer's/injury's anatomical tissues are obscured such that extent of soft tissue damage cannot be observed or palpated, the pressure ulcer/injury is considered unstageable. Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable, as illustrated at https://npiap.com/page/PressureInjuryStages. Stage 4 Pressure Ulcer were defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Tunneling was defined as a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound."

Review of wound/ostomy services, dated 11/8/23 (prior to facility admission), documented full thickness right posterior upper thigh pressure injury that was first assessed on 8/11/23.

Review of Observation Detail List Report for R9's initial admission assessment, dated 11/10/23, documented right lateral thigh/hip wound measurement was unable to be obtained due to wound vac(uum) in place.

Review of Wound Management Detail Report, observation date 11/22/23, documented right hip posterior pressure ulcer was unstageable with zero percent of wound covered by slough tissue and zero percent of wound covered by eschar tissue.

Review of Wound Management Detail Report, observation date 11/30/23, documented right hip posterior pressure ulcer was unstageable with zero percent of wound covered by slough tissue and zero percent of wound covered by eschar tissue. Tunneling was present.

Review of Wound Management Detail Report, observation date 12/3/23, documented right hip posterior pressure ulcer was unstageable with zero percent of wound covered by slough tissue and zero percent of wound covered by eschar tissue.

Review of wound round progress notes, dated 3/22/24, documented unstageable pressure injury present on admission measuring 1.5x2 with 5cm tunneling at 1 o'clock. 100% granulation with moderate purulent/serosanguineous drainage.

During a concurrent interview and record review on 4/24/24 at 10:20 AM Resident Care Manager (RCM) stated that she completed the MDS assessments and also does weekly wound rounds where she measures wounds with Director of Nursing (DON) or another LN. RCM and surveyor conducted joint review of 11/10/23 Admission and 2/11/24 Quarterly MDS entry of M0100A that showed resident did not have a pressure ulcer/injury but later entry on M0300E1 that showed resident had one unstageable pressure ulcer/injury. RCM stated that these entries were not congruent with each other and M0100A was incorrect because resident did have a pressure ulcer/injury. When further asked how unstageable pressure injury was determined, RCM stated that unstageable was entered because that was the diagnosis shown but agreed after reviewing MDS manual that since wound did not have slough or eschar from admission, unstageable was not accurate.

During an interview on 4/26/24 at 11:58 AM DON stated that the MDS was not coded accurately for R9's pressure ulcer.

Based on observation, interview, and record review the facility failed to ensure a staff adhered to professional standards related to medication preparation and administration when a staff pre-poured medication for four of nine residents (Resident [R]20, R23, R25, R26) observed for medication administration.

The deficient practice placed residents at risk of receiving the wrong medication.

Findings:

During medication administration observation on 04/24/24, at 08:40 AM, Medication Aide (MA) 4 stated that it has been a while since she did "medication pass" in the facility. MA 4 added, "I don't know the residents. They're not in the room. Other residents were in the dining room so I have to re-approach them." MA 4 went inside the medication room and she opened the "West Hall" medication cart. In the first drawer of the medication cart was observed four medication caps with pre-poured medication. MA 4 explained, "I popped them (referring to the medication in the cups) and kept it here because she (resident) was not in the room. I have to keep it and just like what I've said I have to re approach them." According to MA 4, she is not aware that pre-pouring medication is not an acceptable practice and stated, "I thought you can keep it (referring to the pre poured medications)."
The four medication cups with pre-poured medications were marked as follows:
"20" - MA 4 stated the number refers to residents room and explained that resident "was refusing" the medication.
"25 (with resident's first name)"- MA 4 stated, resident is "not in her room that's why I prepared the meds."
"26 (with resident's first name)"- MA 4 stated, resident is "not in her room."
"23 (with resident's first name)" - MA 4 stated, "She's not in her room, probably she's in the dining room."

During an interview on 04/25/24, at 10:13 AM, the Director of Nursing stated, "Pre popping (of medication) is not a good practice. The best practice is to check the resident first before preparing for the medication because sometimes they will refuse and if they refused and you already did the prep then the meds needs to be wasted."

Review of facility policy titled, "Administering Medications" dated April 2019 indicated, "Medications are administered in a safe and timely manner, and as prescribed." Further review of the policy indicated, "5.    
Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan...20. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be "flagged." After completing the medication pass, the nurse will return to the missed resident to administer the medication. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose..."

Based on interview and record review, the facility failed to provide the care and services, that were resident centered, in accordance with the professional standards of practice to meet each resident's needs, for 1 of 5 sampled resident (R) (R10) reviewed for unnecessary medication use. The facility failed to ensure R10's bowel care was provided in accordance with physician's orders. This failure increased the resident's risk for unmet care needs, bowel impaction, and discomfort from constipation.

Findings include:

Review of Resident 10's (R10) record indicated the facility admitted the resident in November 2023 with diagnoses including depression, diabetes, and dementia. R10's Minimum Data Set (MDS-assessment tool) dated 3/24/24 documented resident's brief interview for mental status was 13, indicating resident was cognitively intact.

During an interview on 4/22/24 at 2:05 PM with R10 and R10's family member, both stated that resident had issues with constipation.

Review of current physician orders documented the following:
*Milk of Magnesia Oral Suspension 400 MG/5ML (Magnesium Hydroxide) **DAW**(Dispense as written) Give 30 ml by mouth as needed for constipation Give on day 3 of no BM (bowel movement) evening shift. Document results. Start date 11/29/23.
*Bisacodyl Rectal Suppository (Bisacodyl) **DAW** Insert 10 mg rectally as needed for constipation. Administer on day three of no BM evening shift after giving milk of magnesium without BM per house protocol. Start date 11/29/23.
*Enema Rectal Enema (Sodium Phosphates) **DAW** Insert 1 dose rectally as needed for Constipation. empty contents of 1 tap water enema per rectum if no results from bisacodyl per bowel protocol. Start date 11/30/23.

Record review of R10's bowel (Point Click Care POC (point of care) response history, size of BM) from admission date to April 23, 2024, Medication Administration Records for February, March, and April 2024 and progress notes from February 1, 2024 to April 23, 2024 documented:
*No BM on 2/4/24, 2/5/24, 2/6/24 and 2/7/24 (4 days). MOM should have been given on 2/6/24 but wasn't.
*No BM on 2/24/24, 2/25/24, 2/26/24, 2/27/24, 2/28/24, 2/29/24, 3/1/24 (7 days). MOM was given on 2/27/24 and 2/28/24 but was ineffective. Suppository should have been given on 2/29/24 but wasn't.
*No BM 4/3/24, 4/4/24, 4/5/24, 4/6/24, 4/7/24 and 4/8/24 (6 days). MOM was given on 4/6/24 and documented as ineffective. Suppository should have been given on 4/7/24 but wasn't.

During an interview on 4/24/24 between 3:00 PM and 3:30 PM Director of Nurses (DON) stated that R10's physician orders are to given MOM if no BM for 3 days, then suppository if MOM ineffective, then enema if suppository ineffective. When informed of above findings, DON stated that physician's orders should be followed and MOM, suppository or enema should be given as ordered if there is no BM for the three days or if MOM or suppository is ineffective. DON confirmed the Point Click Care tasks "POC (point of care) response history, size of BM" is where staff document resident's bowel movements and would review findings and provide any further information if found. DON confirmed that R10 received opioids and antidepressant medications in which constipation was an adverse side effect.

During an interview on 4/26/24 at 11:58 AM DON stated that she did not have any further documentation to provide to surveyor.

Facility's bowel management protocol was requested but document did not outline bowel regimen or house protocol.

Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled resident (R) (R9) reviewed for pressure injuries received treatment and services consistent with professional standards of practice to promote wound healing when physician orders for pressure injury care was not followed. This failure increased resident's risk for delayed healing and/or having pressure ulcer worsen with its associated complications of pain and infection.

Findings include:


Review of Resident 9's (R9) record indicated the facility admitted the resident in November 2023 with diagnoses including depression, diabetes, and dementia. R9's Minimum Data Set (MDS-assessment tool) dated 2/11/24 documented resident's brief interview for mental status was 10, indicating moderate cognitive impairment.

During concurrent observation and interview on 4/22/24 at 2:36 PM a large dressing was observed on R9's right hip. Licensed Nurse (LN)1 stated R9 was admitted with a large pressure ulcer on her right hip with about 4 to 5 centimeters (cm) of tunneling. (Tunneling is a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound). LN1 stated that the dressing was changed earlier in the day because resident had a lot of drainage.

During concurrent observation and interview on 4/24/24 at 9:22 AM Certified Nursing Assistant (CNA) 6 provided incontinence care to R9. CNA6 stated that resident's right hip dressing was wet a bit and would inform nurse as dressing might need to be changed.

Review of R9's current physician orders documented "Dressing to right thigh/hip. Change BID (twice daily) and prn (pro re nata, as needed) for soiling. as needed." Start date 3/5/24.
1) Cleanse area with wound cleanser and pat dry.
2) Pack with calcium alginate then apply 2 layers of alginate over wound. (Alginate dressings are highly absorptive, non-occlusive dressings made of soft, non-woven calcium alginate fibers derived from brown seaweed or kelp. Alginates provide a moist wound environment and can prevent microbial contamination. They are especially effective for managing heavily draining wounds).
3) Skin prep peri wound. (Apply skin prep on the edges of the wound).
4) Apply a large absorbent dressing.

Observation on 4/24/24 at 1:00 PM showed LN1, with two student nurses present, removing resident's right hip dressing. The dressing was observed with a large amount of drainage. With sterile gloves, LN1 placed a cotton tip covered long stick into the right hip wound and stated that it was 4 cm deep. After measuring the tunneling depth, LN1 held a 1.5 inch by 6 inch strip of calcium alginate at the wound's tunnel entrance and slowly packed the strip into the wound tunnel using the cotton tip covered stick, the strip was advanced into the wound tunnel with a 3 to 4 cm length of calcium alginate extending out of the wound tunnel. LN1 then applied skin prep around the outside edges of the wound and then placed a large dressing over the wound and removed her gloves.

During an interview on 4/24/24 at about 1:1 PM when asked about the physician orders to apply two layers of alginate over the wound, LN1 stated that that is why she left the strip or tail of calcium alginate extending outside the wound tunnel instead of packing all inside the wound tunnel.

During an interview on 4/25/24 at 1:30 PM LN1 stated that she completed R9's dressing change that morning already because there was drainage so dressing needed to be changed earlier. When asked about dressing change process, LN1 stated that she cut the calcium alginate the same as yesterday's wound care leaving a small tail or strip of calcium alginate sticking out of the wound and then covered the wound with the large dressing.

Review of record from ordering nurse practitioner provider (NPP), dated 1/23/24, documented "Order change: cleanse, pat dry, pack with calcium alginate then apply 2 layers of alginate over wound and apply large absorbent dressing bid, hopefully the extra alginate will absorb the dressing. Wound draining quite a bit however the periwound (skin surrounding wound) is intact and no signs of maceration, which is reassuring. Asked nursing to use more calcium alginate to absorb drainage ...."

During an interview with Resident Care Manager (RCM) and Director of Nursing (DON) on 4/25/24 at 3:00 PM RCM stated that she discussed wound care dressing changes with NPP and "after packing wound with calcium alginate, apply 2 layers of alginate over wound" meant that nurses should fold the alginate strip at the wound tunnel entrance before applying the absorbent dressing or cut a small square piece of alginate and place this piece over the wound tunnel entrance so wound is covered with two layers of alginate. When informed of observation and interview with LN1, RCM and DON shook their heads and stated that the dressing change was not completed in accordance with physician's orders.

During an interview with DON and LN1 on 4/25/24 at 3:20 PM, LN1 recalled the dressing change steps which included packing wound with calcium alginate and leaving a small tail of alginate extending from wound tunnel. When asked if she applied two layers of alginate over the wound, LN1 stated "no, I didn't do that."

Facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised date April 2018, documented "the nursing staff and practitioner will assess and document an individual's significant risk factors ...in addition, the nurse shall describe and document/report current treatments."

Based on interview, record review, and review of facility policy, the facility failed to ensure resident received adequate supervision and proper use of wheelchair. In addition, facility failed to complete a thorough investigation to ensure accident hazards and risks were identified, evaluated, and analyzed and failed to develop and implement interventions when one resident (Resident (R) 19) out of two residents reviewed for accidents suffered a fractured femur after her foot was stuck under her wheelchair when staff was wheeling her to the dining room. This failure resulted in harm to resident who suffered from pain, further immobility from leg casting, and emergency room visit and xrays as a result of facility's failures.

Findings include:

Review of the facility policy titled "Accidents and Incidents-Investigating and Reporting," dated 07/2017 indicated " ... The nurse supervisor/charge nurse and/or department director shall promptly initiate and document investigation of the incident by the following data: The date and time the accident/incident took place; The nature of the injury; The circumstances surrounding the incident; Where the incident took place; Names of witnesses and their account of the incident; The injured persons account of incident; The time attending physician notified and family; The condition of the injured person that includes vital signs; Any corrective action taken; Follow-up information and the signature and title of the person completing the report."

Review of R19's electronic medical record (EMR) "Profile" located under the "Profile" tab indicated the resident was admitted to the facility on 10/11/21 with diagnoses of stroke affecting the right dominant side (weakness of right arm and right leg) and dementia.

Review of R19's quarterly "Minimum Data Set (MDS)" located in the EMR under the "MDS" tab with an Assessment Reference Date (ARD) of 04/17/23 documented resident had a cerebrovascular accident (CVA) with hemiplegia or hemiparesis (weakness or inability to move one side of the body), had lower extremity impairment on one side, and required two person physical assist and was totally dependent on staff for transfer (who resident moves between surfaces including to or from bed, chair, wheelchair). In addition, R19's "Brief Interview for Mental Status (BIMS)" score of 9 out of 15 which indicated the resident was moderately cognitively impaired.

Review of R19's care plan, last reviewed/revised date 5/11/23, documented "transfers: dependent, two person assistance with hoyer lift"( a machine used to lift and transfer a person with a minimum of physical effort.

Review of an "Event Report" provided by the facility dated 06/01/23 revealed, "R19's foot and leg jumped off the leg rest and got stuck under the wheelchair after being transferred to the wheelchair by the Hoyer lift from her bed. Resident complained of pain in her knee and was put back to bed."

Review of the "Hospital Report" provided by the facility dated 06/02/23, revealed R19 was transported to the hospital emergency department with a right knee injury. The symptoms included pain and swelling and past right total knee replacement. X-rays revealed a periprosthetic fracture at the distal femoral meta-epiphysis at the medial and lateral femoral condyle with lateral displacement (a broken femur, thigh bone, that occurs around the knee implant). Surgery was not considered since R19 does not walk due to a stroke affecting the right side of her body.

Review of Nurse Practitioner provider note, dated 6/19/23, documented resident was hospitalized for left hemispheric stroke and associated hemiparesis and dysphagia. She is being seen for follow up for right distal femur fracture. "The injury occurred on 6/1/23 when her leg slipped off the footrest and caused her a lot of pain. She was sent to the ER (emergency room) on 6/2/23 when pain worsened, and she was found to have a R(ight) distal femur fracture. She is using PRN (pro re nata, as needed) Oxycodone 2.5 mg 1-3 times daily since return ...usually charted as effective, and once charted as "somewhat effective." Refill request received today .....Her RLE (right lower extremity) is casted to above the need (sp. knee) ..."

During a phone interview on 04/26/24 with Certified Nursing Assistant (CNA) 6 at 8:42 AM revealed "I and another aid [he cannot remember their name] was transferring [R19] using the Hoyer lift from the bed to her wheelchair. The other aide left the room after transfer. I was wheeling [R19] to the dining room when we went over the threshold of her doorway and heading down the hallway, [R19] started yelling and I realized that her right foot was under the wheelchair. I brought [R19] back to her room and she was put back to bed. Her foot fell off the footrest of the wheelchair."

During an interview with the Director of Nursing (DON) on 04/26/24 at 11:02 AM stated, "This was not a thorough investigation. It did not have names, times, interviews. The "Care Plan" did not reflect the incident or have updates. I was not working at this facility at the time of the incident."

During an interview with the Administrator on 04/26/24 at 12:30 PM stated, "A complete assessment and investigation should have been completed for this incident."

During an interview on 5/3/24 at 11:39 AM DON stated it was basic care for staff to ensure that the arms or legs of resident are properly secured and positioned in a comfortable and safe manner, especially for residents with weakness in their arms or legs, when residents are in seated or using their wheelchair. When asked about process steps for transferring residents from bed to chair, DON stated that staff should review the care plan to determine the resident's ability and then follow the care plan. If the resident required a mechanical lift then two staff would provide assistance from transfer from bed to chair. After resident is seated in the wheelchair, staff should ensure the resident is positioned comfortably and ensure their arms and legs are situated and positioned safely, ensure the resident's feet are placed securely on the footrest before unlocking the wheelchair brakes and moving the wheelchair. DON stated that she will provide resident care plan regarding resident's transfer status at the time of 6/1/23 incident and facility's policy on resident transfers to wheelchair.

Review of email from Medical Records Director, dated 5/3/24 at 12:04 PM, documented the facility did not have a policy on resident transfers to wheelchair.

Review of the American Academy of Orthopaedic Surgeons OrthoInfo documented "Periprosthetic femur fractures are most often the result of a fall. These fractures can also be caused by a higher energy force, such as a direct blow to the side of the hip or motor vehicle collision."
,

Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled residents (R) (R22) reviewed for urinary catheter received treatment and services consistent with professional standards of practice for urinary catheterization when staff did not use lidocaine jelly (local pain reliever) when inserting urinary catheter in accordance with physician's orders. This failure caused the resident pain during catheterization.

Findings include:

Review of Resident 22's (R22) record indicated the facility admitted the resident in November 2023 with diagnoses including depression, diabetes, and dementia. R22's Minimum Data Set (MDS-assessment tool) dated 2/11/24 documented resident's brief interview for mental status was 10, indicating moderate cognitive impairment.

Review of R22's physician orders documented:
*Straight cath(eterization) every six hours prn (pro re nata, as needed) no void (no urination) or pt (patient)request. Use Urojet lidocaine (local pain reliever) with straight cath if available. Start Date was 4/2/24. Discontinuation date was 4/11/24.
(straight catheterization is a procedure where a straight flexible tube is inserted into the urethra opening on the penis to allow urine to drain from the bladder for collection).
*Straight cath every six hours PRN no void or pt request every 8 hours for urine retention. Start Date was 4/11/24. Discontinuation date was 4/11/24.
*Straight cath every 8 hours routinely. Estimate urine volume and chart in electronic health record. Please use lidocaine 2% (local pain reliever) gel on catheter tip when doing catheterizations. Start date was 4/12/24. No end date as this was current order.


During an interview on 4/22/24 at 3:49 PM R22 stated that staff have been doing straight caths every eight hours when he asks for it. R22 further stated that he previously had an indwelling catheter (a flexible tube inserted to the bladder to drain urine) for six months to a year but the indwelling catheter was removed and now his bladder muscle is weak so he can't squeeze the urine out as well.

Observation on 4/26/24 at 9:13 AM showed Licensed Nurse (LN)2 with gloved hands opening package of 16 french (16.76 millimeter circumference, 5.33 millimeter outer diameter) urinary catheter, package of lubricating jelly and three betadine swabs onto sterile drape on overbed table while reside laid in bed. LN2 wiped the tip of R22's penis with three large betadine swabs and then placed the tip of the urinary catheter in the mound of lubricating jelly. Some lubricating jelly was observed on the catheter tip. When LN2 inserted the urinary catheter in R22's penis, R22 visibly moved his body away from LN2, grimaced and said "ow, ow, that hurts!" in a loud voice. Urine was observed in the urinary catheter tubing. LN2 asked R22 about his pain. R22 stated that he didn't have much pain until LN2 inserted the urinary catheter. The urinary catheter was in place for a couple of minutes while LN2 pressed her hand on R22's suprapubic area below his belly button. R22 further stated that he had not been in pain until LN2 put in the catheter "that hurt when she put the catheter in."

During an interview on 4/26/24 at 9:30 AM LN2 stated that she had straight cath R22 before and today was similar to previous times. When asked about R22's pain associated with straight caths, LN2 stated that "we are supposed to use 2% lido jelly, but we don't have that right now" and futher stated that lidocaine jelly was present 3 days ago when LN2 last worked. LN2 opened the drawers of the treatment cart and stated that she will contact the satellite pharmacy for lidocaine jelly.

During an interview on 4/26/24 at 9:32 AM Certified Medication Aide (CMA)1 stated that she didn't have lidocaine jelly in her cart as it wasn't an item that would be in her cart.

During an interview on 4/26/24 at 9:34 AM LN2 showed surveyor multiple packages of 2% lidocaine jelly. LN2 stated that the facility had 2% lidocaine jelly and pointed to the bottom drawer of the treatment cart stating that it was right here in the cart under the urinary catheter packages but it was a different type of urinary catheter that she did not like to use and did not use on R22 that morning.

During an interview on 4/26/24 at 11:43 AM Director of Nursing (DON) stated that she asked R22's provider for the lidocaine jelly order to help resident during urinary catheterizations. DON stated that LN2 should have used the lidocaine gel to help reduce R22's pain and should be following physician's orders especially since LN2 knew about the lidocaine order and the lidocaine jelly was available in the treatment cart.

Facility policy Catheterization, Intermittent, Male Resident, revised date October 2010, documented under Preparation section "1. Verify that there is a physician's order for this procedure, 3. Assemble the equipment and supplies as needed."

Facility policy Indwelling (Foley) Catheterization Insertion, Male Resident, revised date August 2022, documented "Catheterization of a male resident can be complicated due to the length of the urethra (18-20 cm) (centimeters). Under Preparation section "9. Assemble the equipment and supplies as needed." Under Equipment and Supplies section " ...3. Lidocaine 2% gel, if ordered."

Based on interview and record review, the facility failed to ensure staff had mandatory training, appropriate competencies and skills set necessary to provide nursing services for three of three reviewed contract staff (or Agency staff).

This failure placed residents at risk of not receiving appropriate services to meet their needs.

Findings:

During an interview on 04/25/24, at 10:32 AM, the Director of Nursing (DON) stated that the facility is utilizing Agency staff (contract staff) because "It's hard to find a staff in areas like here." The DON added, "It is my understanding that they (agency) take their (staff) competency and knowledge." The DON explained, "For agency staff orientation, typically they are oriented to the building, where things are stored and setting up of password by Business office person."

On 04/25/24, at 02:20 PM employee file of Medication Aide (MA) 3 and MA 4 was requested from Business Office Manager (BOM) for review. The BOM stated she will reach out to the staffing agency to request the file. At 02:24 PM, BOM provided copy of certification for Nursing Assistant and Medical Aide for MA 3 and MA 4. According to BOM, the agency informed her that there is no in-service training record on file for MA 3 and MA 4.

On 04/26/24, at 10:53 AM, employee file of Certified Nursing Assistant (CNA) 22 was requested. BOM stated CNA 22 is from a different staffing agency. According to BOM, she sent an email to the agency to find out the training records of CNA 22.

On 04/26/24, at 11:57 AM, BOM confirmed that staffing agencies does not provide continuing education for the agency staff.

On 04/26/24, at 12:17 AM, BOM forwarded through email the copy of certificates for CNA 22.
The certificate were as follows:
75 hrs DSHS (Department of Social and Health Services) Approved Basic Training dated 11/30/2020;
Core Basic Training dated 11/19/2020;
CPR (Cardiopulmonary Resuscitation) First Aid card with expiration date of 11/09/2022
Nurse Delegation Core dated 12/17/2020 and
Nursing Assistant Training Program dated 10/15/2021.

Review of facility policy titled, "In-Service Training, All Staff", dated August 2022 indicated, "...3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training...Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (I) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and
(3) dementia management and resident abuse prevention...Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment...8. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and the hours of training completed."

Based on interview and record review, the facility failed to provide required Registered Nurse (RN) coverage on six of 31 days in October 2023 and six days of 30 days in November 2023.

This failure placed residents at risk for a lack of RN assessment which could result in a delay in identification and response to change in medical conditions.

Findings:

Review of facility's Direct Care Staff Daily Report for October and November 2023 revealed that there is no RN on duty of the following days: 10/1/23, 10/14/23, 10/15/23, 10/22/23, 10/28/23, 10/29/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, and 11/26/23.

During an interview on 04/26/24, at 08:57 AM, the Direct Care Staff Daily Report for October and November 2023 was reviewed with the Business Office Manager (BOM). The BOM confirmed that there is no RN on duty on 10/1/23, 10/14/23, 10/15/23, 10/22/23, 10/28/23, 10/29/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, and 11/26/23 and stated, "Yes, It's possible that there is no RN on those days."

Based on observation, interview and record review, the facility failed to identify, monitor, and evaluate individualized expressions of depression for 2 of 5 residents (R10 and R6) reviewed for unnecessary medication use. These failures increased the potential of not providing the correct data to the prescriber and represented an incomplete evaluation to determine the ongoing use and need for psychotropic antidepressant medications and increased the residents' risk for receiving unnecessary medications with its associated side effects and complications.

Findings include:

Facility policy Psychotropic Medication Use, dated July 2022, documented anti-depressants were considered psychotropic medications. "Psychotropic medication management includes ....d. adequate monitoring for efficacy and adverse consequences ....8. Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes."

Resident 10

Review of Resident 10's (R10) record indicated the facility admitted the resident in November 2023 with diagnoses including depression, diabetes, and dementia. R10's Minimum Data Set (MDS-assessment tool) dated 3/24/24 documented resident's brief interview for mental status was 13, indicating resident was cognitively intact.

Review of R10's current physician orders documented Citalopram Hydrobromide (Celexa, antidepressant) Oral Tablet 20 MG **DAW** ** (Dispense as written) Give 20 mg by mouth one time a day for Depression. Start date 12/13/23.

Review of R10's current Medication Administration Record, Treatment Administration Record, Progress Notes, Point of Care (POC) Response History of Behaviors since 12/28/23 to 4/24/26 showed resident did not exhibit any of the listed behaviors. The listed behaviors were physical behaviors directed at others (grabbing others, hitting others, kicking others, pushing others, physically aggressive towards others, scratching others), verbal behaviors directed at others (accusing of others, cursing at others, express frustration/anger at others, screaming at others, threatening others), socially inappropriate behaviors (disruptive sounds, disrobing in public, entering other resident's rooms/personal space, public sexual acts, repetitive motions rummaging, spitting, throwing/smearing food, throwing/smearing bodily waste), other behaviors not directed at others (agitated, anxious, restless, delusions, elopement/exit seeking, hallucinations, hitting, hoarding, insomnia, not sleeping, neglecting self care, pacing, panic, picking at self, refusing care, sad/tearful, scratching self, screaming not at other, self injury, wandering, withdrawing/isolating. The behaviors outlined in the Behavior Monitoring was not resident-centered, individualized or specific to the resident.

During an interview on 4/24/24 at 9:46 AM R10 was sitting in wheelchair in room. Resident stated that Celexa antidepressant did not sound familiar to her but stated that she did take an anti-depressant. When asked how someone would know she's depressed, R10 stated that sometimes she gets depressed and this occurs when she is worried about her family and she would tell others that she is worried and thinking about things or if she can't sleep because she is thinking about things. R10 stated that last night she woke up thinking it was time to get up but it was only midnight. It was quiet and she had too much time to think and worry and that's when she blows things out of proportion.

During an interview on 4/25/24 at 1:33 PM Certified Medication Aide (CMA)1 stated that she knew R10 well and she knows resident is depressed when she just stays in bed and doesn't want to go to activities

During an interview 4/24/24 at 2:41 PM Director of Nursing (DON) stated that when R10 first came to the facility, resident was tearful. When asked how R10 expressed depressive behavior, DON stated that it was tearfulness and social isolation and if these behaviors are seen, then medications are adjusted. DON stated that behavior monitoring is documented in progress notes. When informed of POC behavior monitoring listing physical and verbal behaviors directed at others and progress notes do not reflect monitoring of behaviors that identifies resident's individualized behavior or expression of depression and resident's statements about how she expresses depression and staff perceptions are different and is not being monitored or tracked. DON nodded head and stated "I understand what you are saying." DON stated that facility had not identified R10's specific behaviors or monitored these behaviors.
, Resident 6

1. Review of R6's Facesheet indicated R6 was admitted on 09/15/23, with diagnoses including major depressive disorder (mood disorder that causes a persistent feeling of sadness) and anxiety (a feeling of fear, dread, and uneasiness).

During an interview on 04/23/24, at 03:26 PM, Licensed Practical Nurse (LPN) 1 stated, R6 will become "agitated of certain staff" and will start "yelling and cussing and sudden outburst and being angry." LPN 1 further explained R6 manifestation of depression when "he is not eating or taking snack. He's depress if he's not talking to his favorite staff."

Review of R6's Order Summary Report indicated an order for the following anti-depressant medications with a start date of 12/04/23:
Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 75 MG to 225 mg by mouth one time a day related to Major Depressive Disorder and Anxiety Disorder and
Wellbutrin SR Oral Tablet Extended Release 12 Hour 150 MG (Bupropion HCl) to give 1 tablet by mouth every morning and at bedtime related to related to Major Depressive Disorder and Anxiety Disorder.

Review of R6's Medication Administration Record (MAR) for April 2024 indicated, "Monitor for effectiveness of psychotropic medication administration. Progress note behaviors Qshift [every shift] every day and night shift" with a start date of "02/16/2024 [at] 2200 [10 PM]."

Review of R6's care plan for the use of Psychotropics (medications that affect behavior, mood, thoughts, or perception) initiated on 12/05/23 indicated, "PSYCHOTROPIC: [R6] is on antidepressant medication Venlafaxine HCl and Wellbutrin SR r/t [related to] DX [diagnosis] for major depressive disorder" With the following Interventions: "Document in POC (Point of Care) and or PN (progress notes), identified behaviors and interventions as they occur. Give psychotropic meds per order. Gradual dose reductions as recommended. Notify responsible party and PCP (Primary Care Physicia) with any changes or recommendations. Monitor for effectiveness and monitor for adverse side effects including however not limited to: drowsiness, headache, lightheadedness, nausea, vomiting, constipation, rash, itchiness, SOB (shortness of breath), chewing movements, puckering of the mouth, loss of coordination, muscle tremors, jerking movements and stiffness, rocking movements, dry mouth, and runny nose. Report to MD adverse side effects. PHQ-9 [questionaire for depressive symptoms] as needed. Refer to psychiatrist/counselor as needed. Will be monitored at Psychotropic meeting quarterly and PRN (pro re nata, as needed)."

During an interview on 04/23/24, at 04:30 PM, R6's order summary, MAR and care plan were reviewed with the Director of Nursing (DON). The DON acknowledged that specific target behaviors for the use of antidepressants were not identified, monitored and evaluated. The DON further stated,
"It has to be specific (referring to resident's behavior). The staff should monitor specific behavior or specific manifestation."

Based on observation, interview, and record review, the facility failed to ensure that medication administration was free of medication error rate of 5% of greater. Three medication administration errors were identified out of 26 opportunities during medication administration observation on 4/24/24.

This failure has the potential for resident discomfort or jeopardize the resident's health and safety.

Findings:

1. During medication administration observation 04/24/24, at 08:20 AM, Medication Aide (MA) 4 was observed administering the medications to Resident (R)13. MA 4 administered one tablet of Metformin HCl (hydrocloride) 500 mg (milligram) to R13. Metformin HCL is a drug used to control high blood sugar.

Review of R13's medication order summary indicated an order for "Metformin HCl Oral Tablet 500 MG" to give "1000 mg by mouth two times a day."

2. During medication administration observation 04/24/24, at 08:27 AM, MA 4 was observed administering the medications to R24. MA 4 administered two tablets of Potassium Chloride (KCl) ER (extended released) 20 meq (milliequivalent). MA 4 also administered other medications (a total of 12 tablets) to R24 with water in a "5 OZ" (five ounces) plastic cup.

Review of R24 medication order, dated 12/04/23 indicated, "Potassium Chloride ER Oral Tablet Extended Release 20 MEQ" to "Give 2 tablet by mouth two times a day for Potassium Replacement."

Review of Pharmacy Consultant "Clinical Review" documentation dated 04/24/24 indicated, "Potassium Chloride does not have to be administered with food. Administering with fluids is more important to dilute the KCl so that the stomach doesn't pull fluids to dilute it itself and cause a stomach ache. For patient's who do experience stomach aches when receiving KCl, taking with food and water can decrease the stomach issue."

According to the National Institute of Health (NIH) DailyMeds article for "LABEL: POTASSIUM CHLORIDE tablet, extended release" updated on 02/19/21, "Potassium Chloride Extended-release Tablets, USP is indicated for the treatment and prophylaxis of hypokalemia with or without metabolic alkalosis [when stomach acid is decreased or certain electrolyte levels drop] , in patients for whom dietary management with potassium-rich foods or diuretic dose reduction is insufficient...Take Potassium Chloride Extended-release Tablets, USP with meals and with a glass of water or other liquid. Do not take Potassium Chloride Extended-release Tablets, USP on an empty stomach because of its potential for gastric irritation."

According to Mayo Clinic instruction for Proper Use of Potassium Supplement retrieved from https://www.mayoclinic.org/drugs-supplements/potassium-supplement-oral on 05/02/24, "...For patients taking the extended-release tablet form of this medicine: Swallow the tablets whole with a full (8-ounce) glass of water. Do not chew or suck on the tablet. Some tablets may be broken or crushed and sprinkled on applesauce or other soft food. However, check with your doctor or pharmacist first, since this should not be done for most tablets. If you have trouble swallowing tablets or if they seem to stick in your throat, check with your doctor. When this medicine is not properly released, it can cause irritation that may lead to ulcers..."

3. On 04/24/24 at 11:15 AM, MA 4 stated she will give Protonix (used to treat heartburn) and Glipizide (used to treat high blood sugar) to R24. MA 4 explained, she did not see where the medications were kept that is why she was not able to give it "earlier" to R 24. At 11:17 AM, MA 4 administered one tablet of Protonix 20 mg and one tablet of Glipizide 5 mg to R24.

Review of R24's Medication Administration Record (MAR) indicated, "glipizide Oral Tablet 5 MG Give 1 tablet by mouth two times a day" and to "Give 30 minutes before meals" The MAR indicated a scheduled time to administer the medication, at "07:30 [AM]" and at "1700 [5 PM]"

During an interview with the Director of Nursing (DON) on 04/25/24 at 09:54 AM, the medication administration observation was discussed. The DON verbalized the importance of "giving the right medication" and "as scheduled." The DON also stated that MA 4 is an agency staff and she will provide an in-service to all Medication Aide staff.

Review of facility policy titled, "Medication Administration Schedule" dated, November 2020 indicated, "...4. Scheduled medications designated as time-critical (medications that may cause harm or sub-therapeutic effect if administered before or after the scheduled time) are administered at the scheduled time (for example, rapid-acting insulin) or within 30 minutes of the scheduled time.
5. Time critical medications are designated by the pharmacy and include:
a. medications that are scheduled more than every four hours;
b. scheduled opioids used for chronic pain or palliative care;
c. immunosuppressive agents used for organ transplant rejection or to treat myasthenia gravis;
d. medications that need to be administered apart from other medications; and
e. medications that need to be administered before, with, or after meals..."

Review of facility policy titled, "Administering Medications" dated April 2019 indicated, "4. Medications are administered in accordance with prescriber orders, including any required time frame...10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication..."

Review of facility policy titled, "Adverse Consequences and Medication Errors" dated April 2014 indicated, "5.  
A "medication error" is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medications errors include:
a. omission - a drug is ordered but not administered;
b. unauthorized drug- a drug is administered without a physician's order;
c. wrong dose (e.g., Dilan/in 12 ml ordered, Dilan/in 2 ml given);
d. wrong route of administration (e.g., ear drops given in eye);
e. wrong dosage form (e.g., liquid ordered, capsule given);
f. wrong drug (e.g., vibramycin ordered, vancomycin given);
g. wrong time; and/or
h. failure to follow manufacturer instructions and/or accepted professional standards (e.g., failure to
shake medication that is labeled "shake well," crushing a medication on the "do not crush list" without an order)..."

Based on interview, the facility failed to ensure the Dietary Manager (DM) who was designated to act as the Director of Food and Nutrition Services was qualified to be the DM. This had the potential to affect 32 of 32 residents in the facility who consumed food from the kitchen.

Findings include:

During an interview on 04/22/24 at 1:15 PM with the DM revealed "The last DM left almost a month ago and I just accepted the position of DM. I do not have any formal training, but I have signed-up to take the Certified Dietary Manager (CDM) classes."

Interview with the Administrator on 04/23/24 at 12:36 PM revealed "We just promoted our cook to DM, and he was willing to take the CDM classes. Our dietician is only in the facility once a month. I will make sure that the DM finishes his course, and we get back on track."

Based on observation, interview, and sample of a test tray, the facility failed to ensure food was at an appetizing temperature when being served to the residents. This had the potential to affect all 32 residents who consumed food from the kitchen.

Findings include:

During an interview on 04/22/24 at 3:56 PM, Resident (R)16 stated, "The food is cold. Half the time I do not eat it."

During an interview on 04/22/24 at 4:10 PM, R24 stated, "The food is cold and not good. Who wants to eat cold food that is hard?"

During the Resident Council Meeting held on 04/24/24 at 10:45 AM the 11 residents in attendance all agreed that the food was cold whether they eat in the dining room or if they eat in their room.

A test tray was made on 04/25/24 at 12:35 PM that was tasted by Cook 1 and the surveyor. The tray was the last tray made and on the last cart going out to the hall. The cart was noted not to be insulated and was made of metal. The pureed meatballs, mixed vegetables and mashed potatoes were all lukewarm. The spinach casserole was warm, and the pureed vegetables were cold. Cook 1 stated "The pureed vegetables are cold. The only thing that was actually warm was the casserole."

During an interview with the Dietary Manager (DM) on 04/25/24 at 12:49 PM revealed "My expectation for the kitchen is to provide healthier meals that are hot and taste good. Staff has to be trained to do things properly."

During an interview on 04/26/24 at 12:11 PM with the Administrator revealed "We need education in the kitchen and we have a lot of room for improvement."

A request for a policy related to food temperatures was made and none was provided prior to the exit of the survey.

Based on observation, interview, review of facility policy, and review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure pureed food was kept at appropriate temperatures while on the steam table prior to serving to the residents. The facility further failed to ensure all items in the freezer and refrigerator were sealed, labeled or dated, shelving and equipment were kept free from dust and crumbs, and that the dietary staff performed hand hygiene along with wearing a beard cover properly. These failures had the potential to affect all 32 residents in the facility who consumed food from the kitchen.

Findings include:

Interview on 04/26/24 to 12:11 PM with the Administrator revealed "We have to keep a clean kitchen. We need training in the kitchen and for things to be done properly."

Review of the facility's policy titled, "Food Storage," dated 01/2014 revealed, "All products should be dated upon receipt and when they are prepared. Use "use-by-dates" on all food stored in refrigerators ...Any open products should be placed in seamless plastic or glass containers with tight-fitting lids and labeled and dated ..."

Review of the US FDA 2022 Food Code revealed:
- cleaned equipment and utensils shall be stored in a clean, dry location where they are not exposed to splash, dust, or other contamination
- food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils and after touching bare human body parts other than clean hands and clean, exposed portions of arms; after handling soiled equipment or utensils; during food preparation, as often as necessary, to remove soil and contamination and to prevent cross contamination when changing tasks; and after engaging in other activities that contaminate the hands.

1.During an observation and interview on 04/25/24 at 12:05 PM revealed Cook 1 completing the steam table food temperatures. The pureed vegetables temperature was 120 degrees Fahrenheit (F). Cook 1 stated "This should be 135 degrees F and I am putting the pureed vegetables in the oven." At 12:15 PM, the pureed vegetables were put back on the steam table and the temperature was 130 degrees F. Cook 1 confirmed he did not reheat the pureed vegetables to get them above 135 degrees F and proceeded to start plating the lunch trays.

2.During an observation on 04/22/24 at 1:15 PM, the following observations in the kitchen were made with and verified by the Dietary Manager (DM):

The refrigerator contained one bag of cheese that was open to air with no label or date. The refrigerator also contained one bag of ham that was not in its original packaging with no label or date.

The freezer contained one bag of potato tots, broccoli, corn, green beans, chicken nuggets, chicken chimichangas, belgian waffles, bacon strips, sausage links, garlic bread, and cookies that
were all open to air and had no label or date.

There were two metal drying racks with dust and crumbs collected on them that contained kitchen equipment and pans that were ready for use. The racks were also sticky to the touch.

A stand mixer had dried crumbs on the top of it and yellowish-brown dried stains down the back of the stand.

There was an open box of rice under the counter that was not sealed shut.

The toaster had crumbs all over it from breakfast that had not been cleaned.

A metal container on the counter next to the stove that contained clean serving utensils was visibly dirty with what looked like old grease.

Metal plate covers that had been used to serve the dining room residents were reused for resident room trays before being washed.

Observation of Dietary Aide (DA)1 revealed the DA had a full beard and mustache and only had half of his beard covered and did not have his mustache covered. When questioned, he stated "I did not know that I had to have it all covered. I thought only the part that hung down." DA 1 also did not change his gloves or wash his hands between preparing trays, going in and out of the refrigerator and taking carts to the halls.

Interview with the DM on 04/25/24 at 12:49 PM revealed "I expect the staff to be trained to do things properly. We need to keep a cleaner kitchen."

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program (IPCP) to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection as evidenced by:

1.The facility failed to ensure the EBP (Enhanced Barrier Precautions) was practiced for 1 of 1 resident (R) (R3) in the facility with an enteral feeding tube as observed during R3's incontinence care, linen change and care of feeding tube and for 1 of 1 resident (R9) in the facility with pressure injury as observed during 1 of 1 wound care observation.

2. The facility failed to change gloves and perform hand hygiene to prevent cross contamination during 2 of 2 incontinence care observations (R3 and R9).

3. Staff did not perform hand hygiene in between resident task and changing of glove during medication administration.

These failures increased the risk for the spread of infection and its associated discomfort and decline in physical condition.

Findings include:

1. Review of the CMS's Quality Safety Oversight (QSO)-24-08-NH Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24 and effective 4/1/24, showed "Enhanced Barrier Precautions" (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The QSO further showed EBP recommendations now include use of EBP for the residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

Resident 3

Review of Resident 3's (R3) record indicated the facility admitted the resident in January 2022 with diagnoses including cerebral infarction (stroke) and chronic obstructive pulmonary disease (lung disease making it difficult to breathe). R3's Minimum Data Set (MDS-assessment tool) dated 2/1/24 documented resident's brief interview for mental status was 14, indicating no cognitive impairment. R3's current physician's orders documented resident had a percutaneous endoscopic gastrostomy (PEG) tube (a flexible tube surgically inserted into the abdomen to stomach for feeding and medication administration).

Observation on 4/23/24 at 8:49 AM showed Certified Nursing Assistant (CNA)12 providing incontinence care to R3. R3's room had no transmission precautions signage on door or isolation cart outside room. CNA12 donned (put on) gloves but did not don a gown. CNA12 stood next to R3's bed with CNA's scrub pants touching resident's bed linens. CNA12 opened resident's briefs and wiped resident's front private area, rolled resident towards the window and wiped resident's buttocks area. CNA12 rolled resident's wet briefs under resident's hips. Without changing gloves, CNA12 touched and placed a clean brief under resident and then rolled resident onto his back and then doffed (removed) gloves.

Observation on 4/23/24 at 8:57 AM showed Licensed Nurse (LN)1 enter room and turn off tube feeding machine. LN1 wore gloves but no gown. LN1 then disconnected gastrostomy tube (GT) connecting resident from the tube feeding machine.

Observation on 4/23/24 at 8:58 AM showed CNA12 and CNA6 in R3's room. Both CNAs wore gloves but no gowns. CNA12 dressed resident with CNA12's pants observed touching resident's bed linens. R3 stated that he needed another brief change. CNA12 opened brief while resident laid in bed on his back, and wiped resident's front private area and then rolled resident on his side facing the wall. Using the same gloved hands, CNA12 touched and placed new clean brief under resident and wiped resident's buttocks and then turned resident onto his back and fastened briefs. CNA12 completed dressing resident, including putting on resident's shoes. CNA6 placed gait belt around resident's upper chest while resident sat on the edge of the bed. CNA6 held onto gait belt while resident held onto transfer pole and CNA12 stood in front of the resident guiding resident to the wheelchair. While resident was seated in wheelchair, CNA6 lifted and repositioned resident in the chair, CNA12 changed resident's shirt, removed his oxygen tubing from his nose. Resident's abdomen was observed with gastrostomy feeding tube in place and dressing intact.

During an interview on 4/23/24 at 9:12 AM CNA12 confirmed that she changed R3's briefs twice, changed resident's linens and transferred resident into his chair without wearing a gown. CNA12 confirmed resident's briefs were wet and stated that she changed her gloves once after incontinence care was completed. When asked about touching new clean briefs with same gloves used to wipe resident's private areas of urine and touching dirty soiled briefs, CNA12 nodded her head and stated that she understood she probably shouldn't have touched clean briefs with dirty gloves but that is how she provides incontinence care. When asked about wearing a gown during the above cares, CNA12 stated that a gown is not needed for R3 because resident is not on any precautions and the only resident in the facility that requires staff to use a gown is the R133 who is on contact precautions.

During an observation on 4/23/24 at 2:47 PM Certified Medication Aide (CMA)3 was observed flushing R3's GT. CMA3 stated that she completed administering resident's medications via the GT. CMA3 wore gloves but not a gown. When asked about wearing a gown while performing this task, CMA3 stated that she hasn't worn a gown when providing cares for R3 and asked if she was supposed to.

R9


Review of Resident 9's (R9) record indicated the facility admitted the resident in November 2023 with diagnoses including depression, diabetes, and dementia. R9's Minimum Data Set (MDS-assessment tool) dated 2/11/24 documented resident's brief interview for mental status was 10, indicating moderate cognitive impairment, and resident had one unstageable pressure ulcers/injuries due.

Review of R9's current physician orders documented "Dressing to right thigh/hip. Change BID (twice daily) and prn (pro re nata, as needed) for soiling. as needed." Start date 3/5/24.

Observation on 4/24/24 at 9:11 AM showed CNA6 providing incontinence care to R9. R9's room had no transmission precautions signage on door or isolation cart outside room. CNA6 had gloves on but not a gown. CNA6 rolled resident towards the window and removed resident's briefs. CNA6's pants were observed touching resident's bed linens. CNA6 wiped a small amount of stool from resident and then placed pad under resident's buttocks. Resident was rolled onto her back and CNA6 wiped resident's front private area. CNA6 then doffed gloves and donned new gloves. No hand hygiene was performed between glove changes. CNA6 placed a new clean brief on resident and repositioned resident, pillows and linen as resident stated that her legs hurt. CNA6 repositioned resident several times.

During an interview on 4/24/24 at 9:22 AM CNA6 stated that you need to change gloves when going from dirty to clean tasks. When asked about hand hygiene such as using hand sanitizer after removing dirty gloves and before putting on new gloves, CNA6 shook head no and said that wasn't done and is not usually done unless there is a lot of stool.

Observation on 4/24/24 at 1:00 PM showed Licensed Nurse (LN)1 with two student nurses present removing resident's right hip dressing that was saturated with drainage. With sterile gloves, LN1 placed a cotton tip covered long stick into the right hip wound and stated that it was 4 cm deep. The wound had tunneling. LN1 stated resident was admitted with pressure ulcer that was improving. LN1 was not observed wearing a gown while changing resident's right hip pressure injury dressing.

Review of R9's current physician orders documented "Dressing to right thigh/hip. Change BID (twice daily) and prn (pro re nata, as needed) for soiling. as needed." Start date 3/5/24.

INTERVIEWS

During an interview on 4/23/24 at 3:21 PM Director of Nursing stated that she was also the facility's infection preventionist (DON/IP). DON/IP stated that the facility has not implemented Enhanced Barrier Precautions (EBP) yet as since it was a recommendation and not a requirement. Reviewed QSO-24-08-NH EBP with DON/IP showing 4/1/24 effective date. DON/IP stated that she was not aware EBP was now an infection control requirement and stated that EBP should have been done for residents with feeding tubes and wounds but it has not yet been done.

During an interview on 4/24/24 at 3:23 PM DON/IP when asked about the steps for incontinence care, DON/IP stated staff should perform hand hygiene, don gloves, remove soiled briefs, perform incontinence care, dispose of soiled brief, doff gloves, perform hand hygiene, don gloves, place new brief on. When informed of observations for R3 and R9, DON/IP stated that staff should be changing gloves between dirty and clean tasks and performing hand hygiene between glove changes to prevent cross contamination and acknowledged this was not done.

POLICY

Facility policy Handwashing/Hand Hygiene, dated revised August 2019, documented "This facility considers hand hygiene the primary means to prevent the spread of infections." The policy listed when hand hygiene should be performed including "h. before moving from a contaminated body site to a clean body site during resident care....m. after removing gloves..."

Facility policy Enhanced Barrier Precautions, dated August 2022, documented "Enhanced barrier precautions (EBPs) are used as an infection preveniton and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloes for EBPs include:
a. dressing....c. transferring; d. providing hygiene, e. changing linens; f. chanign briefs...g, device care or use (...feeding tube....); and h. wound care (any skin opening requiring a dressing)...EBPs are indicated....for residents with wounds and/or indwelling medical devices regardless of MDRO colonization..."

, Staff did not perform hand hygiene in between resident task and changing of glove.

On 04/24/24, at 11:48 AM, Licensed Practical Nurse (LPN) 1 was observed checking the blood sugar of R13. LPN 1 don on a pair of glove, did not perform hand hygiene before donning glove and checked the blood sugar. LPN 1 removed the glove and don on a new pair of glove without performing hand hygiene in between changing of gloves.

During medication administration observation on 04/24/24, at 03:10 PM, Medication Aide (MA) 3 entered the room of R6 and hand the medication cap to the resident. R6 took the medication and hand over the medication cap back to MA 3. MA 3 threw the medication cap in the garbage and went out of the resident's room. MA 3 went straight to the medication cart and started to document the medication administration in the computer. MA 3 did not perform hand hygiene. When asked, MA 3 acknowledged not performing hand hygiene and stated, ""Thank you for the reminder" and proceeded to perform hand hygiene using alcohol-based hand rub (ABHR or hand sanitizer).

According to Center for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Setting guidelines retrieved from https://www.cdc.gov/handhygiene/providers, on 04/30/24, "Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis." Under "Glove Use" indicated, "Gloves are not a substitute for hand hygiene.
If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves."

Based on observation, interview and record review, the facility failed to maintain two of two Wrist Blood Pressure (BP) devices used in the facility according to manufacturer's instruction for use (MIFU).

These failure had the potential to affect the functioning of the device which can result in inaccurate blood pressure reading, in addition to ineffective cleaning and disinfection of the device.

Findings:

During an observation on 04/24/24, at 08:20 AM, Medication Aide (MA) 4 checked the blood pressure (BP) of Resident (R) 8 using the wrist BP device. MA 4 did not clean or disinfect the BP device and placed the device on top of the medication cart after use.

During an observation on 04/24/24, at 10:12 AM, MA 4 came out of the room 37 holding the wrist BP device. MA 4 stated, "I haven't clean that yet (referring to the BP device) and placed the device on the top of the medication cart. MA 4 took Super Sani-Cloth purple top wipes (disinfectant wipes) and quickly wiped the BP device using one piece of wipes. Then MA 4 placed the device on top of the medication cart. MA 4 explained that the facility is using Sani-Cloth purple top wipes to clean and disinfect medical devices including the wrist BP device.

During an interview on 04/25/24, at 09:54 AM, the Director of Nursing (DON) stated there were two wrist BP devices in the facility, the "Kroger" (brand of device) and the Sejoy (brand of device) wrist BP device. The Kroger Wrist Blood Pressure Monitor BP3NPI- 3EKRO instruction manual was reviewed with the DON. The manual indicated, "8. Care and maintenance... b) Clean the device with a soft, dry cloth. Do not use gasoline, thinners or similar solvents. Spots on the cuff can be removed carefully with a damp cloth and soapsuds..." The Sejoy wrist BP instruction manual provided by the facility did not include cleaning and maintenance of the device. The DON stated they are not able to find the instructions on how to clean and disinfect SeJoy wrist BP. The DON also added the facility will no longer use wrist BP device.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) received the required dementia care in-service training for five of five CNA staff reviewed.

This failure placed residents with dementia at risk of not receiving appropriate care and services to attain or maintain their highest practicable self.

Findings:

During an interview on 04/25/24, at 10:32 AM, the Director of Nursing (DON) stated that the facility is utilizing Agency staff (contract staff) because "It's hard to find a staff in areas like here." The DON added, "It is my understanding that they (agency) take their (staff) competency and knowledge."

Review of the following employees file and training record revealed no evidence of Dementia care in-service training:
1. CNA 16, facility regular staff;
2. CNA 6, facility regular staff;
3. Medication Aide (MA) 3- CNA, a contract employee from staffing agency;
4. MA 4- CNA, a contract employee from staffing agency and
5. CNA 22, a contract employee from staffing agency.

On 04/25/24, at 02:20 PM, the staffing agency agreement, dated 8/2/23 was reviewed with the Business Office Manager (BOM). The agreement indicated under the Facility Obligation, "f.   
Provision of Equipment. Supplies and Training. Facility will provide Assigned Employees with all equipment, facilities, supplies and training (including HIPAA privacy and security training) reasonably necessary for them to perform their duties hereunder. Facility will train Assigned Employees with regard to all Facility policies and procedures that may be adopted or Implemented from time to time which, In Facility's Judgment, will enable Assigned Employees to successfully perform their specific Job duties..." The BOM stated, she is not aware of the training agreement with the staffing agency.

On 04/25/24, at 03:35 PM, staff training record was reviewed with the DON. The DON confirmed that she had not done a Dementia Care training for the staff including contract staff.

ON 04/26/24, at 11:57 AM, the BOM stated she reached out to the staffing agency to get a copy of the staff training record. BOM confirmed that MA 3, MA 4 and CNA 22 did not have an updated training on their file per the staffing agency.

Review of facility policy titled, "In-Service Training, All Staff", dated August 2022 indicated, "...3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training...Required training topics include the following:
a.      
Effective communication with residents and family (direct care staff);
b.      
Resident rights and responsibilities;
c.      
Preventing abuse, neglect, exploitation, and misappropriation of resident property including:
(I)     
activities that constitute abuse, neglect, exploitation or misappropriation of resident property;
(2)     
procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and
(3)     
dementia management and resident abuse prevention..."

Based on observation, interview and record review it was determined the facility failed to maintain comfortable temperatures, clean resident personal care items and provide a clean resident room for 1 of 1 dining room and 1 of 2 sampled residents (#22) reviewed for environment. The placed residents at risk for unhome like conditions. Findings include:

1. Resident 22 admitted to the facility in 2023 with diagnoses including anxiety and muscle weakness.

a. On 3/3/24 at 2:25 PM Witness 1 (Family) stated Resident 22 informed her that her/his floors were "hardly cleaned" and had stains from the previous week.

On 3/3/24 at 2:50 PM Resident 22 was observed to be in bed. The resident's floor was observed to be dirty with large dried spills and several strands of floss throughout the room. Resident 22 stated the floor "had not been cleaned for a long time."

Review of the February 2024 Resident Council Minutes indicated multiple residents stated their rooms were not cleaned in two weeks.

On 3/5/24 a housekeeping form entitled, "Rooms Cleaned" indicated Resident 22's room was not cleaned from 3/1/24 to 3/5/24.

On 3/5/24 at 9:20 AM Staff 5 (Housekeeping) stated resident rooms were cleaned at a minimum of twice a week. Staff 5 stated cleaning of rooms included sweeping and mopping the floors.

On 3/5/24 at 9:30 AM Staff 4 (Maintenance Manager) stated Resident 22's room was not cleaned since Thursday (2/29/24). Staff 4 acknowledged Resident 22's floors were dirty and needed to be cleaned.

b. The 11/26/23 Care Plan indicated Resident 22 required assistance with grooming/hygiene and oral hygiene was to be encouraged.

On 3/3/24 at 2:50 PM Resident 22 she/he preferred to brushed her/his teeth once a week due to difficulty getting to the sink. Resident 22 state she/he used the toothbrushes located in the basins sitting on the counter. Resident 22 was observed to have two toothbrush basins; each basin contained a toothbrush. The basins were both dirty with dried and crusty white toothpaste throughout. The toothbrushes were also observed to have dried and crusty toothpaste on the handles.

On 3/5/24 at 9:35 AM Staff 6 (NA) stated Resident 22 brushed her/his teeth independently and only required assistance with getting to the sink. Staff 6 stated CNAs were responsible for cleaning and wiping down the toothbrushes and basins. Staff 6 acknowledged Resident 22's toothbrushes and basins were dirty and needed to be replaced.

On 3/7/24 at 9:27 AM Staff 2 (DNS) acknowledged the identified findings for Resident 22.

2. Review of the February 2024 Resident Council Minutes indicated residents stated there was "no heat in the dining room."

On 3/5/24 at 10:22 AM during a Resident Council interview Resident 4, Resident 10 and Resident 23 stated the dining room was cold and residents were unable to enjoy their food during meals. The residents stated some of the residents wrapped themselves in blankets while they ate, which was not comfortable, or went back to their rooms early and were not able to finish their meals due to being too cold. The residents further stated the issue was brought up before and the residents were told, "They were working on it."

On 3/5/24 at 10:43 AM Staff 4 (Maintenance Director) was asked to take a temperature reading of the dining room. The dining room temperature indicated the outer wall (adjacent to the outside window) was 63.5 degrees, the inner wall was 65.5 degrees and the kitchen wall (middle) was 67 degrees. Staff 4 stated the dining room heating system broke in November of 2023 and they were waiting for a replacement part.

Based on interview and record review it was determined the facility failed to complete a baseline care plan within 48 hours of admission for 1 of 2 sampled residents (#131) reviewed for ADL care. This placed residents at risk for lack of care and services. Findings include:

Resident 131 admitted to the facility on 2/8/24 with diagnoses including stroke and muscle weakness.

Resident 131's care plan revealed the first care area was initiated on 2/12/24; the resident had right sided hemiplegia (paralysis to one side of the body) and required assistance with ostomy care, dressing, bed mobility, showering, personal hygiene, oral care and transfers.

On 3/5/24 at 2:14 PM Staff 2 (DNS) acknowledged the baseline care plan was not completed within the required 48 hours after admission.

Based on observation, interview, and record review it was determined the facility failed to update resident care plans for 1 of 1 sampled resident (#132) reviewed for hospice. This placed residents at risk for lack of appropriate care. Findings include:

Resident 132 admitted to the facility on 2/23/24 on hospice status and had diagnoses including heart failure and weakness.

The 3/3/24 request for a physician order indicated Resident 132 had "boggy" (abnormal texture of tissues characterized by sponginess, usually because of high fluid content) heels and an order was requested for "booties." This was signed on 3/4/24 with no additional instructions.

The 3/2024 TARs indicated the following was to start on 3/5/24:
-Ensure Prevalon boots (boots used to keep the heels elevated off the mattress to relieve pressure) were worn while in bed to assist with offloading bilateral heels every shift.

The 3/6/24 care plan indicated Resident 132 had skin impairment to both heels and "Prevalon boots and skin prep applied as ordered." The care plan did not include information that the Prevalon boots were to be worn while the resident was in bed.

1. On 3/6/24 at 1:00 PM Resident 132 was observed in bed wearing non-skid socks. The resident's Prevalon boots were sitting on a small table in the corner of the room.

On 3/6/24 at 1:08 PM Staff 19 (CNA) acknowledged Resident 132 was not wearing the Prevalon boots while in bed and stated he did not notice it on the care plan a few days ago so "it must be something new."

On 3/6/24 at 1:39 PM Staff 19 stated he reviewed Resident 132's care plan and it indicated the boots were to be applied "as ordered." Staff 19 stated he was unaware of what the orders were.

On 3/7/24 at 10:38 AM Staff 3 (LPN Resident Care Manager) acknowledged the care plan was not updated to reflect the use of the Prevalon boots while in bed.

2. On 3/7/24 at 6:05 AM Resident 132 was observed in bed resting. The resident's Prevalon boots were sitting on the floor near the head of the bed. No staff were present in the hall.

On 3/7/24 at 6:12 AM Staff 19 stated he just arrived for day shift. Staff 19 observed Resident 132 and acknowledged she/he was in bed resting and not wearing the Prevalon boots.

On 3/7/24 at 10:38 AM Staff 3 (LPN Resident Care Manager) acknowledged the care plan was not updated to reflect the use of the Prevalon boots while in bed.

Based on observation, interview and record review it was determined the facility failed to provide nail care and oral care to a dependent resident for 1 of 2 sampled residents (#131) reviewed for ADLs. This placed residents at risk for lack of grooming and skin impairments. Finding include:

Resident 131 admitted to the facility on 2/8/24 with diagnoses including stroke and muscle weakness.

1. On 3/4/24 at 10:23 AM Resident 131 stated she/he had not brushed her/his teeth since admitting to the facility on 2/8/24 and staff did not provide a toothbrush or toothpaste, and did not offer to assist her/him with oral care. Resident 131 stated "it would be nice to have someone brush my teeth."

On 3/4/24 at 10:23 AM Resident 131's room was observed and there was no toothbrush or toothpaste found. Resident 131's teeth appeared to be unclean and her/his breath had a foul odor.

On 3/4/24 at 2:28 PM Staff 2 (DNS) observed Resident 131's room and was unable to locate a toothbrush or toothpaste. Resident 131 told Staff 2 she/he had not brushed her/his teeth since she/he admitted to the facility. Staff 2 stated the expectation was for staff to provide supplies and assistance with oral care.

2. On 3/4/24 at 10:23 AM Resident 131 stated her/his toenails were last trimmed two months ago. Resident 131 stated staff did not offer to trim her/his toenails and she/he wanted them trimmed.

On 3/4/24 at 10:23 AM Resident 131's toenails were observed to extend past the end of her/his toes by at least a quarter of an inch.

On 3/4/24 at 2:28 PM Staff 2 (DNS) observed Resident 131's toenails and acknowledged her/his nails extended past the end of her/his toes. Staff 2 stated the expectation was for staff to provide assistance with nail care.

Based on observation, interview, and record review it was determined the facility failed to maintain oxygen equipment for 1 of 1 sampled resident (#4) reviewed for oxygen. This placed residents at risk for lack of respiratory care. Findings include:

Resident 4 admitted to the facility in 2014 with diagnoses including chronic obstructive pulmonary disease.

The 12/30/23 physician order indicated Resident 4 was to receive oxygen at two liters via nasal cannula to keep oxygen saturation greater than 90%.

On 3/6/24 at 12:07 PM Resident 4 was observed to receive oxygen via a nasal cannula. The oxygen filter was observed to have light gray dust particles on the outside that were removed when touched. The humidifier bottle was observed to be empty.

On 3/6/24 at 1:50 PM Staff 2 (DNS) observed Resident 4's oxygen filter and acknowledged the filter contained dust and acknowledged the humidifier was empty.

Based on observation, interview and record review it was determined the facility to provide sufficient nursing staff to ensure residents attained their highest practicable psychosocial well-being for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include:

On 3/5/24 a list was requested for residents who required the following care. The facility provided lists of residents who:
-Required assistance with eating: 7.
-Required two-person assistance with transfers: 5.
-Required a mechanical lift with transfers: 8.
-Required assistance with dressing: 25.
-Required assistance with bathing: 26.
-Required assistance with toileting: 18.
-Residents who were incontinent: 17.
-Residents with wandering behaviors: 3.
-Residents with behavioral healthcare needs: 18.

Review of Resident Council Meeting notes revealed the following staffing concerns:
- November 2023: residents indicated there was not enough staff and call lights were too long.
- December 2023: residents indicated they could not find staff on the floor "especially at night". Call light wait times were, "still too long."
- January 2024: residents indicated meals arrived late.
- Febuary 2024: residents indicated trays were not being picked up and showers were not done or were missed.

Interviews with residents revealed the following concerns:
- On 3/3/24 at 3:33 PM Resident 6 stated she/he had to wait up to 45 minutes for assistance after pushing the call light.
-On 3/6/24 at 12:07 PM Resident 4 stated she/he had to wait for a half hour for the call light to be answered when she/he needed to use the bed pan. Resident 4 stated once she/he was on the bed pan it took staff an additional 30 minutes to take her/him off the bed pan. Resident 4 further stated she/he normally got up and went to the dining room for lunch, but because it took staff so long to assist her/him and she/he required a mechanical lift to get up for lunch, she/he did not go to the dining room today (3/6/24), and was, "a little upset."

Observations and interviews revealed the following concerns:
-On 3/3/24 at 12:10 PM observations by the survey team revealed residents eating in the dining room. Staff 7 (RN) stated the facility was short staffed and Staff 13 (CMA) had to work as a CNA which left all resident medications and treatments for Staff 7 to administer. Staff 7 was observed to administer morning medications as late as 1:32 PM. Insulins due prior to lunch were observed to be administered to residents as late at 1:17 PM. Staff 7 was observed rushing around and was not able to administer medications and treatments timely.

-On 3/6/24 at 11:12 AM Staff 19 (CNA) stated staffing was "hit and miss" and the facility would benefit from additional staff to help with nail care and showers. Staff 19 stated if the facility was short staffed he was not able to take breaks. Staff 19 stated care was "rushed" when they were short staffed and staff were not able to give person-centered care to residents.

-On 3/6/24 at 11:59 AM Staff 11 (CNA) stated the acuity level of the residents was high and today she did not have time to get Resident 4 out of bed and down to the dining room, per the resident's preference. Staff 11 stated Resident 4 required a two-person sit to stand lift and staff did not have time to get the resident up because several residents were incontinent that morning. Staff 11 stated a lot of residents required two-person transfer assistance and assistance with eating; and some residents had behaviors that needed to be addressed. Staff 11 stated the facility was short-staffed about once a week.

-On 3/6/24 at 2:27 PM Staff 10 (CNA) stated there were a lot of residents who required higher acuity including mechanical lifts. Staff 10 stated when the facility was short-staffed, staff were unable to complete nail care, showers, and restorative therapy. Staff 10 stated he was not able to take lunches and breaks when the facility was short-staffed.

On 3/5/24 at 9:10 AM and on 3/7/24 at 6:26 AM Staff 18 (Staffing Coordinator) stated it was difficult to fill shifts due to lack of staff and agency staff availability and the facility was short-staffed about once a week. Staff 18 further stated the facility had high acuity residents who required incontinence care and two-person assistance due to resident behaviors. Staff 18 stated incontinence care and showers were not always completed when the facility was short staffed. Staff 18 acknowledged the facility was short staffed on 3/3/24 and there was only one RN completing treatments and medications for the entire facility.

Based on interview and record review it was determined the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week for 3 of 28 days reviewed for RN staffing coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include:

A review of the Direct Care Staff Daily Reports from 2/2/24 through 3/1/24 revealed the following days with no RN coverage:
-2/10/24
-2/11/24
-3/1/24

On 3/5/24 at 9:10 AM Staff 18 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified dates.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5 percent. There were six errors in 27 opportunities resulting in a 22 percent error rate. This placed residents at risk for adverse medication side effects. Findings include:

1. Resident 14 admitted to the facility in 2022 with diagnoses including stroke.

The 2/23/24 physician order indicated Resident 14 was to receive Eliquis (anticoagulant medication) 2.5 mg once daily.

The 3/2024 MARs indicated Eliquis was to be administered in the morning.

On 3/3/24 at 12:34 PM Staff 7 (RN) was observed to administer the morning dose of Eliquis. Staff 7 acknowledged the medication was administered late as she was still passing morning medications.

2. Resident 2 admitted to the facility in 2015 with diagnoses including chronic pain and opioid dependence.

The 2/4/24 physician order indicated Resident 2 was to receive methadone (opioid medication) twice daily for opioid dependence.

The 3/2024 MARs indicated methadone was scheduled at 9:30 AM and 9:30 PM.

On 3/3/24 at 12:52 PM Staff 7 (RN) was observed to administer the 9:30 AM dose of methadone 20 mg to Resident 2 (3 hours and 22 minutes after it was due). Staff 7 stated the previous dose of methadone was administered on the evening of 3/2/24 and acknowledged the methadone was administered late, as she was still passing morning medications.

3. Resident 13 admitted to the facility in 2019 with diagnoses including diabetes.

The 2/27/24 physician order indicated Resident 13 was to receive Admelog insulin 16 units before meals.

The manufacturer instructions for Admelog insulin pen indicated to prime the pen with two units of insulin prior to administering the insulin dose.

On 3/3/24 at 1:03 PM Staff 7 (RN) was observed to administer 16 units of Admelog insulin to Resident 13. Staff 7 did not prime the insulin pen with the two units recommended by the manufacturer prior to administering the Admelog insulin.

On 3/3/24 at 1:03 PM and 2:26 PM Staff 7 stated she was not aware insulin pens needed to be primed prior to administration and acknowledged the insulin was not administered before lunch as ordered.

4. Resident 7 admitted to the facility in 2014 with diagnoses including diabetes.

The 2/27/24 physician order indicated Resident 7 was to receive Novolog insulin 15 units before meals.

The manufacturer instructions for Novolog insulin pen indicated to prime the pen with two units of insulin prior to administering the insulin dose.

On 3/3/24 at 1:11 PM Staff 7 (RN) was observed to administer 15 units of Novolog insulin to Resident 7. Staff 7 did not prime the insulin pen with the two units recommended by the manufacturer prior to administering the Novolog insulin.

On 3/3/24 at 1:11 PM and 2:26 PM Staff 7 stated she was not aware insulin pens needed to be primed prior to administration and acknowledged the insulin was not administered before lunch as ordered.

5. Resident 16 admitted to the facility in 2023 with diagnoses including diabetes.

The 2/27/24 physician order indicated Resident 16 was to receive 18 units of Humalog before meals.

The 3/2024 MARs indicated Resident 16 was to receive 15 units of Humalog before meals. The start date was 2/6/24.

The manufacturer instructions for Humalog insulin pen indicated to prime the pen with two units of insulin prior to administering the insulin dose.

On 3/3/24 at 1:17 PM Staff 7 (RN) was observed to administer 15 units of Humalog insulin to Resident 16. Staff 7 did not prime the insulin pen with the two units recommended by the manufacturer prior to administering the Humalog insulin.

On 3/3/24 at 1:17 PM and 2:26 PM Staff 7 stated she was not aware insulin pens needed to be primed prior to administration and acknowledged the insulin was not administered before lunch as ordered.

On 3/4/24 at 12:33 PM Staff 3 (LPN Resident Care Manager) stated the correct order for Resident 16's Humalog insulin was 15 units before meals. Staff 3 provided a copy of the signed clarification of Humalog orders dated 3/4/24 and acknowledged the discrepancy.

6. Resident 11 admitted to the facility in 2023 with diagnoses including chronic obstructive pulmonary disease (COPD).

The 2/27/24 physician orders indicated Resident 11 was to receive Advair Diskus one puff twice daily related to COPD and to rinse the mouth with water and spit after each inhalation.

The 3/2023 MARs indicated Advair Diskus was due at 8:00 AM.

On 3/3/24 at 1:32 PM Staff 7 (RN) was observed to give Resident 11 the Advair Diskus for administration (five hours and 32 minutes after it was due). Staff 7 did not ask Resident 11 to rinse her/his mouth and spit.

On 3/3/24 at 1:32 PM and 2:26 PM Staff 7 stated she did not instruct Resident 11 to rinse and spit after the use of the Advair Diskus and acknowledged it was given late as she was still passing morning medications as of 1:32 PM.

Based on observation, interview, and record review it was determined the facility failed to ensure medications were secured and failed to ensure proper labeling of biologicals for 1 of 1 facility reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy and unauthorized access to potentially harmful medications. Findings include:

1. On 3/3/24 at 12:10 PM Staff 7 (RN) was observed standing at a medication cart in the dining room preparing medications. There were several resident medication cards containing medication, and a cup that contained one white pill sitting on top of the cart. Staff 7 walked down the hall and left the medication cart unlocked and unattended with the medications sitting on top of the cart. There were several residents in the dining room.

On 3/3/24 at 12:13 PM Staff 7 returned to the medication cart and acknowledged the top of the cart had resident medication cards, as well as a pill in a cup, resident medications were inside the cart and the cart was left unlocked and unattended.

2. On 3/3/24 at 1:03 PM an open and undated Admelog insulin pen was observed in the treatment cart.

On 3/3/24 at 1:03 Staff 7 (RN) acknowledged the Admelog insulin pen was open and not labeled with an open date.

3. On 3/3/24 at 1:11 PM an open and undated Novolog Flex insulin pen and an open and undated Basalgar insulin pen were observed in the treatment cart.

On 3/3/24 at 1:11 PM Staff 7 (RN) acknowledged the Novolog Flex insulin pen and the Basalgar insulin pen were open and not labeled with open dates.

Based on observation and interview it was determined the facility failed to ensure the dietary manager met the required qualifications for 1 of 1 kitchen reviewed for competent staffing. This placed residents at risk for unmet nutritional needs. Findings include:

On 3/6/24 at 2:31 PM Staff 14 (Dietary Manager) was observed to direct staff while working in the kitchen. Staff 14 stated he worked in the kitchen for three years and was employed as the dietary manager for two years. Staff 14 stated he was not a certified dietary manager and did not take the classes to become a dietary manager.

On 3/7/24 at 8:57 AM Staff 1 (Administrator) acknowledged Staff 14 did not meet the qualifications for the Dietary Manager position.

Based on observation and interview it was determined the facility failed to ensure foods and bulk ingredients were labeled and stored in a way to minimize food spoilage, failed to maintain a clean and sanitary environment for storage of kitchen equipment and cookware and failed to wear hair restraints in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include:

1. On 3/3/24 at 12:19 PM the walk-in refrigerator in the facility's kitchen was observed to contain the following improperly stored items:
-two moldy bell peppers stored in a bag, undated.
-a half gallon of unopened whip cream with a use by date of 2/22/24.
-slices of white cheese - three different bundles - no label and undated.

On 3/3/24 at 12:30 PM in the prep area, the surveyor observed two opened 50-pound bags, one bag of bread crumbs was rolled down closed, the second bag of all-purpose flour was torn open and the flour open to the air under a prep table. In the prep area, a five-gallon bucket was positioned on the floor under an open drop ceiling tile with water dripping from the ceiling. The bucket contained a brownish liquid. The bucket was between the prep table with the open flour bag and bread crumbs and a storage rack which contained a deli slicer machine and two large clear plastic drink dispensers. Staff 15 (Dietary Aide) stated the water heater pipe burst about a week or two ago which caused the pipe to leak.

On 3/3/24 at 12:40 PM Staff 15 acknowledged the expired and undated items in the refrigerator and stated he was unsure how the items in the refrigerator were missed. Staff 15 stated he was unaware they could not store the bread crumbs and flour in bags and had to be in covered containers.

On 3/6/24 at 2:31 PM Staff 14 (Dietary Manager) acknowledged the items found in the refrigerator were not disposed of timely. Staff 14 acknowledged the flour and bread crumbs should be in covered containers.

2. On 3/3/24 at 12:40 PM the surveyor requested Staff 15 (Dietary Aide) test the bleach buckets for correct chemical solution concentration. Staff 15 stated he had not tested the bleach buckets all day and was unable to find the test strips to test the chemical solution concentration. Staff 15 and Staff 16 (Cook/Dietary Aide) searched for the test strips and stated they were out of test strips for the past couple of days.

On 3/6/24 at 2:31 PM Staff 14 (Dietary Manager) stated he expected staff to test the bleach buckets at least once before each meal and when the bleach needed to be replaced.

3. On 3/3/24 at 12:19 PM Staff 15 (Dietary Aide) was observed without a hairnet and beard covering while assisting with tray line. Staff 16 (Cook/Dietary Aide) was observed plating the food and was not wearing a beard covering.

On 3/5/24 at 11:57 AM Staff 17 (Dietary Aide) was observed during tray line to use her gloved hands to rearrange her clothing, adjust her eyeglasses then touched several food items on a tray.

On 3/5/24 at 11:58 AM Staff 17 the surveyor intervened and Staff 17 acknowledged she touched her clothing and glasses and should have completed hand hygiene before touching the food tray.

On 3/6/24 at 10:48 AM Staff 14 (Dietary Manager) was observed not wearing a beard covering while preparing sides for the lunch meal. The surveyor requested Staff 14 test the bleach buckets. Staff 14 used gloved hands to the bleach bucket, and then proceeded to pour barbecue sauce into individual containers.

On 3/6/24 at 10:50 AM the surveyor intervened and Staff 14 acknowledged he should have removed his gloves, washed his hands and put on a new pair of gloves before pouring the barbecue sauce.

On 3/6/24 at 2:31 PM Staff 14 stated he expected staff to always follow hand hygiene and to wear hairnets and beard coverings when in the kitchen.

Based on interview and record review it was determined the facility failed to ensure records were accurate, complete, and readily accessible for 2 of 6 sampled residents (#s 14 and 16) reviewed during medication pass. This placed residents at risk for unmet care needs. Findings include:

1. Resident 14 readmitted to the facility in 2022 with diagnoses including atrial fibrillation (AFIB) (irregular heart rhythm).

a. The 1/19/24 physician order indicated Resident 14 was to receive Eliquis 5 mg BID for AFIB.

The 2/22/24 prescription refill request indicated Resident 14 had a dose change to Eliquis 2.5 mg once daily due to having blood in the urine.

The 2/23/24 physician order indicated Resident 14 was to receive Eliquis 5 mg BID for AFIB.

Resident 14's 2/2024 and 3/2024 MARs indicated the following:
-2/1-2/19 Eliquis 5 mg at 9:00 AM and 9:00 PM.
-2/20 Eliquis 5 mg at 9:00 AM.
-2/21 Eliquis 5 mg was not administered-the MAR indicated it was due every other day.
-2/22 Eliquis 5 mg at 9:00 AM
-2/23 Eliquis 5 mg was not administered-the MAR indicated it was due every other day.
-2/24-3/5 Eliquis 5 mg at 9:00 AM

On 3/5/24 at 10:37 AM Staff 2 (DNS) stated Resident 14 had hematuria (blood in the urine) and the Eliquis order was changed from BID to once daily.

On 3/5/24 at 11:58 AM Staff 3 (LPN Resident Care Manager) acknowledged the identified multiple discrepancies between Resident 14's Eliquis orders and the MARs.

b. Resident 14's 2/9/24 urology visit notes were requested from Staff 3 (LPN Resident Care Manager) on 3/5/24.

Resident 14's 2/9/24 urology notes were provided to the Surveyor on 3/5/24. The notes indicated the resident had hematuria (blood in the urine) and recommended discussing with her/his provider the risks and benefits of an "anticoagulation holiday" in the setting of atrial fibrillation and she/he would consider stopping this.

On 3/5/24 at 11:58 AM Staff 3 stated Resident 14 went to the urologist on 2/9/24 and the resident did not return to the facility with an after-visit summary. Staff 3 stated the facility did not get records from the 2/9/24 visit until 2/23/24 (14 days later). Staff 3 stated Resident 14's urologist recommendations were reviewed by the physician and her/his Eliquis dose was changed based on the recommendations.

2. Resident 16 admitted to the facility in 2023 with diagnoses including diabetes.

The 2/27/24 physician order indicated Resident 16 was to receive 18 units of Humalog before meals.

The 3/2024 MARs indicated Resident 16 was to receive 15 units of Humalog before meals. The start date was 2/6/24.

On 3/4/24 at 12:33 PM Staff 3 (LPN Resident Care Manager) stated the correct order for Resident 16's Humalog insulin was 15 units before meals. Staff 3 provided a copy of the signed clarification of Humalog orders dated 3/4/24 and acknowledged the discrepancy.

Based on interview and record review it was determined the facility failed to ensure a resident received coordination for end-of-life care for 1 of 1 sampled resident (#132) reviewed for hospice. This placed residents at risk for a lack of coordination of care. Findings include:

Resident 132 admitted to the facility on 2/23/24 on hospice and had diagnoses including heart failure and weakness.

On 3/5/24 Resident 132's clinical record was reviewed, and hospice notes were not located.

On 3/5/24 at 2:38 PM Staff 8 (LPN) stated hospice staff visited Resident 132 but she was not sure how hospice staff communicated with the facility.

On 3/6/24 at 2:40 PM Staff 3 (LPN Resident Care Manager) stated when hospice staff visited Resident 132 it was "hit or miss" for communication. Staff 3 stated if hospice staff had a question they asked the charge nurse and usually it was regarding bowel movements or pain medications. Staff 3 further stated new orders from hospice were written on a blank piece of paper and left with the nurse, or hospice staff talked to the nurse after the visit. Staff 3 stated the facility did not receive notes or after-visit summaries from the hospice provider.

On 3/6/24 Resident 132's hospice notes and hospice care plan was requested by the Surveyor.

On 3/7/24 at 10:38 AM Staff 3 provided a hospice plan of care and hospice notes for Resident 132. Staff 3 acknowledged the hospice notes and care plan were not received by the facility until 3/6/24 after it was requested by the Surveyor.

***********
OAR 411-087-0100 Physical Environment: Generally

Refer to F584
***********
OAR 411-086-0040 Admission of Residents

Refer to F655
***********
OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F657
***********
OAR 411-086-0010 Administrator

Refer to F849
***********
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F677, F695 and F759
***********
OAR 411-086-0100 Nursing Services: Staffing

Refer to F725, F727
***********
OAR 411-086-0260 Pharmaceutical Services

Refer to F761
***********
OAR 411-086-0250 Dietary Services

Refer to F801 and F812
***********
OAR 411-086-0300 Clinical Records

Refer to F842
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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 03/13/2023 and 03/19/2023, 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 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 03/06/2023 and 03/12/2023, 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 interview and record review it was determined the facility failed to ensure residents were treated in a dignified manner for 1 of 1 sampled resident (#9) reviewed for abuse. This placed residents at risk for diminished quality of life. Findings include:

The facility's 2/2021 Dignity Policy & Procedure specified residents were treated with dignity and respect at all times.

Resident 9 was admitted to the facility in 1/2022 with diagnoses including surgical aftercare.

Resident 9's 12/15/22 Annual MDS indicated the resident was cognitively intact and required staff assistance with ADLs.

A 1/9/23 facility Event Report, completed by Staff 16 (RN), indicated there was an incident of alleged verbal abuse on 1/8/23 at 1:40 PM. The report specified Staff 27 (Personal Care Assistant) reported Staff 26 (Former agency CNA) talked loudly and yelled at Resident 9. The incident occurred in Resident 9's room while Staff 26 provided incontinence care. The report indicated Resident 9 felt safe and she/he did not have a change in mood or behavior after the incident.

Resident 9's Progress Notes revealed the resident did not experience a negative psychosocial outcome related to the 1/8/23 incident.

On 2/6/23 at 9:14 AM Staff 16 stated she recalled the incident on 1/8/23. Staff 16 stated Staff 27 reported she overheard Staff 26 speak loudly to Resident 9. Staff 16 stated she provided care to Resident 9 after the incident and the resident stated she/he was okay. Staff 16 stated Staff 26 had a loud, masculine voice and his voice was often heard in the hallway.

On 2/6/23 at 2:12 PM and 2:23 PM Staff 5 (LPN/Resident Care Manager) and Staff 6 (LPN/Resident Care Manager) stated they were aware of the 1/8/23 incident and conducted part of the investigation. Staff 5 and Staff 6 stated Staff 26 spoke to Resident 9 inappropriately and made the resident cry and feel embarrassed about being incontinent.

On 2/6/23 at 3:58 PM Staff 27 stated she witnessed the 1/8/23 incident between Resident 9 and Staff 26. Staff 27 stated she overheard Staff 26 in Resident 9's room, speaking loud and rudely to the resident. Staff 27 stated she entered Resident 9's room and witnessed Staff 26 repeatedly sigh and ask the resident, "What's wrong with you, what's your problem?" Staff 27 stated Resident 9 cried and apologized during the interaction and she asked Staff 26 to leave the room.

On 2/7/23 at 11:04 AM Resident 9 stated she/he remembered the 1/8/23 incident with Staff 26. Resident 9 stated she/he had an incontinent episode, needed help to clean up and Staff 26 was in her/his room to assist with care. Resident 9 stated Staff 26 spoke to her/him disrespectfully, made her/him feel frustrated and upset and she/he cried. Resident 9 stated she/he did not feel scared or unsafe.

On 2/8/23 at 12:43 PM an attempt to contact Staff 26 was unsuccessful.

On 2/9/23 at 2:11 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) reviewed the incident report and the findings of this investigation. Staff 2 and Staff 3 acknowledged Staff 26 was disrespectful to Resident 9 and did not treat the resident in a dignified manner.

Based on observation, interview and record review it was determined the facility failed to ensure married residents were able to share a room when requested for 1 of 1 sampled resident (#8) reviewed for choices. This placed residents at risk for diminished quality of life. Findings include:

Resident 8 was admitted to the facility in 9/2014 with diagnoses including stroke.

Resident 8's 1/16/23 Quarterly MDS revealed the resident was cognitively intact.

Resident 10 was admitted to the facility in 1/2018 with diagnoses including blindness and depression.

Resident 10's 1/19/23 Quarterly MDS revealed the resident was cognitively intact.

On 2/5/23 at 3:26 PM Resident 8 stated she/he married Resident 10 on 10/31/22. Resident 8 stated she/he asked the facility management about sharing a room and bed with her/his spouse after getting married and was told neither was a possibility. Resident 8 stated she/he felt depressed about not being able to share a room or bed with her/his spouse and the whole situation was very upsetting.

On 2/7/23 at 8:28 AM Resident 10 stated she/he asked the former administrator about sharing both a room and bed with her/his spouse after getting married and was told no on both accounts.

On 2/8/23 at 8:41 AM Staff 10 (CNA) stated Resident 8 and 10 were both upset about the bed situation and not being able to share a room. Staff 10 stated the former administrator told the residents they needed to move to a different facility if they wanted to share a room.

On 2/8/23 at 10:53 AM Staff 4 (Social Services Director) stated Resident 8 and 10 exchanged wedding vows in the facility on 10/31/22. Staff 4 stated she thought the residents spoke to the former as well as current administrator about sharing a room.

On 2/8/23 at 1:25 PM Staff 1 (Administrator) stated he became aware Resident 8 and 10 wanted to share a room and bed approximately a week earlier and was planning to discuss the possibility of sharing a room and bed with both residents.

Based on observation, interview and record review, it was determined the facility failed to provide a homelike environment for 4 of 7 residents (#s 8, 18, 19, and 20), 1 of 2 halls, and 1 of 1 community shower room reviewed for environment. This placed residents at risk for living in an unhomelike environment. Findings include:

The facility's Maintenance Service Policy and Procedure, revised 12/2009, revealed the maintenance department was responsible to maintain the building, grounds and equipment. Functions of the maintenance personnel was to maintain the building in compliance with current federal, state and local laws, regulations and guidelines.

1. On 2/5/23 the following concerns were identified:
- at 3:40 PM Resident 8's window frame was cracked, missing a piece of the window sill, a section of the window blinds were missing, her/his walls had scuffs and missing paint.
- at 1:50 PM Resident 18's window seal was cracked and lifted to allow cold air into her/his room.
- at 11:31 AM Resident 19's window seal was cracked with a large piece missing.
- at 1:49 PM Resident 20's vanity leg was scuffed and missed a large section of laminate.

On 2/9/23 at 11:55 AM Staff 31 (Maintenance Director) confirmed and acknowledged the need for repairs in the resident rooms during the walk through with the surveyor.

On 2/10/23 at 10:38 AM Staff 1 (Administrator) acknowledged the need for repairs and expected the residents' rooms to be homelike.

2. A 1/12/23 public complaint was made to the State Agency which alleged the facility's "back hall" was cold.

On 2/5/23 at 2:18 PM Resident 18 stated she/he was often cold in her/his room. Resident 18 stated it was cold in the hallway especially when she/he had to go through the cold hall to get a shower.

The following observations were made in the facility of cool/cold temperatures:
- 2/5/23 at 3:57 PM thermostat was at 65 degrees and thermometer at 65 degrees to west of room 36.
- 2/6/23 at 12:47 PM cool air was felt outside room 41 and the thermostat and wall thermometer to the west of room 36 stated 70.
- 2/7/23 at 8:46 AM thermostat was at 65 degrees and thermometer at 67 degrees to west of room 36.
- 2/7/23 at 11:33 AM thermostat was at 67 degrees and thermometer at 68 degrees to west of room 36.
- 2/8/23 at 8:57 AM thermostat was at 58 degrees and thermometer at 66 degrees to west of room 36.

On 2/6/23 at 8:53 AM Staff 9 (Activity Director) stated the residents did not typically have groups in the small dining room because it was too cold.

On 2/9/23 at 11:55 AM Staff 31 (Maintenance Director) acknowledged the cold hallway near room 36 during the walk through with the surveyor.

On 2/10/23 at 10:38 AM Staff 1 (Administrator) acknowledged the need for repairs and the cold tempature.

3. On 2/5/23 at 2:18 PM the resident bathroom across from room 56 was observed with a stained, dirty looking shower floor, a hole in the laminate flooring, a hole in the wall behind the door, multiple scuffs and missing paint on the wall from the exit to the shower.

On 2/9/23 at 11:55 AM Staff 31 (Maintenance Director) confirmed and acknowledged the disrepair in the residents' bathroom during the walk through with the surveyor.

On 2/10/23 at 10:38 AM Staff 1 (Administrator) acknowledged the need for repairs and expected the residents' rooms to be homelike.

Based on interview and record review it was determined the facility failed to complete a thorough investigation of an allegation of abuse for 1 of 1 sampled resident (# 9) reviewed for abuse. This placed residents at risk for abuse and inaccurate investigations. Findings include:

The 10/2005 Oregon Nursing Facility Abuse Reporting and Investigation Guide for Providers specified a thorough investigation is a systematic collection of information that describes and explains an incident or series of incidents. The investigation seeks to determine if abuse occurred, how the incident occurred, and how to prevent further occurrences. Critical component(s) of any investigation include the timely initiation of the investigation and the thoroughness of the investigation. The evidence data should be accurate and appropriate to include testimonial, documented, pictorial and physical evidence as applicable to come to a conclusion and it is important that conclusions not be reached without adequate information. Each investigation must seek to answer who, what, where, when, why and how, through interviews, comprehensive record review and observations. Interviews may include but are not limited to: reported victim(s), reported perpetrator(s), CNA(s), staff in immediate area or who provided services, roommate(s), visitors and/or family.

The facility's 12/2016 Abuse Prevention Program Policy & Procedure specified the following:
- Identify and assess all possible incidents of abuse.

Resident 9 was admitted to the facility in 1/2022 with diagnoses including surgical aftercare.

Resident 9's 12/15/22 Annual MDS indicated the resident was cognitively intact, was frequently incontinent of bowel and required staff assistance with ADLs.

A 1/9/23 facility Event Report, completed by Staff 16 (RN) specified the following on 1/8/23 at 1:40 PM:
- Description: a CNA talked loudly to the resident;
- Event Details: Alleged verbal abuse;
- Location: Resident Room;
- Name of person reporting: [Staff 27 (Personal Care Assistant)];
- Name of alleged perpetrator: [Staff 26 (Former agency CNA)];
- Witnesses: No;
- Resident interview: Not completed.

The facility's Occurrence Investigation Final Summary, signed and dated 1/10/23 by Staff 6, and signed and dated 1/12/23 by Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) included the following statements from Staff 27 and Resident 9, an emailed statement from Staff 26's staffing agency and a final report summary:

- Staff 27 statement: "CNA went into this resident's room right before lunch, [her/his] room was covered in poop, and CNA was yelling at the resident saying, 'what is wrong with you?' Resident responded stating, 'Please don't be mad at me, I didn't mean to,' resident was crying."

- Resident 9 statement: "The guy with the long hair got mad at me. He swore and used a lot of words, I didn't say anything, I just let him ramble."

- Staff 26 emailed statement: "At 12:30 PM, CNA on shift found patient covered in their own feces. Patient was also eating lunch and did not seem to be bothered by this. The patient also left [feces] on the floor and had filled their sink to the brim with [feces]. CNA then cleaned the patient room and notified charge nurse."

The "final report" portion summarized:
- PCA immediately went into the resident's room and was able to ensure resident's safety. Resident has been placed on alert and is being monitored for [signs and symptoms] of emotional distress related to this incident. Resident's son has been updated...Resident and [her/his] son have been educated on [her/his] rights and reporting abuse to the charge nurse, [Resident Care Manager], DNS or administrator. Abuse has not been ruled out at this time.

No additional interviews with staff, residents, visitors, the alleged perpetrator or other potential witnesses were included in the Event Report or the Occurrence Investigation Final Summary.

On 2/7/23 at 2:55 PM and 2/9/23 at 2:11 PM Staff 1 (Administrator), Staff 2 and Staff 3 reviewed the Event Report and the Occurrence Investigation Final Summary. Staff 3 stated based on the facility's investigation and summary, the conclusion of this alleged allegation was unclear and she was unsure if abuse was ruled out. Staff 2 stated the investigation was not comprehensive, there were "missing pieces" to the investigation and additional staff, such as anyone who was in the vicinity at the time of the alleged incident and anyone on shift should have been interviewed. Staff 1 confirmed no interview was conducted with Staff 26, the emailed statement from the staffing agency was not a comprehensive witness statement and the facility should have attempted to interview the alleged perpetrator.

Based on observation, interview and record review it was determined the facility failed to develop and implement a comprehensive care plan to meet residents' needs for 3 of 12 sampled residents (#s 1, 8 and 16) reviewed for ADLs, nutrition, positioning and bowel and bladder. This placed residents at risk for not receiving appropriate adaptive equipment and incontinent care needs. Findings include:

1. Resident 1 was admitted to the facility in 2/2022 with diagnoses including cellulitis and a brain injury.

The 9/6/22 Bedside Care Plan (a tool used by CNAs to provide care) indicated the resident attempted to toilet herself/himself throughout the day and night, unfortunately Resident 1 was unable to ensure she/he was "cleaned properly/new brief application." Staff were to provide incontinence assistance frequently throughout each shift which included peri-care (cleaning private areas of a resident) and changing of Resident 1's brief.

A revised care plan dated 1/10/23 revealed Resident 1 had a diagnosis of urinary incontinence related to functional mobility, was at risk for pressure injury, history of cellulitis and required assistance with some of her/his ADLs. Resident 1 required staff assistance for ADLs and staff were to provide incontinence care after each incontinent episode. Resident 1 often took herself/himself to the restroom and required staff assistance with hygiene, and reminder to change her/his brief. Staff were to check her/his incontinence pads with ADL cares and as needed.

A 1/12/23 Urinary CAA revealed Resident 1 required assistance with toileting and was occasionally incontinent of bladder. Resident 1 was on a diuretic and was at risk for incontinent episodes related to mobility.

Random observations from 2/5/23 through 2/9/23 revealed Resident 1 smelled of urine and her/his bedroom including bed, bedding and bathroom had a strong urine odor that permeated out into the hallway.

On 2/7/23 at 11:22 AM Staff 15 (Personal Care Aide) stated Resident 1 was "pretty independent" and made "messes." Staff 15 stated Resident 1 smelled of "strong" urine including her/his clothing. Staff 15 stated she received report during shift change and referred to the care plan in the computer or the in-room-care plan to determine Resident 1's care needs.

On 2/7/23 at 12:27 PM Staff 16 (RN) stated Resident 1 smelled of urine and was independent with toileting and changing her/his own brief. Staff 16 stated it was expected CNAs were to implement and follow the care plan.

On 2/7/23 at 10:07 PM Staff 12 (CNA) stated Resident 1 was independent for incontinence care but did smell of urine. Staff 12 stated she referred to the care plan located in the electronic record or the in-room-care plan in Resident 1's room.

On 2/8/23 at 9:27 AM Staff 10 (CNA) and at 10:28 AM Staff 18 (CMA/Staffing Coordinator) both stated Resident 1 was independent with toileting but required some assistance with incontinence care but at times refused assistance. Staff 10 and Staff 18 stated Resident 1 smelled of urine. Staff 10 and Staff 18 stated when providing care for Resident 1 they referred to the in-room-care plan and received information during shift change.

On 2/9/23 at 1:56 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were all present for an interview. Staff 1 and Staff 2 stated staff were expected to keep Resident 1 odor free as much as possible and to ensure appropriate incontinence care was provided. Staff 1, Staff 2 and Staff 3 stated CNAs were expected to implement and follow the care plan.


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2. The facility's Policy and Procedure for Repositioning, revised 5/2013, revealed the purpose was to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individual care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning was critical for a resident who was immobile or dependent upon staff for repositioning.

Resident 16 admitted to the facility in 3/2019 with diagnoses including Alzheimer's (loss of memory and mental functions) and Parkinson's Disease (disorder of central nervous system).

Resident 16's care plan 8/2/20 intervention was to assist her/him to change positions, transfers, and bed mobility as needed. She/he would call for staff assistance to help with repositioning. The care plan directed staff to provide two-person assistance with bed mobility.

Resident 16's 12/20/21 Bedside Care Plan for positioning directed staff that Resident 16 would call for staff when she/he would like to be readjusted in bed.

Record review of the 1/1/23 to 2/8/23 Point of Care Turning/Repositioning revealed Resident 16 was repositioned one to three times a day.

On 2/5/23 Resident 16 was observed in her/his bed, on her/his right side, legs bent, head of bed tilted upward, and in the same position on the following times: 11:20 AM, 12:24 PM, 2:27 PM, and 3:37 PM.

During observations from 2/5/23 to 2/9/23, between 8:00 AM to 5:00 PM, Resident 16 made eye contact but did not respond to yes/no questions or greetings.

On 2/9/23 at 2:54 PM Staff 21 (CNA) stated she was directed to follow the Bedside Care Plan for resident care needs. Staff 21 stated Resident 16 did not call for assistance to be repositioned. Staff 21 acknowledged Resident 16 did not get turned very often.

On 2/10/23 at 10:32 AM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) acknowledged they expected care plans to be developed and implemented for residents.

, 4. Resident 8 was admitted to the facility in 9/2014 with diagnoses including stroke and hemiplegia (paralysis of one side of the body).

The 1/16/23 Quarterly MDS revealed the resident was cognitively intact, was independent with eating outside of set-up assistance from staff and did not experience any swallowing issues.

A 2/1/23 Nursing Progress Note revealed Resident 8 experienced an episode of choking at lunch which required a CNA to perform an abdominal thrust to clear.

Resident 8's Care Plan revised on 2/1/23 included the following goal and interventions:
-The resident was to remain free from choking.
-Speech therapy to evaluate and treat.
-Staff to ensure proper positioning during meals.
-Staff to remind the resident to take small sips of water between each bite.
-Staff to encourage the resident to eat her meals in the main dining room.

A review of the resident's Bedside Care Plan, updated 9/30/22, did not indicate the resident was at risk for choking and did not include any interventions to prevent choking.

Interviews conducted on 2/7/23 between 1:02 PM to 1:22 PM with Staff 10 (CNA), Staff 17 (CMA), Staff 21 (CNA) and Staff 33 (CNA) indicated they all utilized the resident's Bed Side Care Plan to gain information on how to care for residents. Staff 10, Staff 17, Staff 21 and Staff 33 stated they were unaware Resident 8 had a choking episode, stated the resident was independent with eating outside of set-up assistance and were not aware Resident 8 was at risk for choking.

On 2/7/23 at 1:30 PM Staff 16 (RN) stated she was unsure if Resident 8 had any interventions in place related to eating and safety. Staff 16 reviewed the resident's Bed Side Care Plan in her/his chart and stated Resident 8 was independent at meal times.

On 2/7/23 at 2:23 PM Staff 6 (LPN/Resident Care Manager) stated after the 2/1/23 choking incident staff were expected to encourage the resident to take small sips of water between bites of food, encourage the resident to take small bites of food and ensure appropriate positioning for Resident 8 at mealtimes. Staff 6 reviewed the resident's Care Plan and Bed Side Care Plan and confirmed they did not match.

On 2/8/23 at 12:03 PM Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were informed of the findings. Staff 2 confirmed the Bed Side Care Plan should have been updated after the choking incident as CNAs used the Beside Care Plan to obtain information about residents.

Based on interview and record review it was determined the facility failed to ensure resident care plans were revised to accurately reflect the resident needs for 1 of 4 sampled residents (# 15) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include:

Resident 15 admitted to the facility in 11/2020 with diagnoses including dementia and anxiety.

A 1/12/23 Quarterly MDS indicated Resident 15's BIMS score was eight indicating moderate cognitive impairment. Resident 15 was totally dependent on one-person assistance with personal hygiene and required extensive one-person assistance with dressing.

A revised care plan dated 1/16/23 revealed Resident 15 had an ADL deficit related to stroke and decreased physical functioning and dementia. Staff were directed to provided one-person assistance with dressing and personal hygiene.
-The care plan did not indicate Resident 15 refused ADL care needs except at times did not allow staff to brush her/his teeth.
-A review of the electronic record did not reveal Resident 15 refused to have her/his clothing changed.

Random observations from 2/5/23 through 2/6/23 revealed Resident 15 in the same blue long sleeve t-shirt which had food stains and food particles all over the entire front of her/his long sleeve t-shirt.

On 2/7/23 at 9:43 AM Staff 17 (CMA) stated Resident 15 required one-person assistance with dressing and noticed she/he had the same shirt on for a "couple of days." Staff 17 stated staff were to re-approach if Resident 15 refused to have her/his shirt changed.

On 2/7/23 at 11:12 AM Staff 15 PCA (Personal Care Aide) stated Resident 15 required one-person assistance with dressing and she/he was in the same dirty t-shirt on 2/5/23 and 2/6/23. Staff 15 stated Resident 15 refused ADL care at times and if she/he refused to be changed staff were to re-approach her/him and report to the charge nurse.

On 2/7/23 at 8:59 PM Staff 13 (RN) stated Resident 15 had baseline confusion and required one person assistance with dressing. Staff 13 stated at times Resident 15 refused to remove her/his clothes prior to going to bed and was put to bed with dirty clothing. Staff 13 indicated this behavior was reported to day shift and Staff 13 expected day shift to change her/his clothing.

On 2/9/23 at 1:56 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were all present for an interview. Staff 2 and Staff 3 stated staff were expected to implement and follow the care plan and if Resident 15 refused to be assisted with her/his clothing being changed staff were to re-approach her/him. Staff 2 stated if Resident 15 refused often, then the care plan should have been updated to reflect the refusals.

Based on interview and record review it was determined the facility failed to ensure qualified staff administered medicated powders for 1 of 3 sampled residents (#1) reviewed for bowel and bladder care. This placed residents at risk for receiving inadequate treatment. Findings include:

The Oregon State Board of Nursing Scope of Practice Standards for Certified Nursing Assistants, Oregon Administrative Rule 851-063-0030 outlined the following:
Skin Care to include application of non-prescription pediculicides; application of topical barrier creams and ointments for skin care; maintenance of skin integrity; prevention of pressure, friction, and shearing; and use of anti-pressure devices.

Resident 1 was admitted to the facility in 2/2022 with diagnoses including cellulitis and a brain injury.

A physician order dated 10/23/22 directed staff to apply Nystatin powder (anti-fungal) to peri-area twice daily and ensure area was dry prior to applying the powder.

A Fax Sheet dated 11/16/22 from Staff 14 (LPN) revealed Resident 1 ate 10-15 ml of Nystatin powder from a medication cup that was in her/his room at approximately 9:05 AM. Resident 1 had a light cough and was complaining of a sore throat at that time. Poison control was contacted and staff were instructed to monitor closely. Resident 1 had no further symptoms or outcome related to the ingested Nystatin powder.

On 2/7/23 at 12:27 PM Staff 16 (RN) stated on 11/16/22 the Nystatin powder was placed in Resident 1's room in a small cup for CNAs to apply to her/his skin and the Nystatin powder was not supposed to be left on the counter unattended.

On 2/7/23 at 10:07 PM Staff 13 (RN) stated she heard about the incident when Resident 1 ingested the Nystatin powder because it was left in her/his room unattended and nurses were to apply the Nystatin powder. Staff 13 stated a CNA could apply the Nystatin powder if an RN was present.

On 2/7/23 at 10:33 PM Staff 11 (CNA) stated nurses put Nystatin powder in a small cup and gave it to the CNAs to apply to residents. Staff 11 stated she placed the Nystatin powder on the residents without a nurse being present "all the time."

On 2/8/23 at 12:16 PM Staff 14 stated he recalled the incident when Resident 1 ingested the Nystatin powder on 11/16/22 and was not sure how or why the Nystatin powder was left in her/his room without staff present. Staff 14 stated he called poison control regarding the incident.

On 2/9/23 at 1:56 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were all present for an interview. Staff 3 stated she was aware Resident 1 ingested the Nystatin powder on 11/16/22 and stated the Nystatin powder was left in Resident 1's room unattended. Staff 2 and Staff 3 stated nurses were to apply Nystatin powder to all residents; not CNAs.

Based on observation, interview and record review it was determined the facility failed to provide grooming assitance and nail care for 4 of 8 sampled residents (#s 1, 14, 15 and 16) reviewed for bowel and bladder and ADL care. This placed residents at risk for unmet needs. Findings include:

1. Resident 15 admitted to the facility in 11/2020 with diagnoses including dementia and anxiety.

A 1/12/23 Quarterly MDS indicated Resident 15's BIMS score was eight indicating moderate cognitive impairment. Resident 15 was totally dependent on one-person assistance with personal hygiene and required extensive one-person assistance with dressing.

A revised care plan dated 1/16/23 revealed Resident 15 had an ADL deficit related to stroke and decreased physical functioning and dementia. Staff were directed to provide one-person assistance with dressing and personal hygiene.

Random observations from 2/5/23 through 2/6/23 revealed Resident 15 in the same blue long sleeve t-shirt which had food stains and food particles all over the entire front of the residents t-shirt.

On 2/7/23 at 9:43 AM Staff 17 (CMA) stated Resident 15 required one-person assistance with dressing and noticed she/he wore the same shirt for a "couple of days."

On 2/7/23 at 11:12 AM Staff 15 PCA (Personal Care Aide) stated Resident 15 required one-person assistance with dressing and she/he was in the same dirty t-shirt on 2/5/23 and 2/6/23.

On 2/7/23 at 8:59 PM Staff 13 (RN) stated Resident 15 had baseline confusion and required one-person assistance with dressing. Staff 13 stated at times Resident 15 refused to remove her/his clothes prior to going to bed and was put to bed with dirty clothing. Staff 13 indicated this behavior was reported to day shift and Staff 13 expected day shift to change out her/his clothing.

On 2/9/23 at 10:45 AM Staff 5 (LPN/Resident Care Manager) stated Resident 15 required a one-person assistance with dressing and staff were expected to change her/his clothing daily. Staff 5 stated if Resident 15 refused staff were expected to re-approach her/him at least three times. Staff 5 stated Resident 15 was known to refuse changing her/his clothing.

On 2/9/22 at 1:56 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were all present for an interview. Staff 2 and Staff 3 stated staff were expected to implement and follow the care plan if Resident 15 refused to be assisted with her/his clothing being changed; staff were to re-approach her/him.

2. Resident 1 was admitted to the facility in 2/2022 with diagnoses including cellulitis, legal blindness and a brain injury.

The 9/6/22 Bedside Care Plan (a tool used by CNAs to provide care) indicated the resident attempted to toilet herself/himself throughout the day and night, "unfortunately Resident 1 was unable to ensure she/he was cleaned properly/new brief application." Staff were to provide incontinence assistance frequently throughout each shift which included peri-care and changing of Resident 1's brief.

A 12/26/22 Annual MDS and 1/12/23 Urinary CAA indicated Resident 1's BIMS score was six indicating severe cognitive impairment. Resident 1 required assistance with toileting and was occasionally incontinent of bladder. Resident 1 was on a diuretic (medication to help rid the body of salt and water) and was at risk for incontinent episodes related to mobility.

A revised care plan dated 1/10/23 revealed Resident 1 had a diagnosis of urinary incontinence related to functional mobility, was at risk for pressure injury, had a history of cellulitis and required assistance with some of her/his ADLs. Resident 1 required staff assistance for ADLs and staff were to provide incontinence care after each incontinent episode. Resident 1 often took herself/himself to the restroom and required staff assistance with hygiene, and a reminder to change her/his brief. Staff were to check her/his incontinence pads with ADL cares and as needed.

Random observations from 2/5/23 through 2/9/23 during the day and evening shift revealed Resident 1 smelled of urine and her/his bedroom including bed, bedding and bathroom had a strong urine odor that permeated out into the hallway.

A review of the electronic medical record revealed no information regarding if Resident 1 refused assistance with incontinence care or was assisted on a regular basis regarding her/his incontinence care needs.

On 2/5/23 at 1:29 PM Resident 1 stated she/he took herself/himself to the bathroom all the time without assistance.

On 2/7/23 at 9:43 AM Staff 17 (CMA) stated Resident 1 "always" smelled of urine and her/his bedroom and bathroom had a strong odor. Staff 17 stated she believed Resident 1 toileted herself/himself and did not require assistance from staff.

On 2/7/23 at 11:22 AM Staff 15 (Personal Care Aide) stated Resident 1 was "pretty independent" and made "messes." Staff 15 stated Resident 1 smelled of "strong" urine including her/his clothing. Staff 15 stated her/his room and bathroom "always" smelled like urine and there were times when her/his dirty laundry basket was full of urine-soaked clothing or bedding and not emptied timely.

On 2/7/23 at 12:27 PM Staff 16 (RN) stated Resident 1 smelled of urine, including her/his room, bedding and bathroom. Staff 16 stated there were times Resident 1 was wet and her/his bed soaked and leaking urine from the previous shift. Staff 16 stated Resident 1 was independent with toileting and changing her/his own brief.

On 2/7/23 at 10:07 PM Staff 12 (CNA) stated Resident 1 was independent for incontinence care but did smell like urine. Staff 12 stated Resident 1's mattress was "often" soaked of urine and Resident 1 would sometimes hid her/his wet briefs.
On 2/8/23 at 9:27 AM Staff 10 (CNA) and Staff 18 (CMA/Staffing Coordinator) both stated Resident 1 required some assistance with incontinence care and at times refused assistance. Staff 10 and Staff 18 stated Resident 1 smelled of urine and she/he was a "heavy wetter" because she/he had difficulty getting up at night. Staff 10 stated her/his bed was "often" soaked in urine and her/his room and bathroom had a "very strong" smell of urine all the time. Staff 10 stated she reported concerns to the resident care managers.

On 2/9/23 at 1:56 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were all present for an interview. Staff 1 and Staff 2 stated staff were expected to keep Resident 1 odor free as much as possible and to ensure appropriate incontinence care was provided. Staff 1, Staff 2 and Staff 3 stated CNAs were to change bedding when and if needed but housekeeping was responsible for cleaning of Resident 1's room. Staff 2 was not aware laundry was not being picked up in Resident 1's room.

,
3. Resident 16 was admitted to the facility in 3/2019 with diagnoses including Alzheimer's (memory loss and impaired mental functions) and Parkinson's Disease (disorder of central nervous system).

Resident 16's 12/8/22 Quarterly MDS revealed she/he was totally dependent on staff with two-person physical assistance needed for bed mobility. She/he was assessed as always incontinent of bowel and bladder.

Resident 16's 12/20/21 Bedside Care Plan revealed she/he was incontinent of both bowel and bladder, directed staff to provide incontinence care every two hours/PRN and to apply a barrier cream PRN.

On 2/8/23 at 12:51 PM Staff 2 (Regional Nurse Consultant/Infection Preventionist) provided the Point of Care History for ADLs/toilet use for 1/1/23 to 2/8/23. Review of the documentation revealed the following care was provided:
-1/3/23 at 8:48 PM one-person physical assistance with total dependence.
-1/5/23 at 3:56 AM one-person physical assistance with total dependence.
-1/7/23 activity did not occur.
-1/12/23 at 1:39 PM one-person physical assist with total dependence.

No additional information was provided to indicate Resident 16's incontinence care was completed every two hours and PRN as ordered.

Random observations from 2/5/23 through 2/9/23, between 8:00 AM to 5:00 PM revealed Resident 16 smelled of urine and her/his bedroom had a strong urine odor which permeated out into the hallway.

On 2/9/23 at 2:54 PM Staff 21 (CNA) stated Resident 16 often held her/his urine for long periods of time and the urine often had a strong odor. Resident 16 often soaked and over flowed her/his incontinence briefs. Resident 16 was often in need to be reapproached to change the soaked incontinence briefs.

On 2/10/23 at 10:32 AM Staff 1 (Administrator), Staff 2 and Staff 3 (DNS) acknowledged they expected residents to be checked and incontence briefs changed every two hours or as needed.
, 4. Resident 14 was admitted to the facility in 9/2018 with diagnoses including Alzheimer's disease, schizoaffective disorder (a chronic mental health disorder characterized by symptoms such as hallucinations or delusions) and general muscle weakness.

An 11/28/22 Quarterly MDS assessment revealed Resident 14 required one person limited assistance to complete personal hygiene tasks.

On 2/5/23 at 12:43 PM Resident 14's finger and toe nails were observed to be long and untrimmed.

On 2/8/23 at 2:19 PM Resident 14's nails on her/his left hand were observed to be trimmed but the nails on her/his right hand and toes remained long and untrimmed. Resident 14 reported she/he trimmed her/his fingernails on her/his left hand and stated she/he usually forgot to ask for help to trim her/his other nails.

No evidence was found in Resident 14's clinical record to indicate staff provided regular assistance with nail care.

On 2/8/23 at 2:11 PM Staff 19 (RN) stated the trimming nails task was not listed on Resident 14's TAR. She confirmed Resident 14's nail care was expected to be completed once a week by a CNA.

On 2/9/23 at 12:56 PM Staff 2 (Regional Nurse Consultant/Infection Preventionist) acknowledged the need to provide nail care for residents who were dependent on staff for ADLs.

Based on observation, interview and record review, it was determined the facility failed to provide an ongoing program to support individual activity interests and preferences for 1 of 1 sampled resident (#10) reviewed for pain. This placed residents at risk for unmet psychosocial needs. Findings include:

The facility's 6/2018 Activity Programs Policy statement indicated the activity programs were designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident ... Activity programs included activities which promoted the following: self-esteem; comfort; pleasure; education; creativity; success; and independence.

Resident 10 admitted to the facility in 1/2018 with diagnoses including blindness, pain and depression.

Resident 10's 11/10/22 activities care plan revealed she/he used discouraging remarks and language when around other residents, which made other residents uncomfortable and upset. The goal was for Resident 10 to be "allowed to participate in facility activities while not impacting other residents' quality of life." The intervention was the activity department had a "trigger" word if she/he became agitated. The words "slow down" were supposed to remind her/him to stop and think... "A meeting was held with the Administrator, DNS, Activities Director" and her/him to plan for her/him to re-enter activities. No information in the care plan directed staff towards Resident 10's specific leisure activity interest, preferences or diversional activity interests for in-room or group activities.

Resident 10's activities Bedside Care Plan, dated 9/30/22, directed staff that Resident 10 liked to attend activities in the main dining room, to remind her/him of daily activities and encourage participation. No information directed staff towards Resident 10's specific leisure activity interest, preferences or diversional activity interests for in-room or group activities.

Resident 10's 12/2022 Activity Participation documented her/his activity participation as the following:
-12/3/22 one-on-one, she/he wanted to talk to administration about coming back to group activities. Activity Director was to let administration know.
-12/6/22 one-on-one, she/he was interested to meet the new activity assistant and put some holiday decoration on the window.
-12/7/22 one-on-one, she/he received a holiday card from staff.
-12/14/22 one-on-one, she/he had a good day and lunch with a friend.
-12/17/22 one-on-one, covered her/him with blanket on 12/16/22.
-12/23/22 group, she/he went to a Christmas party.
-12/25/22 one-on-one, she/he said "Merry Christmas" to Activity Director.
-12/31/22 one-on-one, she/he experienced breathing issues and Activity Assistant obtained assistance from staff.

Resident 10's 1/2023 Activity Participation documented her/his activity participation as the following:
-1/1/23 one-on-one, she/he received an activity calendar and won a prize from an in-room game.
-1/6/23 one-on-one, gave her/him some water and made sure was comfortable.
-1/19/23 game, bingo for 30 minutes.
-1/24/23 group, she/he was thankful.
-1/24/23 group game of Yahtzee.
-1/26/23 group Bingo.
-1/29/23 group Bingo.
-1/31/23 group trivia.

The 1/19/23 Quarterly MDS indicated Resident 10's BIM score was 14 (cognitively intact).

In an interview on 2/8/23 at 1:21 PM Resident 10 stated he/she slept often during the day due to boredom. Resident 10 stated she/he enjoyed Bingo and Yahtzee games.

The facility's Activity Calendar reviewed on 2/9/23 at 2:18 PM revealed Bingo and Yahtzee were offered on average four times a week.

On 2/9/23 at 11:15 AM Resident 10 was observed in her/his bed during the Bingo group activity. Resident 10 stated she/he was told by staff she/he could not go to Bingo today due to bowel care.

On 2/9/23 at 11:48 AM Staff 9 (Activity Director) stated Resident 10 was banned from group activities by the past administration due to her/his behavior. Staff 9 stated Resident 10 could come back to groups and the activity care plan included the intervention with a "safe" word for behaviors. Staff 9 stated all the one-on-one and group activities were documented on the Activity Participation section in the electronic health records. Staff 9 revealed groups often were in low attendance due to staffing shortages and residents were not able to get to groups. Staff 9 revealed no additional individual one-on-one activities or group activities which were person-centered to meet Resident 10's individual leisure interests and diversional activities.

On 2/10/23 at 10:31 AM Staff 1 (Administrator) stated he expected each resident to have an individual activity program and care plan.

2. Resident 16 admitted to the facility in 3/2019 with diagnoses including Alzheimer's (destroys memory and mental functions) and Parkinson's Disease (disorder of central nervous system).

Resident 16's 8/2/20 care plan intervention included to assist her/him to change positions, transfers, and bed mobility as needed. She/he called or staff assistance to help with repositioning. Bed mobility directed a two person assistance was required.

Resident 16's 1/4/21 Physician Order directed staff to turn/reposition every two hours while in bed, four times a day at 7:00 AM, 3:00 PM, 5:00 PM and 9:00 PM.

Resident 16's 1/4/21 Physician Order directed staff to "turn/reposition every two hours while in bed, every two hours, 12:00 AM, 2:00 AM and 4:00 AM."

Resident 16's 12/20/21 Bedside Care Plan for positioning indicated Resident 16 called for staff when she/he wanted to be readjusted in bed. The Bedside Care Plan lacked the physician order directions to turn/reposition.

Record review of the 1/1/23 to 2/8/23 Point of Care Turning/Repositioning revealed Resident 16 was repositioned one to three times a day.

On 2/5/23 Resident 16 was observed in her/his bed, on her/his right side, legs bent, head of bed tilted upward, and in the same position on the following times: 11:20 AM, 12:24 PM, 2:27 PM, and 3:37 PM.

On 2/9/23 at 2:54 PM Staff 21 (CNA) stated she was directed to follow the bedside care plan for resident care needs. Staff 21 stated Resident 16 was not turned or repositioned every two hours.

On 2/10/23 at 10:32 AM Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) acknowledged they expected staff to follow the physician orders as directed.




, Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 5 sampled residents (#s 16 and 273) reviewed for edema and positioning. This placed residents at risk for adverse outcomes related to edema and positioning. Findings include:

1. Resident 273 was admitted to the facility in 1/2023 with diagnoses including edema (swelling caused by excess fluid in body tissues).

A physician's order dated 1/12/23 indicated Resident 273 was to be weighed daily and weight changes were to be reported to the resident's provider.

Resident 273's 1/18/23 Dehydration/Fluid Maintenance CAA indicated staff were to ensure accurate weights were taken daily each morning before breakfast and the charge nurse was to monitor for any increased swelling and notify the resident's provider.

A review of Resident 273's daily weight records from 1/20/23 through 2/8/23 revealed missing weights on the following days: 1/25/23, 1/26/23, 1/30/23, 2/2/23, 2/3/23 and 2/4/23.

A review of Resident 273's daily weight records from 1/20/23 through 2/7/23 revealed the following weight changes:
-On 1/20/23 the resident weighed 268.4 pounds. On 1/21/23 the resident weighed 244 pounds. This represented a 24.4 pound weight change.
-On 1/22/23 the resident weighed 247.6 pounds. This represented a 3.6 pound weight change.
-On 1/23/23 the resident weighed 237 pounds. This represented a 10.6 pound weight change.
-On 1/24/23 the resident weighed 248.6 pounds. This represented a 11.6 pound weight change.
-On 1/27/23 the resident weighed 250.8 pounds. This represented a 2.2 pound weight change.
-On 1/28/23 the resident weighed 250.2 pounds. This represented a 0.6 pound weight change.
-On 1/29/23 the resident weighed 250.4 pounds. This represented a 0.2 pound weight change.
-On 1/31/23 the resident weighed 247.8 pounds. This represented a 2.6 pound weight change.
-On 2/1/23 the resident weighed 248.2 pounds. This represented a 0.4 pound weight change.
-On 2/5/23 the resident weighed 240.8 pounds. This represented a 7.4 pound weight change.
-On 2/6/23 the resident weighed 244 pounds. This represented a 3.2 pound weight change.
-On 2/7/23 the resident weighed 241.1pounds. This represented a 2.9 pound weight change.

On 2/9/23 at 11:40 AM Staff 2 (Regional Nurse Consultant/Infection Preventionist) confirmed the resident was missing daily weights and re-weights as well as consistent notification of the provider of the weight changes the resident experienced, especially the weight changes noted on 1/21/22, 1/23/23, 1/24/23 and 2/5/23. Staff 2 stated the original order was unclear and reporting parameters should have been clarified at the time of admission.

3. 1. Resident 6 was admitted to the facility in 10/2010 with diagnoses including heart failure and chronic kidney disease.

A 6/16/22 Event Report/Investigation revealed the following:

-Resident 6 was found on the floor in her/his bedroom and had fallen on her/his way to the bathroom.
-Resident 6 reported she/he was attempting to go to the bathroom when she/he fell on the floor.
-Resident 6 was assessed and was assisted up into her/his chair by three staff members. Resident 6 complained of left sided rib cage pain, was short of breath and thought she/he "broke" her/his ribs.
-The resident was agitated and anxious.
-Resident 6 was sent out to the hospital for further assessment.
-A report from the hospital confirmed the resident fractured six ribs and sustained a fracture to her/his hip that was non-operable.
-The incident report did not include when the resident was last toileted, ADL care provided or when resident was last seen (in bed, chair). There were no witness statements included aside from Staff 5 (LPN/Resident Care Manager) who entered the room first and Staff 18 (Former RN) who assisted when Resident 6 was sent out to the hospital.

On 2/9/23 at 10:22 AM Staff 5 stated she was present on 6/16/22 when Resident 6 fell and she heard her/him calling for help. Staff 5 stated she entered the room and Resident 6 was on the floor, the call light was not activated and she alerted Staff 18 for assistance. Staff 5 stated Resident 6 indicated she/he self-transferred and fell on her/his way to the bathroom and was complaining of shortness of breath and rib pain. Staff 5 stated there were three or four staff in the residents room and assisted her/him to the recliner per her/his request. Staff 5 stated the resident was sent out to the hospital for further evaluation. Staff 5 stated she completed the investigation and should have included witness statements, what the resident was doing prior to the fall, who assisted her/him with toileting or ADL care, if the call light was activated and if any other staff or residents may have witnessed anything unusual. Staff 5 stated once her investigation was completed it was turned into administration for review.

On 2/9/23 at 2:03 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were all present for an interview. Staff 1, Staff 2, and Staff 3 indicated they were new to the building and were not present for the 6/16/22 incident. Staff 2 stated she did not care for the current forms utilized regarding incident reports and would expect staff to complete a thorough investigation. Staff 2 stated it would be important to include all nursing staff involved, who was assigned the resident, when last toileted and when last seen. The investigation should be initiated by nursing staff and include witness statements or anyone who may have been involved or close to the area that may have heard what occurred to assist with ruling out abuse and neglect. Staff 2 stated the investigation would then be reviewed by Staff 2 and Staff 3 to ensure all facts were accurate or if further investigation needed to be completed.


, Based on observation, interview and record review it was determined the facility failed to ensure interventions were in place and followed to reduce the risk of accidents for 3 of 6 sampled residents (#s 6, 8 and 273) reviewed for nutrition and accidents. This placed residents at risk for repeated choking incidents and falls. Findings include:

1. Resident 8 was admitted to the facility in 9/2014 with diagnoses including stroke and hemiplegia (paralysis of one side of the body).

Resident 8's 1/16/23 Quarterly MDS revealed the resident was cognitively intact, was independent with eating outside of set-up assistance from staff and did not experience any swallowing issues.

A 2/1/23 facility Event Report, completed by Staff 6 (LPN/Resident Care Manager) revealed the following on 2/1/23 at 12:22 PM:
- Description: Choking event;
- Event Details: Resident ate lunch and a piece of bread got stuck in her/his throat;
- Location: Resident spouse's room;
- Notes: During lunch, the resident sat up in her/his wheelchair in her/his spouse's room when she/he had a choking episode. The resident was found by Staff 34 (CNA) after her/his spouse yelled for help. Staff 34 performed an abdominal thrust and a piece of sandwich came out of her/his mouth. The resident was repositioned and given water.

The "final report" portion summarized: Resident 8 declined the offer to downgrade her/his diet to a softer texture and was encouraged to dine in the main dining room for all meals due to her/his risk of choking/aspirating. Orders were received for speech therapy to evaluate and treat which was to occur on 2/8/23.

An update was made to Resident 8's Care Plan on 2/1/23 which included the following goal and interventions:
-The resident was to remain free from choking.
-Speech therapy to evaluate and treat.
-Staff to ensure proper positioning during meals.
-Staff to remind the resident to take small sips of water between each bite.
-Staff to encourage the resident to eat her meals in the main dining room.

A review of the resident's Bedside Care Plan, updated 9/30/22, did not indicate the resident was at risk for choking and did not include any interventions to prevent choking.

Observations on 2/7/23 between 12:10 PM to 1:01 PM revealed the following:
- At 12:10 PM Staff 21 (CNA) placed the resident's meal tray on her/his overbed table in her/his room. Staff 21 woke up Resident 8 and elevated her/his bed to a 45 degree angle, handed the resident her/his call light and left the room.
- No staff were present in Resident 8's hall from 12:21 PM to 12:30 PM.
- At 12:34 PM Staff 17 (CMA) entered Resident 8's room, raised the head of the bed to 60 degrees, administered medications and left the room.
- No staff were present in Resident 8's hall from 12:37 PM to 12:40 PM.
- No staff, outside of a housekeeper, were present in Resident 8's hall from 12:48 PM to 12:51 PM.
- No staff were present in Resident 8's hall from 12:52 PM to 1:00 PM.
- At 12:56 PM Resident 8 was asleep with food in her/his mouth.
- At 1:01 PM Staff 15 (Personal Care Assistant) entered Resident 8's room.

Interviews conducted on 2/7/23 between 1:02 PM to 1:22 PM with Staff 10 (CNA), Staff 17 (CMA), Staff 21 (CNA) and Staff 33 (CNA) indicated they all utilized the resident's Bed Side Care Plan to gain information on how to care for residents. Staff 10, Staff 17, Staff 21 and Staff 33 stated they were unaware Resident 8 had a choking episode, stated the resident was independent with regards to eating outside of set-up assistance and were not aware Resident 8 was at risk for choking.

On 2/7/23 at 1:30 PM Staff 16 (RN) stated she was unsure if Resident 8 had any interventions in place related to eating. Staff 16 reviewed the resident's Bed Side Care Plan in her/his chart and stated Resident 8 was independent at mealtimes.

On 2/7/23 at 2:23 PM Staff 6 (LPN/Resident Care Manager) stated after the 2/1/23 choking incident staff were to encourage the resident to take small sips of water between bites of food, encourage the resident to take small bites of food and ensure appropriate positioning for Resident 8 at mealtimes. Staff 6 stated she expected the head of a resident's bed to be elevated to as close to 90 degrees as possible when eating. Staff 6 reviewed the resident's Care Plan and Bed Side Care Plan and confirmed they did not match.

On 2/8/23 at 8:59 AM Staff 34 (CNA) stated he discovered Resident 8 choking on 2/1/23 after being alerted by the resident's spouse who yelled for help. He stated he gave the resident a few thrusts, and after which, some bread came up and Resident 8 was able to fully communicate. Staff 34 stated staff were expected to be present in each hall during mealtimes in case of incidents such as this.

On 2/8/23 at 12:10 PM Staff 2 (Regional Nurse Consultant/Infection Preventionist) stated she gathered basic information about the choking incident and provided an in-service to staff on 2/7/23. Staff 2 stated she asked the resident on 2/7/23 if she/he was willing to eat breakfast in the dining room on 2/8/23 to which Resident 8 agreed. Staff 2 stated the in-servicing related to this event should have occurred immediately after the incident on 2/1/23, and according to the care plan interventions from 2/1/23, the resident should have been supervised at mealtimes until further instruction was provided post her/his speech therapy evaluation on 2/8/23. Staff 2 confirmed the staff failed to provide appropriate and sufficient supervision to Resident 8 following the choking incident on 2/1/23.

2. Resident 273 was admitted to the facility in 1/2023 with diagnoses including fracture of left leg.

Resident 273's 1/18/23 Admission MDS indicated the resident was cognitively intact and totally dependent on two or more staff assistance with toileting and transferring.

A review of Resident 273's 1/22/23 Care Plan revealed the following:
- The resident was at risk to fall (as evidenced by the resident's recent fracture as a result of a fall).
- The resident required assistance from two staff with transfers.
- The resident was dependent on two staff with toileting needs.

A 1/23/23 facility Event Report, completed by Staff 19 (RN) specified the following on 1/23/23 at 12:20 PM:
- Description: Controlled witnessed fall from standing to sitting on floor;
- Event Details: [Resident] received care during fall, standing;
- Location: Resident room;
- Name of person reporting: Staff 21 (CNA);
- Resident interview: [Resident] was stood and held on to grab bar outside of restroom in [resident] room and had controlled slide to the floor;
- Staff/Other Interview: [Resident] stood and held on to grab bar outside restroom in [resident] room and had controlled slide to the floor.

The facility's Occurrence Investigation Final Summary, signed by Staff 6 (LPN/Resident Care Manager) but not dated, included the following:
- The resident had been experiencing pain and edema in her/his lower extremities which may have contributed to the fall;
- Resident had a fall care plan initiated; and
- Ensure two staff assisted the resident with transfers and standing cares for safety.

On 2/10/23 at 9:13 AM Staff 21 stated she assisted Resident 273 out of the resident's bathroom on 1/23/23 when the resident grabbed the assist bar outside of her/his bathroom and attempted to swing herself/himself into her/his wheelchair. Staff 21 stated she assisted the resident to the ground. Staff 21 stated she thought Resident 273 required assistance of two staff with transfers and toileting at the time of the resident's admission but thought the resident required assistance of one staff person at the time of the 1/23/23 fall.

On 2/10/23 at 9:43 AM Staff 3 (DNS) confirmed Staff 21 did not implement or follow Resident 273's care plan at the time of the 1/23/23 fall.

4. A 10/28/22 complaint was received which alleged the facility was "understaffed" and call light wait times were long and took "forever" to receive care.

A 11/1/2020 Waiver Request Form approved by DHS (Department of Human Service) revealed the following:
- The facility was approved for a wireless call light system through 12/31/30.
-The wireless call light system would provide improved functionality a traditional call light system by alerting staff members immediately on their handheld devices and workstations.
-The system additionally allowed text communication.

Random observations from 2/5/23 through 2/9/23 during day and evening shift revealed no visual call light systems on 2 of 2 halls and strong urine odors and feces were present throughout day and evening shift.

On 2/5/23 at 3:19 PM Staff 21 (CNA) stated the facility was "often" short staffed and utilized PCAs (Personal Care Aide) to assist with ADL care needs. Staff 21 stated the PCAs were to be supervised or paired up with a CNA but that did not always occur.

On 2/5/23 at 3:28 PM Staff 20 (PCA) stated she was assigned five to seven residents and was supposed to work with a CNA but was not always assigned to a CNA. Staff 20 stated she asked for a CNA if she needed to use the mechanical lift or a two-person transfer.

On 2/7/23 at 9:25 AM Staff 17 (CMA) stated the facility was "always" short staffed regarding CNA coverage and call light wait times were to be answered in less than 10 minutes. Staff 17 stated she did not know how long call lights were on because she did not have the wireless application on her phone so would not be "alerted" if a call light was activated. Staff 17 stated "I probably should download the application on my personal phone."

On 2/7/23 at 12:27 PM Staff 16 (RN) stated there were not enough CNAs in the building to provide appropriate ADL care and resident call light wait times were greater than 30 minutes. Staff 16 stated residents would sat in a wet and soiled brief because the lack of CNA coverage. Staff 16 stated mealtimes were difficult because "many" residents required assistance with eating and it delayed residents who had their call light activated. Staff 16 stated if she was at the nurses' station, she could access the call light system but when out on the floor it was more difficult to know when a call light was activated.

On 2/7/23 at 1:29 PM Staff 15 (PCA) stated she was typically assigned six to eight residents and "many" residents at the facility had high acuity needs. Staff 15 stated call light wait times were up to 45 minutes (was expected to be answered in six or seven minutes) and residents sat in wet and soiled briefs due to not having enough staff available. Staff 15 stated not all residents were able to receive scheduled showers or restorative services. Staff 15 stated not "everyone" had the wireless call light system downloaded on their phones.

On 2/7/23 at 3:20 PM Staff 14 (LPN) stated CNAs were responsible for call lights and were in and out of rooms "a lot." Staff 14 stated the call light system was a wireless application and he did not have the application downloaded on his phone. When asked how he knew how long a call light was on or activated he stated, "I just keep tabs on the residents, staff, don't take breaks and that's how I roll."

On 2/7/23 at 9:38 PM Staff 12 (CNA) stated the facility was "often" short CNA coverage on all shifts. Staff 12 stated call light wait times would range from 20 minutes up to or greater than 48 minutes and not all staff answered call lights. Staff 12 sated residents complained of long call light wait times and sat in wet and soiled briefs. Staff 12 stated the facility had "many" resident who required a mechanical lift or two-person assistance with ADL care. Additionally, Staff 12 stated room 35 often had "soaked" bedding including her/his mattress and no housekeeping in the past few weeks to assist with clean-up because they all quit.

On 2/8/23 at 9:27 AM Staff 10 (CNA) stated the facility was "always" short staffed for CNA coverage and PCAs were "often" paired up or hall partners, and PCAs were to be overseen by a CNA. Staff 10 stated call light wait times ranged from 18 minutes or greater than 20 minutes and residents complained of sitting in wet and soiled briefs. Staff 10 stated not all staff answered or even had the wireless application on their phones to know when and if a resident activated a call light.

On 2/8/23 at 3:05 PM a list was provided which revealed how many residents in the facility required two-person physical assistance, a mechanical lift, required assistance with eating and residents in the facility who had behaviors:
-Nine residents required a mechanical lift (which required two-staff person assistance)
-14 residents required two-person physical assistance.
-Four residents required assistance with eating and three residents required supervision/frequent checks.
-Seven residents had behaviors.

On 2/8/23 at 10:24 AM Staff 28 (CMA/Staffing Coordinator) acknowledged the facility struggled with ensuring CNA coverage was provided and utilized PCAs "a lot." Staff 28 stated she was not always able to pair up a CNA and a PCA together because the facility did not have enough CNAs to work. Staff 28 stated the current mechanism for the call light system was not "always consistent" and not all staff used the call light system or had the application on their phone. Staff 28 stated all staff were expected to answer call lights but were not always "all hands-on deck" when answering call lights or even knew if a call light was activated.

On 1/12/23 at 1:19 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) acknowledged the facility struggled with CNA coverage and utilized PCAs to ensure they had enough staff to assist with ADL care for residents. Staff 2 acknowledged PCAs were to be supervised and limited to what cares they could provide by themselves. Staff 2 stated call lights were an issue because not all staff utilized the wireless call light system or had access to it. Staff 1 and Staff 2 stated it was expected all staff were responsible for answering call lights.
,
5. During the Resident Council meeting on 2/7/23 at 2:30 PM, two residents, who could independently ambulate, were in attendance. A third resident came to the meeting at 2:46 PM and stated she/he was late due to lack of staff. At 3:00 PM another resident came to the meeting and stated she/he was late due to lack of staff assistance. They reported at least one other resident indicated she/he wanted to attend but they did not know why she/he was not at the meeting.

During the meeting the residents stated the facility was often short-staffed to provide care. The residents indicated staff were not appropriately trained or oriented to provide care and the call lights often took 45 minutes to an hour to get assistance.

On 2/9/23 at 11:48 AM Staff 9 (Activity Director) stated on 2/7/23 she reminded staff and residents at 1:45 PM about the Resident Council meeting which was to start at 2:30 PM. Staff 9 stated group activity attendance was low at times due to lack of staff.

On 2/8/23 at 10:24 AM Staff 28 (CMA/Staffing Coordinator) acknowledged the facility struggled to ensure CNA coverage was provided. Staff 28 stated the current mechanism for the call light system was not "always consistent" and not all staff used the call light system or had the application on their phone. Staff 28 stated all staff were expected to answer call lights but were not always answered or even knew if a call light was activated.

On 1/12/23 at 1:19 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) acknowledged the facility struggled with CNA coverage to ensure they had enough staff to assist with ADL care for residents. Staff 2 stated call lights were an issue because not all staff utilized the wireless call light system or had access to it. Staff 1 and Staff 2 stated it was expected all staff were responsible for answering call lights.







, Based on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to attain and maintain the highest practicable wellbeing for 3 of 8 sampled residents (#s 8, 17, 273) and 2 of 2 halls reviewed for staffing. This placed residents at risk for lack of timely assistance for ADL care needs. Findings include:

1. Resident 8 was admitted to the facility in 9/2014 with diagnoses including stroke.

Resident 8's 1/16/23 Quarterly MDS revealed the resident was cognitively intact.

On 2/5/23 at 11:52 AM Resident 8 stated she/he waited up to an hour for staff to respond to her/his call light and regularly waited over 30 minutes for staff to respond.

On 2/8/23 at 8:41 AM Staff 10 (CNA) stated staff were expected to answer resident call lights within five minutes but that was not always realistic. Staff 10 stated she was not able to consistently complete all of her assigned duties, including answering call lights in a timely manner.

A review of Resident 8's Alarm History from 1/29/23 through 2/4/23 revealed the following call light response times:
- 1/30/23: 30 minutes, 17 seconds;
- 1/31/23: 35 minutes, 25 seconds;
- 2/1/23: 1 hour, 36 minutes, 7 seconds;
- 2/3/23: 39 minutes; 52 seconds;
- 2/3/23: 57 minutes, 15 seconds.

On 2/8/23 at 12:21 PM Staff 2 (Regional Nurse Consultant/Infection Preventionist) stated she expected staff to answer call lights within 15 minutes. Staff 2 reviewed the resident's Alarm History and confirmed the staff did not answer call lights in a timely manner.

2. Resident 17 was admitted to the facility in 1/2021 with diagnoses including stroke.

Resident 17's 1/9/23 Quarterly MDS revealed the resident was cognitively intact.

On 2/5/23 at 12:28 PM Resident 17 stated she/he regularly waited over 30 minutes for staff to respond to her/his call light.

On 2/8/23 at 8:41 AM Staff 10 (CNA) stated staff were expected to answer resident call lights within five minutes but that was not always realistic. Staff 10 stated she was not able to consistently complete all of her assigned duties, including answering call lights in a timely manner.

A review of Resident 17's Alarm History from 1/22/23 through 1/26/23 revealed the following call light response times:
- 1/22/23: 37 minutes, 23 seconds; and
- 1/22/23: 35 minutes, 16 seconds.

On 2/8/23 at 12:21 PM Staff 2 (Regional Nurse Consultant/Infection Preventionist) stated she expected staff to answer call lights within 15 minutes. Staff 2 reviewed the resident's Alarm History and confirmed the staff did not answer call lights in a timely manner.

3. Resident 273 was admitted to the facility in 1/2023 with diagnoses including fracture of left fibula.

Resident 273's 1/18/23 Admission MDS revealed the resident was cognitively intact.

On 2/5/23 at 11:09 AM Resident 273 stated she/he had to wait long periods of time for staff to respond to her/his call light, at times up to 40 minutes. Resident 273 stated she/he had numerous incontinence episodes as a result of staff not responding to her/his call light in a reasonable amount time.

On 2/8/23 at 8:41 AM Staff 10 (CNA) stated staff were expected to answer resident call lights within five minutes but that was not always realistic. Staff 10 stated she was not able to consistently complete all of her assigned duties, including answering call lights in a timely manner.

A review of Resident 273's Alarm History from 1/22/23 through 2/6/23 revealed the following call light response times:
- 1/22/23: 1 hour, 37 minutes, 50 seconds;
- 1/23/23: 53 minutes, 22 seconds;
- 1/23/23: 50 minutes, 50 seconds;
- 1/23/23: 40 minutes, 8 seconds;
- 1/23/23: 35 minutes, 20 seconds;
- 1/24/23: 45 minutes, 26 seconds;
- 1/25/23: 34 minutes, 33 seconds;
- 1/25/23: 30 minutes, 39 seconds;
- 1/26/23: 34 minutes, 37 seconds;
- 1/30/23: 1 hour, 32 minutes, 23 seconds;
- 1/31/23: 30 minutes, 58 seconds;
- 1/31/23: 40 minutes, 37 seconds;
- 2/1/23: 58 minutes, 41 seconds;
- 2/3/23: 1 hour, 3 minutes, 13 seconds;
- 2/3/23: 58 minutes, 21 seconds;
- 2/3/23: 41 minutes, 4 seconds;
- 2/4/23: 30 minutes, 43 seconds;
- 2/5/23: 33 minutes, 3 seconds; and
- 2/6/23: 45 minutes, 0 seconds.

On 2/8/23 at 12:21 PM Staff 2 (Regional Nurse Consultant/Infection Preventionist) stated she expected staff to answer call lights within 15 minutes. Staff 2 reviewed the resident's Alarm History and confirmed the staff did not answer call lights in a timely manner.

Based on observation, interview and record review it was determined the facility failed to employ kitchen staff who met the required qualifications for 1 of 1 kitchen reviewed for competent staffing. This placed residents at risk for unmet nutritional needs. Findings include:

On 2/7/23 at 9:27 AM Staff 7 (Kitchen Manager) was observed working in the kitchen and directed staff. He reported he did not yet have Dietary Manager qualifications because he did not complete the required coursework. He stated Staff 1 (Administrator) planned to arrange for him to enroll in the required courses.

On 2/7/23 at 1:04 PM Staff 1 reported he did not yet enroll Staff 7 in the required training to be the facility's Dietary Manager. He stated he did not know when the training was scheduled to start.

Based on interview and record review it was determined the facility failed to ensure snacks were available at non-traditional times or outside of scheduled meal service times for 1 of 1 kitchen and 1 of 5 sampled residents (#6) reviewed for meals. This placed residents at risk for unmet nutritional needs. Findings include:

1. Resident 6 admitted to the facility in 10/2010 with diagnoses including heart failure and chronic kidney disease.

A public complaint was received on 10/28/22 which alleged Resident 6 was not provided with a snack at night or other liquids aside from water due to budget cuts.

On 2/7/23 at 1:15 PM Staff 15 (Personal Care Aide) stated there was a shortage of snacks and beverages in the fall of 2022 and she was told by administration to only allow two drinks per meal because of the budget and the facility had limited snacks. Staff 15 stated this was an on-going concern because when snacks were available to residents they were limited and "often" ran out because the kitchen did not supply enough.

On 2/7/23 at 9:38 PM Staff 12 (CNA) stated she recalled in the fall of 2022 and in 2/2023 snacks were limited and not always available to residents. Staff 12 stated kitchen staff were not good at ensuring there was enough snacks. Staff 12 stated there was no access to the kitchen once it was closed.

On 2/7/23 at 10:33 PM Staff 11 (CNA) stated snacks and beverages were in "limited supply" in 9/2022 and 10/2022 and Resident 6 had concerns regarding snacks and beverages. Staff 11 stated snacks were an ongoing concern because kitchen staff did not make enough sandwiches or provide enough snacks to last during evening and night shift and they "always" ran out of peanut butter and jelly sandwiches.

On 2/8/23 at 9:27 AM Staff 10 (CNA) stated snacks were a concern in the fall of 2022 and she was told it was due to budget cuts. Staff 10 stated residents were limited to two beverages at meals and could only offer snacks at 3:00 PM and 10:00 PM daily. Staff 10 stated residents did not receive snacks because during the fall of 2022 the facility did not have enough staff on the floor to assist with passing out snacks for residents.

On 2/8/23 at 10:54 AM Staff 28 (CMA/Staffing Coordinator) stated snacks were an issue because in the fall of 2022 a resident could only receive one sandwich, one juice and a sign was posted indicating residents could only have "water at night." Staff 28 stated the residents were "not happy."

On 2/9/23 at 2:03 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were all present for an interview. Staff 2 and Staff 3 stated the prior administration posted signs for residents limiting the number of snacks, water and coffee and residents were "not pleased." Staff 3 stated all signs were removed and they did not have limited snacks or beverages. Staff 1, Staff 2 and Staff 3 were not aware there was on-going concerns regarding not having enough snacks on evening and night shift for residents.

, 2. During the Resident Council meeting on 2/7/23 at 2:30 PM, the residents reported the lack of snack availability and the limited number of juices allowed due to budget costs. The residents stated the snacks often ran out and staff told them the kitchen was closed, therefore no snacks were available. Residents reported they obtained their own snacks due the diagnoses of diabetes and if their blood sugar dropped they needed a snack. Residents also reported the y were limited of two juices per meal and they were only allowed water or coffee between meals due to the budget. Signs directed staff to follow this rule.

On 2/7/23 at 9:38 PM Staff 12 (CNA) stated she recalled in the fall of 2022 and in 2/2023 snacks were limited and not always available to residents. Staff 12 stated kitchen staff were not good at ensuring there was enough snacks made and stocked appropriately. Staff 12 stated there was no access to the kitchen once it was closed.

On 2/8/23 at 10:54 AM Staff 28 (CMA/Staffing Coordinator) stated snacks were an issue because in the fall of 2022 a resident could only receive one sandwich and one juice and a sign was posted which indicated residents could only have "water at night." Staff 28 stated the residents were "not happy."

On 2/9/23 at 2:03 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were all present for an interview. Staff 2 and Staff 3 stated the prior administration posted signs for residents limiting the number of snacks, water and coffee and residents were "not pleased." Staff 3 stated all signs were removed and they did not have limited snacks or beverages. Staff 1, Staff 2 and Staff 3 were not aware there was on-going concerns regarding not having enough snacks on evening and night shift for residents.

Based on observation and interview it was determined the facility failed to ensure foods and bulk ingredients were labeled and stored in a way to minimize food spoilage, failed to maintain a clean and sanitary environment for storage of kitchen equipment and cookware and failed to wear hair restraints in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include:

1. On 2/5/23 at 10:53 AM the walk-in refrigerator in the facility's kitchen was observed to contain the following improperly stored items:
-gallon carton of buttermilk (undated opened carton without a discard date);
-ranch dressing (undated opened bottle without a discard date);
-barbecue sauce (undated opened bottle without a discard date; food debris was observed on the outside of the bottle);
-enchilada sauce (opened plastic jar dated "9/1" without a discard date);
-cocktail sauce (undated opened plastic jar without a discard date);
-sour cream (undated opened 5 gallon tub without a discard date);
-mild chunky salsa (undated opened plastic jar without a discard date);
-sweet pickle relish (undated opened plastic jar without a discard date; food debris was observed on the outside of the jar);
-cole slaw dressing (undated opened plastic tub without a discard date);
-low-fat cottage cheese (undated opened plastic tub that expired 1/20/23);
-strawberry preserves (undated opened tub without a discard date);
-individually-wrapped sandwiches dated "1/2 and 1/31;"
-three plastic bags of sliced bread were observed to be opened and not resealed and
-bulk brown sugar stored with three slices of bread scattered on top of the sugar in the bin.

On 2/5/23 at 11:13 AM Staff 35 (Cook/Dietary Aide) stated all open items in the refrigerator should have been labeled with the date they were opened. He said the sandwiches dated "1/2 and 1/31" and the opened bags of bread needed to be thrown out. He said the bread slices were placed in the bulk brown sugar bin "to keep the sugar moist." Staff 35 stated there was no way of knowing how old the bread was in the absence of a log and the bread needed to be removed and the sugar replaced. Staff 35 acknowledged the items should have been discarded.

On 2/5/23 at 11:26 AM the cookware storage racks positioned in the nook between the ovens and prep area on the north side of the kitchen were observed to have food debris crumbs on the shelves, plastic wrap and bubble wrap on the shelves with the large cooking pots and baking sheets. Staff 35 (Cook/Dietary Aide) confirmed cookware and bakeware should not be stored on dirty shelves.

On 2/7/23 at 9:27 AM Staff 7 (Kitchen Manager) confirmed the undated and improperly stored food was discarded. Staff 7 stated he expected cookware and bakeware storage to be cleaned per the kitchen's cleaning schedule.

2. On 2/5/23 at 10:48 AM Staff 35 (Cook/Dietary Aide) stated he was the staff member in charge of the kitchen for the day and was observed to not wear a hair restraint while he prepared food in the kitchen. Staff 35 was observed to search unsuccessfully for the supply of hair restraints and stated he did not know where they were stored. He confirmed he was required to wear a hair net during meal preparation and service. Staff 18 (Laundry Aide/Dietary Aide) advised Staff 35 where the hair restraints were stored.

On 2/7/23 at 9:32 AM Staff 22 (Cook) was observed to actively prepare food with his beard extending below the bottom hem of his face mask without any additional restraint. Staff 7 (Kitchen Manager) observed Staff 22's beard protruding from his face mask and confirmed it was required to be completely restrained.

Based on observation, interview and record review it was determined the facility failed to implement a restorative nursing program to ensure residents maintained strength and independence with ADLs for 1 of 1 sampled resident (#20) reviewed for rehabilitation services. This placed residents at risk for decreased range of motion and ability to participate in daily tasks. Findings include:

Resident 20 was admitted to the facility in 3/2022 with diagnoses including cerebral infarction (stroke).

A review of Resident 20's skilled therapy notes revealed she/he was discharged from PT and OT on 4/27/22.

A review of the signed 4/2022 physician orders revealed Resident 20 was to receive RA arm exercises once a day on Sunday, Monday, Wednesday and Friday and ambulation assistance from two staff members with a front-wheel walker and a wheelchair on Tuesday, Thursday and Saturday.

On 2/5/23 at 1:58 PM Resident 20 stated she/he required assistance of two people to walk due to weakness and tremors. Resident 20 reported, "They aren't doing as much as they should. I feel like I'm getting weaker."

A review of the 12/2023 and 1/2023 TARs revealed Resident 20 was provided RA services a total of five times for the 31 opportunities during both months.

On 2/9/23 at 10:22 AM Resident 20 reported she/he never refused to walk to the dining room or to complete arm exercises.

On 2/9/23 at 10:28 AM Staff 2 (Regional Nurse Consultant/Infection Preventionist) acknowledged these findings and stated, "The RA program needs to be completely rebuilt from the bottom up."

1. Based on observation, interview and record review it was determined the facility failed to process and transport laundry so as to prevent the spread of infection for 1 of 1 laundry rooms and 2 of 2 laundry carts reviewed for infection control. This placed residents at risk for receiving contaminated laundry and infection. Findings include.

a. According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D:
-Do not leave damp textiles or fabrics in machines overnight.

On 2/6/23 at 3:45 PM Staff 31 (Maintenance Director) stated housekeeping staff loaded and started the final load of laundry at the end of their shift each day, which typically occurred between 3:30 PM to 4:00 PM. Staff 31 stated the load of laundry was left in the washing machine overnight until laundry staff loaded the wet laundry into the dryer at the start of their shift the next morning at around 6:00 AM.

On 2/7/23 at 4:53 PM a load of wet laundry was observed in the washing machine and no laundry staff were present.

On 2/8/23 at 9:15 AM Staff 32 (Laundry) stated the typical process for housekeeping staff was to start a load of laundry at the end of their shift. Staff 32 stated laundry staff were responsible to place wet laundry into the dryer at the start of their shift the next morning. Staff 32 confirmed the washing machine contained a load of washed laundry at the start of her shift.

On 2/8/23 at 9:36 AM Staff 31 (Maintenance Director) indicated he was responsible for supervising the laundry department. Staff 31 stated he was unaware wet laundry could not remain in the washing machine overnight.

b. On 2/8/23 at 9:15 AM Staff 32 (Laundry) explained the process for delivering clean laundry. Staff 32 stated she used two different carts and did not cover the carts during laundry delivery.

On 2/8/23 at 9:36 AM Staff 31 (Maintenance Director) indicated he was responsible for supervising the laundry department. Staff 31 stated he was unaware clean laundry was required to be covered during transport.

On 2/8/23 at 1:17 PM Staff 32 delivered clean laundry using a small uncovered metal cart.

2. Based on interview and record review, it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of waterborne pathogens. This placed all residents at risk for exposure to waterborne pathogens. Findings include:

The facility's 7/23/20 Legionella Policy stated the following:
-A risk assessment will be conducted by the water management team annually to identify where legionella and other opportunistic waterborne pathogens could grow.
-Based on risk assessment, control points will be identified. The list of identified points shall be kept in the water management program.
-Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens.
-Routine infection control surveillance date, water quality data, and rounding data shall be utilized to validate the effectiveness of the water management program.

On 2/8/23 at 9:36 AM Staff 31 (Maintenance Director) provided the surveyor with a floor plan of the facility with highlighted areas identifying areas of potential standing water, which included five water dispensers and an ice machine. Staff 31 was not able to provide any other risk assessment that identified other areas where Legionella or other opportunistic waterborne pathogens could grow and spread. When asked about control measures, Staff 31 stated he did not have a system for checking temperatures in the sinks in empty resident rooms or unused resident bathrooms.

On 2/8/23 at 1:18 PM Staff 1 (Administrator) stated the facility did not do any testing for Legionella. Staff 1 confirmed the facility's vulnerability assessment for Legionella was not up to date and there was no system for monitoring water temperatures throughout the facility.

Based on interview and record review it was determined the facility failed to use antibiotic protocols for 1 of 4 sampled residents (#15) reviewed for ADLs. This placed residents at risk for 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 from Clostridioides difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Core elements of a facility Antibiotic Stewardship Program should include analysis of infections and causative bacteria along with resistant data specific to both the facility and the type of infection (Antibiogram). This information should be given to the prescriber for appropriate antibiotic selection. Further retrospective infection surveillance utilizing McGeers Criteria should be conducted to ensure correct use of antibiotic therapy adherence to facility antibiotic use protocols (AUP) and the treatment of true infections versus colonization.

The facility's 12/2016 Antibiotic Stewardship Policy indicated the following:
- The purpose is to monitor the use of antibiotics in our residents.
- Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community.

Resident 15 was admitted in 11/2020 with diagnoses including Alzheimer's disease and personal history of urinary tract infections.

Resident 15's 1/12/23 Quarterly MDS indicated the resident was moderately impaired in cognitive functioning and was always incontinent of bowel and bladder.

A 1/19/23 Nursing Progress Note completed by Staff 14 (LPN) revealed Resident 15 was confused and experienced visual hallucinations. The Progress Note revealed the resident's vital signs were stable, she/he was afebrile (without fever) and the resident did not experience urinary discomfort.

A 1/20/23 unsigned UA (urine analysis) Report revealed the resident was experiencing the following symptoms: abnormal behaviors, visual hallucinations and the resident's urine was tea colored and odorous.

A 1/20/23 Nursing Progress Note completed by Staff 14 (LPN) revealed a rapid urine test was completed and was positive for leukocytes (white blood cells), blood and nitrates (a type of nitrogen chemical). The Progress Note revealed the on-call provider was notified, the resident received an order for Keflex, the resident's vital signs were stable and she/he was afebrile.

A review of Resident 15's 1/2023 MARs revealed the resident received Keflex (an antibiotic used to treat bacterial infections) from 1/20/23 through 1/27/23 for a urinary tract infection.

A 1/25/23 Encounter Note completed by Staff 36 (Medical Director) revealed the resident was on Keflex for a probable urinary tract infection per UA and abnormal behaviors.

A 1/27/23 fax from Staff 19 (RN) notified the provider the resident's family did not feel the antibiotic [Keflex] was working as the resident continued to experience hallucinations.

A review of Nursing Progress Notes from 1/29/23 through 2/5/23 revealed no mention of Resident 15 being confused or experiencing visual hallucinations, urinary complaints, odorous or discolored urine, abnormal vital signs or fever.

Nursing Progress Notes from 2/6/23 revealed the resident experienced some confusion and visual hallucinations and staff were unable to obtain a urine sample.

A 2/7/23 Nursing Progress Note completed by Staff 5 (LPN/Resident Care Manager) revealed the resident had a telemedicine visit with Staff 8 (NP) who ordered Bactrim DS (an antibiotic used to treat bacterial infections).

A review of Resident 15's 2/2023 MARs revealed the resident was scheduled to receive Bactrim DS from 2/7/23 through 2/11/23 for a urinary tract infection.

On 2/8/23 at 11:41 AM Staff 2 (Regional Nurse Consultant/Infection Preventionist) stated facility nurses were not trained to utilize the McGeers criteria (a tool used in infection surveillance specifying specific symptom criteria and a specific number of criteria when determining infection) with regards to infections and antibiotics. Staff 2 stated this was an area of weakness for the facility and she was in the process of training nurses, including the DNS, on the need to utilize the McGeers criteria. Staff 2 stated she experienced difficulty with the facility's attending NP as the NP did not agree with the regulations around antibiotics and prescribed antibiotics based on only one criteria, such as a change in a resident's behaviors.

On 2/9/23 at 1:25 PM Staff 8 (NP) stated she did not require specific criteria when prescribing an antibiotic but prescribed antibiotics based on the resident's overall clinical picture. Staff 8 stated she recently prescribed antibiotics to Resident 15 because the resident's representative demanded she/he start an antibiotic. Staff 8 stated a repeat culture was not required prior to Resident 15 starting on Bactrim DS on 2/7/23 as this resident "tends to grow the same bugs each time" and "it would be a waste of a test."

Based on interview and record review it was determined the facility failed to ensure call lights were functioning for 2 of 2 halls and 1 of 1 sampled resident (#10) reviewed for pain and call lights. This placed residents at risk for unmet needs. Findings include:

A public complaint was received by the State Agency on 1/12/23 which alleged the facility's call light system did not function sometimes.

On 2/5/23 at 1:14 PM, during initial tour, Resident 18 stated the call light system did not always work. She/he stated other residents told her/him their call lights did not function correctly sometimes.

On 2/7/23 at 2:30 PM the Resident Council met and reported the call light system did not always function.

On 2/9/23 at 11:15 AM Resident 10 stated her/his call light did not always function correctly. Resident 10 stated when her/his call light did not work, the only way to get the staff's attention was to yell for help.

A Call light Alarm History report was requested for Resident 10 for 1/1/23 to 2/8/23. The facility provided 225 pages, with an average 24 entries per page, of Alarm History for that time period. Many pages included the alert descriptions as low battery and/or bed cord removed.

On 2/7/23 at 9:25 AM Staff 17 (CMA) stated she did not know how long call lights were on because she did not have the wireless application on her phone so would not be "alerted" if a call light was activated. Staff 17 stated "I probably should download the application on my personal phone."

On 2/8/23 at 10:24 AM Staff 28 (CMA/Staffing Coordinator) stated the current mechanism for the call light system was not "always consistent" and not all staff used the call light system or had the application on their phone. Staff 28 stated all staff were expected to answer call lights but were not always "all hands-on deck" when answering call lights or even knew if a call light was activated.

On 2/9/23 at 3:04 PM Staff 21 (CNA) stated Resident 10's call light did not always function correctly. Staff 21 reported the staff checked in on her/him more frequently and Resident 10 was able to yell for assistance.

On 2/9/23 at 11:55 AM Staff 31 (Maintenance Director) acknowledged the call light alarm system sometimes did not function correctly. He stated the description of low battery signal was when a battery stopped working and often when a resident held the call light alarm button down for extended periods of time. He stated the description of the bed cord removed was often due to the cord being torn out of the wall unit. Staff 31 stated he replaced Resident 10's in-room call light alarm two times in the past year. Staff 31 stated the facility did have concerns with the current call light alarm system.

On 2/10/23 at 10:38 AM Staff 1 (Administrator) acknowledged the concerns with the functioning of the facility's current call light alarm system. Staff 2 (Regional Nurse Consultant) Staff 2 stated call lights were an issue because not all staff utilized the wireless call light system or had access to it.

Based on observation, interview and record review it was determined the facility failed to ensure a proper functioning ventilation system to prevent odors throughout the facility for 2 of 2 halls reviewed for environment. This resulted with residents living with poor ventilation which did not prevent pervasive odors. Findings include:

The facility's Maintenance Service Policy and Procedure, revised 12/2009, revealed the maintenance department was responsible to maintain the building, grounds and equipment. Functions of the maintenance personnel was to maintain the building in compliance with current federal, state and local laws, regulations and guidelines.

Random observations from 2/5/23 through 2/9/23, between 8:00 AM to 5:00 PM revealed strong odors that permeated out into the two hallways and perceived to originate from resident rooms. The odors were constantly present during the observation time.

On 2/9/23 at 11:53 AM Staff 31 (Maintenance Director) walked through the facility with the surveyor. Staff 31 confirmed the strong odors on both hallways. Staff 31 reported he replaced several of the motors in the ventilation system, but the system still needed additional work from an outside company which specialized in ventilation systems. Staff 31 stated the shared resident bathrooms between rooms had no ventilation and no windows to prevent odors from drifting throughout the resident rooms and hallways.

On 2/10/23 at 10:38 AM Staff 1 (Administrator) acknowledged the odors in the facility hallways. Staff 1 acknowledged he and Staff 31 discussed the concerns. Staff 1 declined a walk through the facility with the surveyor.

Based on observation, interview and record review it was determined the facility failed to ensure resident rooms were free from pests for 1 of 2 halls reviewed for environment. This placed residents at risk for pest infestation. Findings include:

The facility's Pest Control Policy and Procedure, revised 5/2018, revealed the facility shall maintain an effective pest control program and identified a pest control company which provided services to the facility.

Fruit flies were observed in the facility on the following:
-2/5/23 at 12:52 PM in room 36.
-2/6/23 at 2:37 PM in room 36.
-2/7/23 at 8:46 AM in the south hallway.
-2/7/23 at 12:03 PM in the conference room.
-2/7/23 at 12:09 PM room 36.
-2/7/23 at 3:23 PM small dining room.
-2/8/23 at 9:22 AM south hall.
-2/9/23 at 12:34 PM public restroom.

On 2/7/23 at 12:09 PM Resident 18 acknowledged the fruit flies in her/his room. Resident 18 stated she/he previously reported to the facility the concern of fruit flies in her/his room.

On 2/9/23 at 11:55 AM Staff 31 (Maintenance Director) confirmed the presence of fruit flies in Resident 18's room and on her/his juice cup straw. Staff 31 was unaware of any way to get rid of the fruit flies other than to remove the resident's juice. He confirmed the facility contracted with a company for pest control.

On 2/10/23 at 10:38 AM Staff 1 (Administrator) state he was unaware of the fruit flies in the facility. Staff 1 acknowledged he expeced the facility to be free from fruit flies.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 26 of 30 days and the use of NAs did not exceed 25% of the CNA staffing ratios for 26 of 30 days reviewed for staffing. This placed residents at risk for delayed assistance and unmet care needs. Findings include:

A review of the 1/7/23 through 2/5/23 Direct Care Staff Daily Reports revealed the facility had insufficient CNA staff 26 out of 30 days:

-1/7/23 day and night shift.
-1/10/23 day and night shift.
-1/11/23 day, evening and night shift.
-1/12/23 day, evening and night shift.
-1/13/23 day, evening and night shift.
-1/14/23 day and night shift.
-1/16/23 day, evening and nigh shift.
-1/17/23 day shift.
-1/18/23 day shift.
-1/19/23 day shift.
-1/20/23 day and evening shift.
-1/21/23 day and evening shift.
-1/22/23 day and evening shift.
-1/24/23 day shift.
-1/25/23 day and evening shift.
-1/26/23 day and evening shift.
-1/27/23 day and evening shift.
-1/28/23 day and evening shift.
-1/29/23 day, evening and night shift.
-1/30/23 day, evening and night shift.
-1/31/23 day and evening shift.
-2/1/23 day and evening shift.
-2/2/23 day and evening shift.
-2/3/23 day and evening shift.
-2/4/23 day and evening shift.
-2/5/23 day and evening shift.

On 2/8/23 at 10:24 AM Staff 28 (CMA/Staffing Coordinator) stated she was not aware PCAs (Personal Care Assistance) were not supposed to be counted as scheduled staff. Staff 28 acknowledged the facility did not meet the correct CNA ratios on multiple days.

On 2/9/23 at 2:24 PM Staff 1 (Administrator), Staff 2 (Regional Nurse Consultant/Infection Preventionist) and Staff 3 (DNS) were present for an interview. Staff 1, Staff 2 and Staff 3 acknowledged they did not meet the required CNA ratio for 26 out of 30 days reviewed.

Based on interview and record review it was determined the facility failed to provide on-site Registered Dietician visits for 1 of 1 facility reviewed for nutrition services. This placed residents at risk for unmet nutritional needs. Findings include:

On 2/7/23 at 9:27 AM Staff 7 (Kitchen Manager) stated the Registered Dietitian for the facility only worked remotely.

During a telephone interview on 2/7/23 at 3:26 PM Staff 23 (Registered Dietitian) stated the position of Registered Dietitian was "remote only" and she had not been to the facility since accepting the position in 9/2022. She reported she was not involved in meal or menu planning and she had "minimal involvement with the kitchen."

A review of documents related to kitchen and dietary operations revealed Staff 23 was the facility's Registered Dietitian.

On 2/9/23 at 11:42 AM Staff 1 (Administrator) confirmed the findings and stated, "I didn't think they had to be here in the facility."

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411-085-0310 Residents' Rights: Generally

Refer to F550 and F559

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OAR 411-087-0100 Physical Environment: Generally

Refer to F584 and F925

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OAR 411-085-0360 Abuse

Refer to F610

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OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F656, F657 and F659

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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F677

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OAR 411-086-0230 Activity Services

Refer to F679

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OAR 411-086-0110 Quality of Care: Nursing Services: Resident Care

Refer to F684

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OAR 411-086-0140 Quality of Care: Nursing Services: Problem Resolution & Preventative Care

Refer to F690

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OAR 411-086-0100 Nursing Services: Staffing

Refer to F725

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OAR 411-086-0250 Dietary Services

Refer to F801, F809 and F812

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OAR 411-086-0220 Rehabilitative Services

Refer to F825

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OAR 411-086-0230 Laundry Services

Refer to F880

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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F881

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411-087-0440 Electrical Systems: Alarm and Nurse Call Systems

Refer to F919

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OAR 411-087-0450 Heating and Ventilating Systems

Refer to F923

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Based on interview and record review it was determined the facility failed to notify the responsible party for 1 of 3 sampled residents (#2) who were reviewed for failure to notify responsible party. This placed residents and responsible parties at risk for delayed notification. Findings include:

Resident 2 admitted to the facility on 5/2021 with diagnosis including respiratory and heart failure.

A 5/26/22 signed admission packet indicated Witness 1 (Family Member) was an authorized person to receive verbal medical information and Witness 1's correct phone number was listed.

A 5/31/22 Admission MDS indicated Resident 2's BIMS score was a 10 which indicated moderate cognitive impairment.

Resident 2's face sheet indicated Witness 1 (Family Member) was Resident 2's representative, emergency contact, power of attorney for financial, health care, and her/his legal guardian.

A 6/8/21 Care Conference Information document revealed Resident 2 did not wish to have anyone on the call during the conference.

A 7/12/21 Letter to Resident 2 indicated the next care conference was scheduled for 8/24/21 from 1:00 PM to 1:30 PM. No documentation was found Witness 1 was notified of the care conference date and time.

A 7/31/21 Social Services Progress Note indicated Resident 2 wanted to call Witness 1 to discuss discharge from the facility. Staff 3 indicated she would follow up by the middle of the week to ensure Resident 2 contacted Witness 1.

No additional notes were found in clinical records Staff 3 followed up with Resident 2 or Witness 1.

An 8/24/21 Care Conference Information document indicated Witness 9 (Ombudsman) attended the care conference but Witness 1 was not in attendance.

A 11/10/21 Social Services Progress Note indicated Social Services had been working with the Ombudsman, POA and Resident 2 as she/he wished to discharge.

A 11/11/21 Social Services Progress Note indicated Staff 3 (Social Services Director) spoke with Witness 1 (Family Member). Witness 1 stated she told Staff 1 (Administrator) she was Resident 2's POA but never received a call back from the facility after Resident 2's admission. Staff 3 indicated there was a hospital note indicating Witness 1 was working on a POA but no follow up notes stated it was completed. Staff 3 indicated Resident 2 also stated Witness 1 was the POA but did not have any documents and the facility was unable to reach her. Witness 1's phone number was listed incorrectly and was updated.

A 11/16/21 Nursing Progress Note revealed Resident 2 had a witnessed fall with a skin tear on her/his right forearm and the ANP (Advanced Nurse Practitioner) was aware. No documentation was found Witness 1 was notified of Resident 2's fall.

A 12/29/21 Nursing Progress Note indicated Resident 2 was focused on her/his breathing and reported it hurt to breath. The ANP was notified and the resident was sent to the emergency room.

No documentation was found in the clinical records Witness 1 was notified of Resident 2 transferring to the hospital.

A 12/29/22 Fax Cover Sheet to Resident 2's ANP indicated Resident 2 was experiencing pain in her/his back and it was painful for her/him to breath. The ANP ordered to send Resident 2 to the emergency department.

On 5/13/22 a public complaint was received which indicated the facility requested documentation for Witness 1 being POA for Resident 2 which was provided. Witness 1 was not contacted by the facility. Staff at the facility claimed they did not have Witness 1's contact information.

On 10/6/22 at 10:48 AM the above information was reviewed with Staff 1 (Administrator) and Staff 2 (DNS). Staff 1 and Staff 2 did not have a comment but stated they wanted to further review the information and provide additional information. No additional information was provided.

1. Based on interview and record review it was determined the facility failed to ensure residents were free from verbal abuse for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for abuse. Findings include:

a. Resident 3 was admitted to the facility in 11/2021 with diagnoses including generalized anxiety disorder, acute kidney failure and pain.

A 4/18/22 Quarterly MDS indicated Resident 3's BIMS score was 14 (cognitively intact) and had physical and verbal behaviors one to three days during the seven days look back period. Resident 3 also had daily behaviors not directed toward others and rejection of care. Resident 3 required extensive assistance with two-person physical assist for toileting.

A 5/30/22 Alleged Abuse Event Report indicated Resident 3 stated Staff 12 (NA) was rude to her/him by stating she/he was dirty and it was disgusting she/he did not wear incontinent products. Resident 3 stated she/he consumed a lot of orange juice which caused her/him to have diarrhea. Staff 12 cussed and stated she/he did it on purpose to cause staff extra work. Resident 3 stated Staff 12 wanted to fight with her/him.

A 5/30/22 signed handwritten statement by Staff 8 (NA) indicated Staff 8 and Staff 13 (CNA) walked down the hall to answer a call light and Staff 12 and Staff 14 were in Resident 3's room changing her/his bed. Staff 8 indicated there was a lot of yelling which and heard cussing from Resident 3's room. Staff 12 came out of Resident 3's room and stated, "she f***ing hates that [woman/man] and that [she/he] tried to kick her in the face and hit her."

A 5/31/22 handwritten statement from Staff 12 indicated she assisted Staff 14 with Resident 3's incontinent episode. Staff 12 stated how hard it was cleaning up after someone who does not wear incontinent products and it was not a very safe way to allow a resident to "exist". Resident 3 told Staff 12 to "shut my f---ing mouth and get the f--k oatta my room" she/he raised a back scratcher in the air to hit Staff 12 two times and told Staff 12 she/he wanted to kick her in the mouth with her/his foot in the air.

A 5/31/22 signed handwritten statement by Staff 14 (NA) stated at 9:50 PM on 5/30/22 Resident 3 required incontinent care. Staff 14 went into Resident 3's room and Resident 12 assisted with the linens. Staff 12 accused Resident 3 of making their job harder and made the staff miserable for not wearing incontinent products. Resident 3 got aggravated, attempted to kick Staff 12 and told her to be quiet. Staff 12 responded "I don't have to be quiet". After Staff 12 left the room Resident 3 was visibly upset and told Staff 14 to "fuck off" and hit Staff 14 in the stomach. Staff 14 finished caring for Resident 3. Before going home Staff 12 was at the nurse's station and stated, "That didn't happen, right?"

A signed undated handwritten statement by Staff 13 (CNA) indicated Staff 8 and Staff 13 were in a resident's room when they heard Resident 3 yelling from down the hall, and Resident 3 screamed "F you get the F out of here." When Staff 13 and Staff 8 walked by Resident 3's and there was still yelling. Around 10:10 PM she heard Resident 3 yelling again and Staff 12 was yelling back at Resident 3. Resident 3 told Staff 12 to get "the F out of my room and don't come back." Staff 12 then stated, "I plan on not coming back." Resident 3 stated "good this is bull s" Staff 12 stated "This is why nobody wants to help you because you treat everyone like shit and don't appreciate anything anyone does for you." Resident 3 picked up her/his back scratcher and acted like she/he was going to hit Staff 12 twice. Staff 12 went up to the bed and said, "Do it Do it [Resident 3] I'm not scared of you." Resident 3 put her/his back scratcher down. When Staff 12 walked out Resident 3 told her not to come back and Staff 12 laughed. Staff 12 came up to Staff 13 and stated she hated Resident 3 because she/he had no appreciation for anyone.

A 6/6/22 Occurrence Investigation Final Summary indicated on 5/30/22 approximately 9:50 PM Staff 14 (NA) requested Staff 12 to assist with Resident 3's incontinent care. Staff 12 stated she did not like to go into Resident 3's room and if Resident 3 stated anything "rude" it would "set her off". Staff 12 went into Resident 3's room and told the resident she/he was purposefully attempting to make their job harder because she/he refused to wear an incontinent product. Resident 3 became agitated and held up her/his back scratcher as if she/he was going to hit Staff 12 with it. Staff 12 was heard on the facility video by the administrator stating, "bring it on [Resident 3], don't threaten it, bring it on." Staff 12 was suspended on 5/31/22 pending the investigation. Verbal abuse was substantiated and Staff 12 was terminated from employment on 6/2/22.

On 9/21/22 at 9:39 AM Staff 8 (NA) stated Resident 3 and Staff 12 did not get along. Staff 8 stated in 5/2022 she heard Staff 12 and Resident 3 yelling at each other.

On 9/27/22 at 12:47 PM Staff 12 stated the facility substantiated the incident on 5/30/22 as verbal abuse. Staff 12 stated she was not a psychiatric nurse and could only take so much stress. Staff 12 stated when she told Resident 3 to "bring it on" she meant she was getting paid to have her hit her and to go ahead and hit her. Staff 12 stated she did not state it as a threat toward Resident 3.

On 10/4/22 Staff 13 (NA) stated she remembered hearing yelling down the hallway and heard someone yelling back. Staff 13 walked down the hallway and Staff 12 was in Resident 3's room. Staff 12 told Resident 3 to hit Staff 12. Resident 3 threatened to hit Staff 12 then put down her/his back scratcher. Staff 13 stated Staff 12 looked like she wanted to be "bigger than [her/him]" and was threatening. Staff 13 stated if she would have been in Resident 3's position she would have felt uncomfortable.

On 10/6/22 at 10:54 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the facility determined Resident 3 was verbally abused by Staff 12 and Staff 12's employment was terminated.

2. Based on observation, interview and record review it was determined the facility failed to ensure residents were free from neglect. The facility failed to ensure there was adequate staffing in place to meet acuity levels, which lead to the inability to provide bathing assistance, the inability to provide timely incontinence care and inappropriate transfer of residents. The facility failed to ensure medications were administered as ordered. The facility failed to ensure pressure ulcers were assessed and monitored appropriately and ensure a resident was adequately hydrated. The cumulative effect of these failures in providing care and services contributed to an environment of neglect for 10 of 16 residents (#s 1, 3, 4, 5, 6, 7, 8, 9, 12 and 13) reviewed. Findings include:

ADL CARE FOR DEPENDENT RESIDENTS

a. Resident 1 required three people assist with transfer to a shower chair, two-person extensive assist for bathing

An 8/1/22 through 9/15/22 Point of Care History revealed Resident 1 was not bathed from 8/2/22 through 8/18/22, 8/20/22 through 8/25/22, 8/27/22 through 9/4/22 and 9/6/22 through 9/15/22.

On 9/15/22 at 12:39 PM Resident 1 was observed with an oily face, flaky skin on her/his forehead and her/his room smelled of body odor.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA) stated Resident 1 was not showered regularly or getting out of bed. Staff 11 stated she observed excessive dead skin on her/his face, and body odor.

On 9/28/22 at 8:18 AM Staff 35 (CNA) stated Resident 1's skin would get flaky when she/he was not showered and there were times maybe one resident received a shower per day.

On 10/4/22 at 10:03 AM Staff 19 (Agency LPN) stated Resident 1 had body odor and at times did not get showered. Staff 19 would observe spilt food on Resident 1 from the previous shift.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

b. Resident 5's Admission MDS indicated Resident 5 did not receive any type of bathing during the seven days look back period and required extensive one person assistance with bathing.

A 3/16/22 through 3/31/22 Point of Care History report indicated Resident 5 was not bathed from 3/16/22 through 3/25/22.

On 9/26/22 Staff 11 (Former CNA) stated Resident 5 received a shower when staff could do them because of short staffing in 3/2022 and 4/2022.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

c. Resident 6's 7/13/22 Admission MDS indicated Resident 6 required one-person physical assistance with bathing.

A 7/7/22 bedside care plan indicated Resident was "requesting to shower".

A 7/7/22 through 8/3/22 Point of Care History report indicated Resident 6 was not bathed from 7/13/22 through 7/25/22 and 7/26/22 through 8/3/22.

On 9/22/22 Witness 11 (Family Member) stated Resident 6 was to receive showers two times per week which did not occur. When Resident 6 discharged home she/he had a rash from head to toe and had dead skin cells all over from not being cleaned.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA) stated she never remembered Resident 6 receiving a shower. Staff 11 stated she observed Resident 6 with greasy hair.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

d. Resident 7 was admitted to the facility in 2019 with diagnoses including Parkinson's disease.

A 5/19/22 care plan indicated Resident 7 required one person assistance for showers to assist with her/his upper and lower body.

A 7/25/22 Quarterly MDS assessment indicated Resident 7 required one-person physical assist with bathing. In the seven days look back period Resident 7 did not receive any type of bathing.

An 8/2022 Point of Care History report indicated Resident 7 was not bathed from 8/8/22 through 8/20/22.

On 10/4/22 Staff 19 (Agency LPN) stated Resident 7 was observed with a very oily face and often appeared disheveled.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

e. Resident 8's 7/13/22 Significant Change MDS indicated Resident 8 was cognitively intact. During the seven days look back period Resident 8 bathing did not occur.

An 8/26/22 Care Plan indicated Resident 8 required one-person assist with showering.

A 7/2022 through 8/2022 Point of Care History report indicated Resident 8 was not bathed from:
-7/1/22 through 7/20/22, 7/21/22 through 7/31/22 and 8/1/22 through 8/31/22.

On 9/15/22 at 12:52 PM Resident 8 stated she/he did not get showers very often because of short staffing.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

Refer to F677

PHYSICIAN ORDERS

f. Resident 8's 7/2022 MAR instructed staff to administer lidocaine adhesive patches, two to the left ribs and one to the left hip once a day in the evening and the patch may remain on for 12 hours due to acute pain from trauma with a start date of 6/28/22 and discontinue date of 7/21/22. The patches and comments indicated the from 7/2/22 through 7/20/22 the lidocaine patch was unavailable.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA/CMA) stated Resident 8's physician order for a lidocaine patch which the insurance would not cover and nothing was done to resolve the issue to get a different medication or to have the medication discontinued. Staff 11 stated she had to mark it as unavailable.

On 10/4/22 at 9:53 AM Staff 19 (Agency LPN) stated Resident 8's Lidocaine patch was unavailable because her/his insurance would not cover the cost and it took a very long time to get a response back from the provider. Staff 19 stated she did not feel Resident 8 was in any additional pain because she/he did not have the patches as she/he was on a lot of pain medication and at times refused the alternative cream when it arrived as a replacement for the patch.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

Refer to F684

PRESSURE ULCERS

g. Resident 5's 3/18/22 bed side care plan indicated Resident 5 was a two-person assist for bed mobility and to rotate her/him every two hours.

A Continuity of Care Document with an effective date of 3/18/22 (document created 9/27/22) revealed Resident 5's "Problems" as pressure ulcer of unspecified buttock, Stage 2 (Partial-thickness skin loss into but no deeper than the dermis. This includes intact or ruptured blisters.).

A 3/16/22 through 3/31/22 Point of Care History report revealed the following for resident moving in bed and staff support for bed mobility out of 32 opportunities.
-One instance of no setup or physical help from staff.
-24 instances of one-person physical assist.
-One instance of Activity did not occur.
-Six instances of no documentation resident was provided bed mobility.

A 3/2022 TAR instructed staff to provide the following for Resident 5:
-On 3/18/22 and 3/25/22 the TAR documented Resident 5 had skin breakdown present.
-Clean coccyx wound with normal saline, apply calmoseptine (moisture barrier and treat minor skin impairments) to open areas and cover with dressing every three days and PRN with a start date of 3/18/22.

A review of the resident's clinical record revealed no explanation, root cause analysis or investigation related to the development of Resident 5's wounds.

A 4/1/22 through 4/17/22 Point of Care History report revealed the following for resident moving in bed and staff support for bed mobility out of 33 opportunities.
-Four instances of no setup or physical help from staff.
-22 instances of one-person physical assist.
-One instance of Activity did not occur.
-Six instances of no documentation resident was provided bed mobility.

A 4/9/22 at 5:52 AM Progress Note indicated Resident 5 had a Stage 2 pressure ulcer on the sacrum area with no signs or symptoms of infection. No additional description of the wound was documented.

A 4/15/22 Progress Note indicated Resident 5 had "many" pressure ulcers on her/his sacrum and groin area.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA) stated Resident 5 did not get repositioned as frequently as care planned because the facility was short staffed in 3/2022 and 4/2022.

On 10/3/22 at 11:04 AM Staff 6 (RN) stated Resident 5 was on "a decline" and she/he had a Stage 1 pressure ulcer because of her/his illness and it was on her/his buttocks. Staff 6 stated the wound progressed to a Stage 2 pressure ulcer.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

h. Resident 12's 8/9/22 Wound Information indicated Resident 12 had an abrasion to the left heel which was 0.8 cm in length, by 0.6 cm in width and the skin was a dark purple area, non-blanchable. Resident 12 stated the skin impairment began before hospitalization.

No documentation was found in clinical records of comprehensive weekly skin assessments between 8/9/22 and 9/14/22.

An 8/31/22 Fax Cover Sheet to Resident 12's ANP (Adult Nurse Practitioner) indicated Resident 12 had a small dark purple non blanchable area on her/his left heel and reported it was painful at times. A request for an order for prevalon (heel protector for heel pressure relief) boot to reduce the pressure to the heel was accepted by the ANP.

A 9/2022 TAR instructed staff to provide Resident 12 a pressure relieving boot to the left lower extremity while in bed with the start date of 9/1/22.
-From 9/2/22 through 9/7/22 it was documented the boot was unavailable.
-On 9/7/22 stated administration was charted late. (unknown if administered)
-On 9/8/22 the boot was refused,
-On 9/9/22, 9/11/22 documented as unavailable,
-On 9/16/22 the comment was the boot was broken.

On 10/6/2022 at 8:30 AM Staff 15 (LPN) stated he could not find Resident 12's pressure relieving boot and marked it was unavailable. Staff 15 stated Resident 12 did not have any treatment to her/his left heel because the wound was not open. Staff 15 stated he was not sure if weekly wound assessments were completed for Resident 12 because there were issues with the facility not having enough staff.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

Refer to F686.

FALL AND ACCIDENT HAZARDS

i. Resident 's 4/6/22 care plan revealed Resident 1 was at risk for falls with interventions including Resident 1 required three people for transfers with a mechanical lift.

An 4/6/22 Occurrence Investigation Final Summary revealed Resident 1 was being transferred from her/his wheelchair to her/his bed with a mechanical lift with the assistance of two-people. Staff reported the lift started to tip and Resident 1 fell onto staff and was assisted to the floor by sliding down the staff member's body. Final report was the care plan was not followed at the time as two staff were transferring the resident when she/he was care planned to be a three-person mechanical lift transfer. The staff were provided one on one education with written expectations which were signed. Resident 1 complained of shoulder pain post fall and pain medication was administered. Resident 1 denied any abuse or neglect.

On 9/15/22 at 12:39 PM Resident 1 stated she/he remembered falling earlier in the year when staff were transferring her/him with a mechanical lift. Resident 1 stated they were transferring her/him and all the sudden she/he was on the floor. Resident 1 stated staff told her/him they were to provide three people instead of two. Resident 1 stated they still only provided two staff as there usually were not enough staff to have three people to assist with transfers.

On 9/28/22 Staff 14 (NA) stated on 4/5/22 Staff 13 (NA) and herself were assisting Resident 1 to transfer and Staff 14 moved a table out of the way and the mechanical lift started to tip and Resident 1 slid down Staff 13's body. At the time Resident 1 was care planned for three-person transfer.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

Refer to F689

j. Resident 1's 8/15/22 Urinary Incontinence and indwelling catheter CAA indicated Resident 1 required extensive to dependent assistance with toileting and she/he was always incontinent of bowel and bladder.

An 8/2022 Point of Care History identified Resident 1 was assisted to the toilet on 15 occasions/shifts during the month and the activity did not occur or was "unanswered" on 78 occasions/shifts during the month.

On 9/15/22 at 12:39 AM Resident 1 stated the staff were not timely to meeting her/his needs and concerns. Resident 1 stated she/he had bowel incontinent episodes multiple times and laid in her/his soiled brief. After one instance in 8/2022 she/he sat in a soiled brief after having a bowel movement for over an hour waiting for assistance.

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated when she arrived onto her shift on 8/13/22 Resident 1 had not received incontinent care the previous shift and she/he sat in fecal matter for over an hour.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

k. Resident 5's 3/18/22 bedside care plan indicated Resident 5 had a Foley catheter and to measure urine output every shift and empty catheter bag.

A review of the 3/2022 TAR revealed no treatments or physician ordered care for Resident 5's catheter.

No documentation was found in the clinical records Resident's Foley catheter was monitored for patent and color from 3/22/22 through 3/25/22 and 3/28/22 through 4/1/22.

3/16/22 to 4/17/22 Search Vitals Results Output for urine revealed 93 out of 72 shifts with no documentation of measured urine output.

On 10/3/22 at 11:04 AM Staff 6 (RN) stated the usual facility protocol was for the facility was to have the basic catheter care in the TAR for a resident who had a catheter.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

l. Resident 8's 7/13/22 Significant Change MDS and Urinary Incontinence and Indwelling Catheter indicated Resident 8 was occasionally incontinent of urine and required extensive assistance with setup only for toilet use.

A 6/1/22 through 6/16/22 review of the "Alarm History since Aug 2021" report revealed 34 out of 192 activations of Resident 8's call light were over 20 minutes wait and two of the 34 were over an hour wait.

A 9/1/22 through evening shift of 9/15/22 Point of Care History revealed 13 occurrences where residents balance when moving on and off the toilet did not occur or the question was unanswered out of 47 opportunities.

On 9/15/22 at 12:52 PM Resident 8 stated when agency staff were not in the facility the call light wait time was about an hour and a half. Resident 8 stated she/he had incontinent episodes quite often because of waiting.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

m. Resident 9's 2/17/22 bedside care plan indicated Resident 9 was incontinent of bowel and bladder.

An 7/2022 Point of Care History revealed for bladder and bowel no documentation of bladder or bowel function was completed for 7/2022. How Resident 9 used the toilet there was either no documentation, unanswered or activity did not occur 58 instances out of 98 opportunities. (On 7/18/22 night shift activity did not occur, day and evening shift total dependence)

An 8/4/22 Nursing Progress Notes indicated Resident 9 had increased confusion and stated did not know her/his name and unsure of her/his location. Resident 9 reported burning during urination. Positive UA results UA report sent to provider and remaining sent to lab. New orders received to start Keflex (A medication is used to treat a wide variety of bacterial infections.) for seven days for UTI.
An 8/12/22 signed Physician Order Report instructed staff to document Resident 9's bowel movement every shift with a start date of 10/11/21.

An 8/2022 Point of Care History revealed Resident 9's documentation for bladder, 8/1/22 through 8/7/22 and 8/20/22 through 8/31/22 there was no documentation of bladder or bowel function, 8/8/22 through 8/19/22 there were 21 instances of no documentation or unanswered and 12 instances of incontinence. (On 8/13/22 day and evening shift "unanswered" and night shift incontinent for bowel and bladder)

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated on 8/13/22 Resident 9 was "soaking wet" when she came on shift.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

n. Resident 13's 6/28/22 Admission MDS and Urinary Incontinence Indwelling Catheter CAA revealed Resident 13's BIMS was eight indicating she/he was moderately impaired. Resident 13 required total dependence of two people physical assist for toilet use. The CAA indicated Resident 13 was always incontinent of bladder and bowel and was dependent on staff for brief changes and peri care.

An 8/17/22 Occurrence Investigation Final Summary indicated Staff 8 (CNA) documented that staff had toileted, fed and provided a partial bed bath for Resident 13. At 11:15 AM Staff 2 (DNS) was notified from another staff member that Resident 13 was not changed all shift. A few minutes after 11:00 Resident 13 was provided incontinent care and reported she/he had dried bowel movement stuck to her/his buttocks and groin area which was reddened.

Point of Care History for 8/17/22 revealed Staff 8 documented Resident 13 was incontinent of bowel function at 8:58 AM.

On 9/21/22 at 10:11 AM Staff 8 stated she provided Resident 13 a partial bed bath and did not provide peri care as she/he was in too much pain and she reported it to the CMA and let her know she would wait to provide incontinent care later to let the pain medication take effect. At 6:00 AM Staff 8 checked Resident 13 and she/he was not incontinent of bowel she wiped the front part as she/he was prone to inventions. Staff 8 stated she documented bowel incontinent care because she knew she/he had a bowel movement, and she was sent home before she could provide incontinent care.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

Refer to F690

HYDRATION
o. Resident 5's 3/17/22 comprehensive care plan indicated Resident 5 was a potential for alteration in nutrition and dehydration. With goal of eating 75 to 100 percent of meals, adequate fluid intake, and no signs or symptoms of dehydration.

A 3/21/22 Progress Note Indicated Resident 5 continued to be lethargic and her/his Foley catheter was patent and draining concentrated yellow urine (urine becomes more concentrated when an individual is less hydrated).

A 4/3/22 at 1:46 AM and 1:35 PM Progress Notes indicated Resident 5's urine was amber in color (which can be an indicator of severe dehydration).

A review of fluid intake records from 3/16/22 to 4/17/22 revealed fluid intake records lack documented monitoring for 44 shifts out of 99 shifts reviewed.

A review of urine output records from 3/17/22 to 4/17/22 revealed no documented monitoring for 64 shifts out of 99 shifts reviewed.

On 9/26/22 Staff 11 (Former CNA) stated it was difficult to make sure all the residents received enough fluids when the facility was short staffed in 3/2022 and 4/2022. Staff 11 stated Resident 5 was not capable of drinking on her/his own and staff needed to hand fluids to Resident 5 while she/he drank.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

Refer to F692

p. A review on 9/21/22 of an updated 11/7/19 Facility Assessment revealed the assessment was not updated, as necessary, or at least annually. The assessment was not comprehensive and did not include any changes in staffing acuity since 2019.

On 9/14/22 at 8:10 AM Witness 2 (Family Member) stated the facility was short staffed often. Witness 2 stated she would hear residents yelling out for help "all the time." Witness 2 stated she saw residents with dirty clothes on.

Interviews from 9/21/22 through 10/6/22, 11 staff interviewed indicated the facility was short staffed and residents did not receive cares as needed.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to work with outside agencies and provide bonuses but continued to have difficulty with finding and retaining staff.

q. Resident 1's 8/15/22 ADL CAA indicated Resident 1 was encouraged to use her/his call light for assistance.

An "Alarm History since Aug 2021" report was reviewed for the following dates: 8/13/22, 9/5/22 and 9/11/22. The report revealed 16 call light response was over 20 minutes for Resident 1's room.

On 9/15/22 at 12:39 AM Resident 1 stated the staff were not timely in meeting her/his needs and concerns. Resident 1 stated she/he has had incontinent episodes of her/his bowels multiple times and had to lay in soiled briefs.

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated in 6/2022 Resident 1 sustained a fall due to long call light wait times when the resident attempted to transfer herself/himself to the toilet. In 8/2022 Staff 8 came onto her shift and the previous shift told her they were too busy to provide incontinent care. Staff 8 was the only CNA scheduled for evening shift and Resident 1 sat in her/his fecal matter for over an hour.

On 9/26/22 at 9:14 AM Staff 13 (Former CNA) stated because the facility was short staffed, Resident 1 did not receive showers, or assistance out of bed.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

r. Resident 3's 12/16/21 care plan indicated Resident 3 was at risk for falls with a history of repeated falls, immobility, and behaviors with interventions including ensure Resident 3's call light was in reach and encourage her/him to use the call light when assistance was needed.

A 4/18/22 Quarterly MDS indicated Resident 3's BIMS was 14 indicating she/he was cognitively intact and required two-person physical assist with bed mobility and toilet use and one person assist with dressing and personal hygiene.

An "Alarm History since Aug 2021" report was reviewed for 6/4/22, 6/12/22, 9/5/22 and 9/9/22. The report revealed ten call light response times over 20 minutes for Resident 3's room.

On 9/15/22 at 12:20 PM Resident 3 stated she/e did not feel there was enough staff to meet her/his needs in a timely manner. Resident 3 stated she/he waited up to 45 minutes for a call light to be answered and then staff would be in and out quickly.

On 9/21/22 at 9:54 AM Staff 8 (CNA) stated on 8/13/22 she came on to her shift and the previous shift told her they were too busy to provide incontinent care. Staff 8 was the only CNA scheduled for evening shift and Resident 3 was one of the many residents who needed incontinent care and was wet.

On 10/6/22 at 10: 55 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation was call light wait times should not be over 10 minutes.

s. Resident 4's 5/15/22 Admission MDS indicated Resident 4 was cognitively intact with a BIMS score of 14. Resident 4 required limited assistance with one-person physical assist and was always continent of bowel and bladder.

A 6/9/22 Occurrence Investigation Final Summary indicated on the night of 6/6/22 Resident 4 was told by Staff 4 that Resident 4 could not be assisted to the toilet.

A Point of History Report from 6/1/22 through 6/30/22 revealed eight instances it was documented Resident 4 was continent and no documentation of incontinence in the month of 6/2022.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA) stated there was only one CNA on night shift on 6/6/22 and Staff 4 told Resident 4 to wet in her/his brief and Staff 4 would provide incontinent care because she was the only CNA working that night.

On 10/5/22 at 5:09 AM Staff 4 stated the night of 6/6/22 to 6/7/22 was the last night she worked alone on night shift with no additional CNA staff to assist. As now Staff 4 will call the facility before each shift she works to make sure there is an additional qualified person to work with her.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

t. Resident 5's 3/18/22 bedside care plan indicated Resident 5 required two-person for bed mobility and to reposition every two hours.

On 6/16/22 a public complaint was received which indicated Resident 5 was re-admitted to the hospital on 4/17/22 and Resident 5 diagnosed with a Stage 4 (Full-thickness skin and tissue loss.) pressure ulcer to her/his lower back. Resident 5 had a bladder infection which resulted in sepsis and a staph infection on the right leg.

On 9/26/22 Staff 11 (Former CNA) stated Resident 5 did not get repositioned as frequently as care planned because of short staffing in 3/2022 and 4/2022.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to work with outside agencies and provide bonuses but continued to have difficulty with finding and retaining staff.

u. Resident 6's 7/2022 Point of Care History revealed on 7/23/22 for evening and night shift there was no documented evidence the resident was toileted.

An event date "7/23-7/24" Occurrence Investigation Final Summary report indicated Resident 6 reported she/he was not checked on all night shift and stated she/he did not have her/his call light or phone and was left with only a sheet as a cover. Resident 6 also reported her/his window was left open all night.

On 10/3/22 at 11:48 AM Staff 33 (NA) stated on night shift of 7/23/22 to 7/24/22 she was the only NA on shift that night. Staff 33 stated she would peek in on Resident 6 from the adjoining bathroom door. Staff 33 stated she thought she saw Resident 6's cords within reach but she was all alone and did not have a hospitality aide that night to assist her and she was "on the run" to make sure resident's needs were met. Staff 33 stated she did remember Resident 6's bed was in a higher position that night.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

v. Resident 7's 8/2022 Point of Care History report indicated on 8/4/22 Resident 7 was dependent or required extensive assist from staff for toileting. On 8/5/22 there was no documentation on the report for day and evening shift and toileting was documented as "did not occur" for night shift.

An Alarm History Since "Aug 2021" report indicated on 8/4/22 at 10:06 AM Resident 7's call light was activated with a response time of 46 minutes and 27 seconds.

On 10/6/22 at 11:17 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they were not aware Resident 7 was on a bed pan for 45 minutes.

w. Resident 8's 7/13/22 Significant Change MDS and Urinary Incontinence and Indwelling Catheter indicated Resident 8 was occasionally incontinent of urine and required extensive assistance with setup only for toilet use.

Review of the "Alarm History since Aug 2021" report from 6/1/22 through 6/16/22 revealed 34 out of 192 activations of Resident 8's call light with over 20 minutes wait with two wait times over an hour.

An 8/26/22 care plan indicated Resident 8 required one-person for transferring to the toilet as she/he sits for long periods of time in her/his bathroom. Resident 8 required one-person assistance for bowel care.

A review of "Alarm History since Aug 2021" report for Resident 8's room revealed 12 call light response times over 20 minutes.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

x. Resident 9's 8/19/22 care plan indicated Resident 9 was frequently incontinent of bladder and the goal was to keep her/him clean, and dry.

An 8/2022 Point of Care History revealed Resident 9's documentation for bladder, 8/1/22 through 8/7/22 and 8/20/22 through 8/31/22 there was no documentation of bladder or bowel function, 8/8/22 through 8/19/22 there were 21 instances of no documentation or unanswered and 12 instances of incontinence. (On 8/13/22 day and evening shift "unanswered" and night shift incontinent for bowel and bladder)

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated there were staffing concerns in the facility from 2/2022 through the end of 8/2022.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

y. Resident 12's 7/26/22 Admission MDS and Urinary Incontinence and Indwelling Catheter CAA revealed Resident 12 was cognitively intact with a BIMs of 15. Resident 12 required extensive two-person physical assist for toilet use.

An "Alarm History since Aug 2021" report revealed five call light response times over 20 minutes for Resident 12's room.

A 9/4/22 Direct Care Staff Daily Report revealed a census of 24 on the night shift no CNAs scheduled.

A 9/5/22 Grievance or Concerns Problem Identification and Follow up Form revealed Resident 12's was provided incontinent care at 10:00 PM on 9/4/22 and at 3:00 AM on 9/5/22 Resident 12 activated her/his call light but no staff came. Resident 12 stated she/he was not provided incontinent care until after 8:00 AM when she/he activated the call light again.

On 9/14/22 at 11:05 AM Resident 12 stated call light wait times go over 20 to 30 minutes a couple of times a week. Resident 12 stated evening was usually the worse and Sundays the facility would only have one CNA and one hospitality aid. Resident 12 stated one evening in 9/2022 she gone with no assistance between 10:00 PM and 3:00 AM. Resident 12 stated she/he activated her/his call light and no one came to assist her/him so she/he filed a grievance.

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated there were staffing concerns in the facility from 2/2022 through the end of 8/2022. On 8/13/22 Staff 8 was the only CNA scheduled for evening shift and Resident 12 which was one of many residents "was soaking wet".

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

z. Resident 16's 7/27/22 Annual MDS Resident 16's BIMS score was a 15 indicating she/he was cognitively intact and was frequently incontinent of bowel and bladder.

An 8/30/22 care plan indicated Resident 16 required assistance for toileting and would activate call light for use of bed pan. Staff were to assist with bed mobility during toileting with one person assist.

An "Alarm History since Aug 2021" reports revealed eight call light wait times over 20 minutes.

On 9/14/22 at 7:44 AM Resident 16 stated call light wait times were "lately lousy". Resident 16 stated she/he usually waited 30 to 40 minutes twice a week usually on weekends for staff to answer her/his call light. Resident 16 stated she/he often had incontinent episode because she/he could not wait. Resident 16 stated staff are usually shorthanded on shower days and she/he was "lucky" if she/he could get a shower once a week.

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated there were staffing concerns in the facility from 2/2022 through the end of 8/2022. On 8/13/22 Staff 8 was the only CNA scheduled for evening shift and Resident 16 was one of many residents who were "soaking wet".

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to take admissions into the facility. Staff 1 stated while creating the schedule they would have enough staff, but at the time of the day something occurs and they would be short staff to work.

Refer to F725

Based on observation, interview and record review it was determined the facility failed to provide care and services to maintain good grooming and hygiene for 5 of 10 sampled residents (#s 1, 5, 6, 7 and 8) reviewed for ADLs and staffing. This placed residents at risk for unmet needs. Findings include:

1. Resident 1 was admitted to the facility in 2018 with diagnoses including low back pain, diabetes and glaucoma.

A 7/23/21 comprehensive care plan indicated Resident 1 required three people assist with transfer to a shower chair, two-person extensive assist for bathing

An 8/1/22 through 9/15/22 Point of Care History revealed Resident 1 was not bathed from:
-8/2/22 through 8/18/22;
-8/20/22 through 8/25/22;
-8/27/22 through 9/4/22;
-9/6/22 through 9/15/22.

On 9/15/22 at 12:39 PM Resident 1 was observed with an oily face, flaky skin on her/his forehead and her/his room smelled of body odor.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA) stated Resident 1 was not showered regularly or getting out of bed. Staff 11 stated she observed excessive dead skin on her/his face, and body odor.

On 9/28/22 at 8:18 AM Staff 35 (CNA) stated Resident 1's skin would get flaky when she/he was not showered and there were times maybe one resident received a shower per day.

On 10/4/22 at 10:03 AM Staff 19 (Agency LPN) stated Resident 1 had body odor and at times did not get showered. Staff 19 would observe spilt food on Resident 1 from the previous shift.

On 10/6/22 at 10:40 AM Staff 1 (Administrator) and Staff 2 (DNS) expected staff to provide two showers per week and would like to have residents be able to shower per their preference and choice.

2. Resident 5 was admitted to the facility on 3/16/22 with diagnoses including acute kidney failure and muscle weakness.

A 3/22/22 Admission MDS indicated Resident 5 did not receive any type of bathing during the seven day look back period and required extensive one person assistance with bathing.

A 3/16/22 through 3/31/22 Point of Care History report indicated Resident 5 was not bathed from 3/16/22 through 3/25/22.

On 9/26/22 Staff 11 (Former CNA) stated Resident 5 received a shower when staff could do them because of short staffing in 3/2022 and 4/2022.

On 10/6/22 at 10:40 AM Staff 1 (Administrator) and Staff 2 (DNS) expected staff to provide two showers per week and they would like to residents be able to have shower per their preferences and choice.

3. Resident 6 was admitted to the facility in 7/2022 with diagnoses including fracture of left thigh bone.

A 7/13/22 Admission MDS indicated Resident 6 required one-person physical assistance with bathing.

A 7/7/22 bedside care plan indicated Resident was "requesting to shower".

A 7/7/22 through 8/3/22 Point of Care History report indicated Resident 6 was not bathed from 7/13/22 through 7/25/22 and 7/26/22 through 8/3/22.

On 9/22/22 Witness 11 (Family Member) stated Resident 6 was to receive showers two times per week which did not occur. When Resident 6 discharged home she/he had a rash from head to toe and had dead skin cells all over from not being cleaned.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA) stated she never remembered Resident 6 receiving a shower. Staff 11 stated she observed Resident 6 with greasy hair.

On 10/6/22 at 11:13 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would like to review for additional information. No additional information was provided.

4. Resident 8 was admitted to the facility in 2010 with diagnoses including spinal cord injury and muscle weakness.

A 7/13/22 Significant Change MDS indicated Resident 8 was cognitively intact. During the seven days look back period Resident 8 bathing did not occur.

An 8/26/22 Care Plan indicated Resident 8 required one-person assist with showering.

A 7/2022 through 8/2022 Point of Care History report indicated Resident 8 was not bathed from:
-7/1/22 through 7/20/22;
-7/21/22 through 7/31/22;
-8/1/22 through 8/31/22.

On 9/15/22 at 12:52 PM Resident 8 stated she/he did not get showers very often because of short staffing.

On 10/6/22 at 11:21 AM Staff 1 (Administrator) and Staff 2 (DNS) indicated they wanted to review the concern further. No additional information was provided.

5. Resident 7 was admitted to the facility in 2019 with diagnoses including Parkinson's disease.

A 5/19/22 care plan indicated Resident 7 required one person assistance for showers to assist with her/his upper and lower body.

A 7/25/22 Quarterly MDS assessment indicated Resident 7 required one-person physical assist with bathing. In the seven days look back period Resident 7 did not receive any type of bathing.

An 8/2022 Point of Care History report indicated Resident 7 was not bathed from 8/8/22 through 8/20/22.

On 10/4/22 Staff 19 (Agency LPN) stated Resident 7 was observed with a very oily face and often appeared disheveled.

On 10/6/22 at 11:19 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they wanted to review Resident 7 and her/his showers. No additional information was provided.

Based on interview and record review it was determined the facility failed to follow physician's orders for 1 of 3 sampled residents (#8) reviewed for accidents. This placed residents at risk for unmet medication needs. Findings include:

Resident 8 was admitted to the facility in 2010 with diagnoses including spinal cord injury and muscle weakness.

A 6/28/22 hospital discharge physician orders indicated to administer lidocaine adhesive three patches once a day to the most painful areas in the evening and the patches were to on for 12 hours due to acute pain from trauma.

A 7/2022 MAR instructed staff to administer lidocaine adhesive patches, two to the left ribs and one to the left hip once a day in the evening and the patch may remain on for 12 hours due to acute pain from trauma with a start date of 6/28/22 and discontinue date of 7/21/22. The patches and comments indicated the from 7/2/22 through 7/20/22 the lidocaine patch was unavailable.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA/CMA) stated Resident 8's physician order for a lidocaine patch which the insurance would not cover and nothing was done to resolve the issue to get a different medication or to have the medication discontinued. Staff 11 stated she had to mark it as unavailable.

On 10/4/22 at 9:53 AM Staff 19 (Agency LPN) stated Resident 8's Lidocaine patch was unavailable because her/his insurance would not cover the cost and it took a very long time to get a response back from the provider. Staff 19 stated she did not feel Resident 8 was in any additional pain because she/he did not have the patches as she/he was on a lot of pain medication and at times refused the alternative cream when it arrived as a replacement for the patch.

On 10/6/22 at 11:24 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they wanted to review the information. No additional information was provided.

Based on interview and record review it was determined the facility failed to assess, implement, follow, and maintain pressure ulcer treatments and prevent pressure ulcers for 2 of 3 sampled residents (#s 5 and 12) reviewed for pressure ulcers. This placed residents at risk for developing and worsening pressure ulcers. Findings include:

1. Resident 5 was admitted to the facility in 3/2022 with diagnoses including stroke.

A 3/1/22 History and Physical Examination revealed Resident 5 had encephalopathy (altered mental state and confusion) from dehydration.

A 3/16/22 Clinical Admission Documentation assessment revealed Resident 5 was at risk for skin breakdown for incontinence and poor nutrition with no skin impairment.

A 3/16/22 Skin Risk Assessment revealed Resident 5 was a high risk for pressure ulcers.

A 3/18/22 bed side care plan indicated Resident 5 was a two-person assist for bed mobility and to rotate her/him every two hours.

A Continuity of Care Document with an effective date of 3/18/22 (document created 9/27/22) revealed Resident 5's "Problems" as pressure ulcer of unspecified buttock, Stage 2 (Partial-thickness skin loss into but no deeper than the dermis. This includes intact or ruptured blisters.).

A 3/16/22 through 3/31/22 Point of Care History report revealed the following for resident moving in bed and staff support for bed mobility out of 32 opportunities.
-One instance of no setup or physical help from staff.
-24 instances of one-person physical assist.
-One instance of Activity did not occur.
-Six instances of no documentation resident was provided bed mobility.

A 3/2022 TAR instructed staff to provide the following for Resident 5:
-Weekly skin check document "-" for no skin breakdown and "+" for skin breakdown present. Follow skin at risk protocol. Document skin issues under "wound management".
-On 3/18/22 and 3/25/22 the TAR documented Resident 5 had skin breakdown present.
-Clean coccyx wound with normal saline, apply calmoseptine (moisture barrier and treat minor skin impairments) to open areas and cover with dressing every three days and PRN with a start date of 3/18/22.

A review of the resident's clinical record revealed no explanation, root cause analysis or investigation related to the development of Resident 5's wounds.

A 3/18/22 Progress Note indicated Resident 5 was found to have two blisters to the coccyx (also known as the tailbone, is a small, triangular bone resembling a shortened tail located at the bottom of the spine) area. No measurements were documented.

A 3/19/22 Progress Note indicated Resident 5 had a small wound on the coccyx area measuring three cm in diameter and wound care was to be completed every other day.

A 3/22/22 Admission MDS indicated Resident 5 was at risk for pressure ulcers with no unhealed pressure ulcers. Under active diagnoses the MDS indicated Resident 5 had a "pressure ulcer of unspecified buttock, Stage 2." The Pressure Ulcer CAA indicated Resident 5 had maceration on her/his bilateral buttocks, and staff were to assist with turning and repositioning.

A 3/26/22 Progress Note indicated Resident 5 had a wound on the sacrum which had partial thickness loss and a red, dry base. No additional wound details were documented.

A 4/1/22 comprehensive care plan indicated the following for Resident 5:
-Required two-person assistance with bed mobility.
-At risk for pressure ulcers, turn and reposition every two hours and PRN.

A 4/1/22 through 4/17/22 Point of Care History report revealed the following for resident moving in bed and staff support for bed mobility out of 33 opportunities.
-Four instances of no setup or physical help from staff.
-22 instances of one-person physical assist.
-One instance of Activity did not occur.
-Six instances of no documentation resident was provided bed mobility.

A 4/2/22 Progress note indicated Resident 5's blisters on her/his coccyx had opened and was approximately three cm by three cm. No additional description of the wound was documented.

A 4/2/22 Wound Management report revealed Resident 5 had opened blisters to the coccyx with measurement of three cm by three cm the wounds were not present on admission.

A 4/4/22 Progress Note indicated "Area cleaned and covered with sacral size foam dressing. Open area has partial thickness and red in wound bed." No additional description of the wound was documented.

A 4/9/22 at 5:52 AM Progress Note indicated Resident 5 had a Stage 2 pressure ulcer on the sacrum area with no signs or symptoms of infection. No additional description of the wound was documented.

A 4/9/22 at 11:42 AM Progress Note indicated Resident 5's pressure ulcers "on bottom" with red base draining a moderate amount of serosanguinous (thin like water with usually a light red or pink ting) drainage.

An 4/2022 TAR instructed staff to complete the following:
-Clean coccyx wound every three days and PRN with normal saline, pat dry applies Calmoseptine (Used to treat and prevent minor skin irritations such as from diarrhea, burns, cuts, and scrapes.) to open areas and cover with dressing with a start date of 3/18/22 and discontinued date of 4/15/22.
-Provide repositioning to offload pressure every two hours with a start date of 4/14/22.
-Clean open areas on sacrum cleanse with wound cleanser, apply alginate (are a strong, versatile, and natural wound care) dressing to open areas apply dressing once a day with start date 4/15/22.

A 4/15/22 Progress Note indicated Resident 5 had "many" pressure ulcers on her/his sacrum and groin area. Sacrum wound one was 3 cm by 2.5 cm by "deep?" unstageable, (Full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) 95 percent covered with necrotic (the death of most or all the cells in an organ or tissue due to disease, injury, or failure of the blood supply.) tissue. Sacrum wound two was an area of 1.5 cm by 1.9 cm by 0.2 cm Stage 2 pressure ulcer. Sacrum wound three was 0.9 by 0.5 by 0.3. (No documentation of a fourth wound) Wound five on the groin was 1.5 cm by 1.0 cm by "deep?" unstageable 80 percent covered by necrotic tissue. "Wound care performed as order."

On 6/16/22 a public complaint was received which indicated Resident 5 was re-admitted to the hospital on 4/17/22 and Resident 5 diagnosed with a Stage 4 (Full-thickness skin and tissue loss.) pressure ulcer to her/his lower back.

On 9/14/22 at 8:11 AM Witness 4 (Family Member) stated Resident 5 had a back sore which was caused from not repositioning her/him. Witness 4 stated she left for a few days and when she returned the sore was on her/his back on not on her/his buttocks. Witness 4 also stated Resident 5's catheter tubing was embedded into her/his leg.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA) stated Resident 5 did not get repositioned as frequently as care planned because the facility was short staffed in 3/2022 and 4/2022.

On 10/3/22 at 11:04 AM Staff 6 (RN) stated Resident 5 was on "a decline" and she/he had a Stage 1 pressure ulcer because of her/his illness and it was on her/his buttocks. Staff 6 could not remember specific area. Staff 6 stated the wound progressed to a Stage 2 pressure ulcer.

On 10/6/22 at 11:04 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would expect weekly wound management for a resident with a pressure ulcer. Staff 2 stated if blisters were found on a boney prominence it would be considered a Stage 2 pressure ulcer. Staff 2 stated it would be expected of staff to complete an investigation if a facility acquired pressure ulcer was identified.

2. Resident 12 was admitted to the facility in 7/2022 with diagnoses including diabetes, muscle weakness and anxiety.

A 7/20/22 Admission Clinical Admission Documentation indicated Resident 12 had a dark purple area on the left heel.

A 7/26/22 Admission MDS revealed Resident 12 was cognitively intact with a BIMs score of 15. Resident 12 was at risk for pressure ulcers but had no pressure ulcers or other skin problems.

An 8/9/22 Wound Information indicated Resident 12 had an abrasion to the left heel which was 0.8 cm in length, by 0.6 cm in width and the skin was a dark purple area, non-blanchable. Resident 12 stated the skin impairment began before hospitalization.

No documentation was found in clinical records of comprehensive weekly skin assessments between 8/9/22 and 9/14/22.

An 8/31/22 (document created on 9/26/22) Wound Information for unspecified Ulcer to the left heel was not present on admission with no observation history and no wound information documented.

An 8/31/22 Fax Cover Sheet to Resident 12's ANP (Adult Nurse Practitioner) indicated Resident 12 had a small dark purple non blanchable area on her/his left heel and reported it was painful at times. A request for an order for prevalon (heel protector for heel pressure relief) boot to reduce the pressure to the heel was accepted by the ANP.

A 9/2022 TAR instructed staff to provide Resident 12 a pressure relieving boot to the left lower extremity while in bed with the start date of 9/1/22.
-From 9/2/22 through 9/7/22 it was documented the boot was unavailable.
-On 9/7/22 stated administration was charted late. (unknown if administered)
-On 9/8/22 the boot was refused,
-On 9/9/22, 9/11/22 documented as unavailable,
-On 9/16/22 the comment was the boot was broken.

A 9/14/22 care plan indicated Resident 12 had a darkened, non-blanchable area on her/his left heel. With interventions including document in weekly skin sheet regarding the status of the wound, encourage fluid, monitor for signs of further breakdown, and notify the registered dietitian for evaluation. The interventions also included pressure relieving boot while in bed, treatment as ordered, turn and reposition as indicated, provide the weekly skin report to Staff 2 noting all of Resident 12's pressure ulcers.

On 10/6/2022 at 8:30 AM Staff 15 (LPN) stated he could not find Resident 12's pressure relieving boot and marked it was unavailable. Staff 15 stated Resident 12 did not have any treatment to her/his left heel because the wound was not open. Staff 15 stated he was not sure if weekly wound assessments were completed for Resident 12 because there were issues with the facility not having enough staff.

On 10/6/22 at 11:34 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would expect weekly wound assessments for Resident 12's left heel pressure ulcer. Staff 2 stated she would like to review the reason for the unavailability of the pressure relieving boot. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 2 of 3 sampled resident (#s 1 and 12) reviewed for accidents. This placed residents at risk for accidents. Findings include:

1. Resident 1 was admitted to the facility in 2018 with diagnoses including low back pain, diabetes and glaucoma.

An 4/6/22 care plan revealed Resident 1 was at risk for falls with interventions including Resident 1 required three people for transfers with a mechanical lift.

An 4/6/22 Occurrence Investigation Final Summary revealed Resident 1 was being transferred from her/his wheelchair to her/his bed with a mechanical lift with the assistance of two-people. Staff reported the lift started to tip and Resident 1 fell onto staff and was assisted to the floor by sliding down the staff member's body. Final report was the care plan was not followed at the time as two staff were transferring the resident when she/he was care planned to be a three-person mechanical lift transfer. The staff were provided one on one education with written expectations which were signed. Resident 1 complained of shoulder pain post fall and pain medication was administered. Resident 1 denied any abuse or neglect.

An 8/15/22 ADL CAA indicated Resident 1 required three-person assistance for transfers with a mechanical lift for safety.

A 9/1/22 through 9/16/22 Point of Care History report revealed two instances Resident 1 was provided one person assist for transfers.

There was no documentation from 9/14/22 through 9/15/22 on how Resident 1 was transferred.

On 9/15/22 at 11:43 AM Resident 1 was observed in the hallway in her/his wheelchair and stated "help me" a staff member came out of a resident room and wheeled Resident 1 into her/his room. Staff 21 (CNA) and Staff 27 (CNA) came out of a room next to Resident 1's room and went into Resident 1's room with a mechanical lift and closed the door.

On 9/15/22 at 12:30 PM Staff 21 (CNA) described the process of how he and Staff 27 transferred Resident 1. Staff 21 stated Resident 1's care plan was on her/his door in her/his room which indicated which sling to use and that she/he had always been a two-person transfer.

On 9/15/22 at 12:38 PM Resident 1's care plan dated 9/30/22 (documented as a future date) was observed on her/his inside closet door and instructed staff to provide three-person mechanical lift for transfers.

On 9/15/22 at 12:39 PM Resident 1 stated she/he remembered falling earlier in the year when staff were transferring her/him with a mechanical lift. Resident 1 stated they were transferring her/him and all the sudden she/he was on the floor. Resident 1 stated staff told her/him they were to provide three people instead of two. Resident 1 stated they still only provided two staff as there usually were not enough staff to have three people to assist with transfers.

On 9/27/22 at 12/18/22 Staff 8 (CNA) stated she was concerned every time she worked with Staff 14 during a mechanical lift transfer as she did not seem to know how to use it correctly. Staff 8 stated after Resident 1 fell with the mechanical lift in 4/2022. Staff 14 received training but she continued to have trouble on knowing how to use the slings correctly.

On 9/28/22 Staff 14 (NA) stated on 4/5/22 Staff 13 (NA) and herself were assisting Resident 1 to transfer and Staff 14 moved a table out of the way and the mechanical lift started to tip and Resident 1 slid down Staff 13's body. At the time Resident 1 was care planned for three-person transfer.

On 10/4/22 at 2:42 PM Staff 13 (Former NA) stated she believed Resident 1 was a two-person transfer before the 4/2022 fall. Staff 13 stated she read the care plan but she stopped looking at the care plan for a resident when she knew for a "fact" what the resident was care planned for. Staff 13 stated she was trained to listen to the charge nurse over what the care plan stated as she would get in trouble if she did not follow the charge nurses' instructions. Staff 13 confirmed the account of Resident 1's fall which occurred on 4/6/22.

On 10/6/22 at 10:33 AM Staff 1 (Administrator) and Staff 2 (DNS) stated it was the expectation for NAs to have a charge nurse in the room if completing a mechanical lift transfer. Staff 2 stated the staff were educated after the fall on how to use the mechanical lift and the expectation was Resident 1 continued to care planned as a three-person transfer.

2. Resident 12 was admitted to the facility in 7/2022 with diagnoses including UTI and repeated falls.

A 7/21/22 baseline care plan indicated she required two-person and was dependent for transfers.

On 8/17/22 a public complaint was received which indicated Resident 12 was care planned for two-person Hoyer (assist in other surface-to-surface patient transfer) mechanical lift and on 8/13/22 Resident 12 was transferred with a sit to stand lift because she/he requested she/he wanted to try it but was not released from physical therapy to use the sit to stand.

An 8/2022 Point of Care History indicated for assistance with transfers for Resident 12 on 8/13/22 day shift the question was unanswered, evening shift the question was unanswered and night shift the activity did not occur.

An 8/16/22 comprehensive care plan indicated Resident 12 required assistance with ADLs and required two-person with a sit to stand lift.

An 8/17/22 Mini Inservice Update from Therapy indicated to update the care plan it was ok for staff to use a mechanical sit to stand lift for all transfer, and bedside commode two person per policy.

On 9/14/22 at 11:05 AM Resident 12 stated she/he remembered in 8/2022 when she/he used a sit to stand to transfer although she/he was not yet approved to use the sit to stand by physical therapy. Resident 12 stated it was a male CNA and she/he did not want to disclose his name as the staff were "good".

On 9/21/22 at 10:08 AM Staff 8 (CNA) stated on 8/13/22 Staff 21 (CNA) completed a transfer with a sit to stand with Resident 12 as she/he requested but she/he was not approved to use the sit to stand for transfers and was care planned for a mechanical lift.

Attempts to reach Staff 21 were unsuccessful.

On 10/3/22 at 11:16 AM Staff 25 (Physical Therapy) stated Resident 12 admitted as a two person assist with a mechanical lift and she/he was completing therapy to train with a sit to stand and a slide board. On 8/17/22 Resident 12 changed from a two-person assist with mechanical lift to a two-person assist with a sit to stand. Staff 25 stated there was a mini-in-service update which was given to nursing staff which included the DNS, RCM and charge nurse when there was a change in level of ADL.

On 10/6/22 at 11:32 AM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the above information. Staff 1 and Staff 2 stated there were CNAs and NAs working with physical therapy and Resident 12 on how to use the sit to stand but they did not know who worked with physical therapy over several days on how to transfer Resident 12 with the sit to stand. No additional information was provided

Based on interview and record review it was determined the facility failed to provide adequate or appropriate incontinence and catheter care for 5 of 8 sampled residents (#s 1, 5, 8, 9 and 13) reviewed for ADLs. This placed residents at risk for unmet incontinence needs. Findings include:

1. Resident 1 was admitted to the facility in 2018 with diagnoses including low back pain, diabetes and glaucoma.

An 8/15/22 Urinary Incontinence and indwelling catheter CAA indicated Resident 1 required extensive to dependent assistance with toileting and she/he was always incontinent of bowel and bladder. Staff were to help with toileting frequently to maintain or improve continence level and maintain skin integrity. Staff were to check and change frequently and provide peri-care after each incontinent episode to maintain skin integrity.

An 8/29/22 care plan indicated Resident 1 was incontinent of both bowel and bladder with a goal to receive assistance from staff when needed for incontinent care Resident 1 was able to call when she/he needed assistance. Interventions included staff provision of incontinent care after each incontinent episode.

An 8/2022 Point of Care History identified Resident 1 was assisted to the toilet on 15 occasions/shifts during the month and the activity did not occur or was "unanswered" on 78 occasions/shifts during the month.

On 9/15/22 at 12:39 AM Resident 1 stated the staff were not timely to meeting her/his needs and concerns. Resident 1 stated she/he had bowel incontinent episodes multiple times and laid in her/his soiled brief. After one instance in 8/2022 she/he sat in a soiled brief after having a bowel movement for over an hour waiting for assistance.

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated when she arrived onto her shift on 8/13/22 Resident 1 had not received incontinent care the previous shift and she/he sat in fecal matter for over an hour.

On 10/6/22 at 10: 38 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they were not aware Resident 1 had sat in her/his bowel movement for over an hour.

2. Resident 5 was admitted to the facility in 3/2022 with a diagnosis of bladder cancer and dehydration.

A 3/16/22 Clinical Admission Documentation assessment revealed Resident 5 was continent of bladder with the use of a catheter.

A 3/16/22 Urinary Incontinence Assessment revealed urinary continence was not rated as Resident 5 had a catheter. Pattern of fluid intake "Describe resident's typical daily fluid intake. Include amounts and time of day." "Consumes large amounts of fluids daily" Resident 5 did not recognize the need to void. Resident 5 was not a candidate for catheter removal. Interventions included absorbent products and skin management, and to continue with current plan of care.

A 3/18/22 bedside care plan indicated Resident 5 had a Foley catheter and to measure urine output every shift and empty catheter bag.

A 3/22/22 Admission MDS and Urinary Incontinence CAA indicated Resident 5 was severely impaired cognitively with short and long-term memory problem. Resident 5 required total dependence with two-person physical assist with toilet use and had an indwelling catheter for comfort and urinary retention. Staff were to provide catheter care every shift with the goal of comfort.

A review of the 3/2022 TAR revealed no treatments or physician ordered care for Resident 5's catheter.

3/17/22 through 3/21/22 Progress Notes indicated Resident 5's Foley catheter was patent and draining yellow urine.

No documentation was found in the clinical records Resident's Foley catheter was monitored for patent and color from 3/22/22 through 3/25/22.

3/26/22 through 3/27/22 Progress Notes indicated Resident 5's Foley catheter was patent and draining yellow urine.

No documentation was found in clinical records Resident 5's Foley catheter was monitored for patent and color from 3/28/22 through 4/1/22.

A 3/31/22 comprehensive care plan revealed Resident 5 was incontinent of urine with interventions of obtain labs, privacy during incontinence care, provide incontinence care after each incontinent episode, report UTI, and report signs of skin break down.

3/16/22 to 4/17/22 Search Vitals Results Output for urine revealed 93 out of 72 shifts with no documentation of measured urine output.

On 4/2/22 (over two weeks after admission), the TAR was updated with instructions to provide the following catheter care for Resident 5:
-Catheter care with soap and water once a day.
-Change Foley catheter every four weeks and PRN.
-Flush Foley catheter with 60 to 100 milliliters normal saline for plugged catheter PRN.

On 10/3/22 at 11:04 AM Staff 6 (RN) stated the usual facility protocol was for the facility was to have the basic catheter care in the TAR for a resident who had a catheter.

On 10/6/22 at 11:11 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation of staff was to have physician orders in place for catheter care.

3. Resident 8 was admitted to the facility in 2010 with diagnoses including spinal cord injury and muscle weakness.

A 7/13/22 Significant Change MDS and Urinary Incontinence and Indwelling Catheter indicated Resident 8 was occasionally incontinent of urine and required extensive assistance with setup only for toilet use.

A 6/1/22 through 6/16/22 review of the "Alarm History since Aug 2021" report revealed 34 out of 192 activations of Resident 8's call light were over 20 minutes wait and two of the 34 were over an hour wait.

An 8/26/22 care plan indicated Resident 8 required one-person for transferring to the toilet as she/he sits for long periods of time in her/his bathroom. Resident 8 required one-person assistance for bowel care.

A review of "Alarm History since Aug 2021" report for Resident 8's room revealed the following call light response times over 20 minutes.
9/1/22:
-12:38 AM 21 minutes 46 seconds.
-5:24 PM 48 minutes 50 seconds.
9/6/22:
-8:47 PM 26 minutes.
9/9/22:
-7:05 PM 25 minutes 10 seconds.
9/10/22:
-7:55 PM 40 minutes 23 seconds.
9/11/22:
5:43 PM 20 minutes 54 seconds.
-7:37 PM 22 minutes 25 seconds.
9/12/22:
-9:11 AM 20 minutes 11 seconds.
9/14/22:
-5:53 AM 49 minutes 48 seconds.
9/15/22:
-4:36 AM 23 minutes 44 seconds.
-10:44 AM 22 minutes 26 seconds.
-6:41 PM 46 minutes 52 seconds.

A 9/1/22 through evening shift of 9/15/22 Point of Care History revealed 13 occurrences where residents balance when moving on and off the toilet did not occur or the question was unanswered out of 47 opportunities.

On 9/15/22 at 12:52 PM Resident 8 stated when agency staff were not in the facility the call light wait time was about an hour and a half. Resident 8 stated she/he had incontinent episodes quite often because of waiting.

On 10/6/22 at 11:20 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation was call light wait times not to go over 10 minutes.

4. Resident 9 was admitted to the facility in 10/2021 with diagnoses including retention of urine.

A 2/17/22 bedside care plan indicated Resident 9 was incontinent of bowel and bladder.

A 7/18/22 Nursing Progress Note indicated Resident 9's peri area was red during shower.

An 7/2022 Point of Care History revealed for bladder and bowel no documentation of bladder or bowel function was completed for 7/2022. How Resident 9 used the toilet there was either no documentation, unanswered or activity did not occur 58 instances out of 98 opportunities. (On 7/18/22 night shift activity did not occur, day and evening shift total dependence)

An 8/4/22 Nursing Progress Notes indicated Resident 9 had increased confusion and stated did not know her/his name and unsure of her/his location. Resident 9 reported burning during urination. Positive UA results UA report sent to provider and remaining sent to lab. New orders received to start Keflex (A medication is used to treat a wide variety of bacterial infections.) for seven days for UTI.

A Continuity of Care Document indicated on 8/4/22 Resident 9 was diagnosed with a UTI.

An 8/4/22 UA Report indicated Resident 9 complained of burning and had increased confusion.

An 8/4/22 SOAP (subjective, objective, assessment, and plan) nurse practitioners note revealed and order for Keflex for seven days.

An 8/12/22 signed Physician Order Report instructed staff to document Resident 9's bowel movement every shift with a start date of 10/11/21.

8/2022 MAR instructed staff to administer Keflex for seven days for UTI with a start date of 8/4/22.

An 8/19/22 comprehensive care plan indicated Resident 9 required one-person maximum assistance with toileting.

An 8/2022 Point of Care History revealed Resident 9's documentation for bladder, 8/1/22 through 8/7/22 and 8/20/22 through 8/31/22 there was no documentation of bladder or bowel function, 8/8/22 through 8/19/22 there were 21 instances of no documentation or unanswered and 12 instances of incontinence. (On 8/13/22 day and evening shift "unanswered" and night shift incontinent for bowel and bladder)

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated on 8/13/22 Staff 8 came onto her shift and the previous shift told her they were too busy to provide incontinent care. Staff 8 was the only CNA scheduled for evening shift and Resident 9 was one of the residents who were "soaking wet".

On 10/4/22 at 10:03 AM Staff 19 (Agency LPN) stated incontinent care was a problem as there was not enough staff to provided incontinent care in a timely manner and residents were left in wet briefs too long. At times there was only one CNA for day shift.

On 10/5/22 at 12:13 PM Staff 5 (CNA) stated she has come onto shift and residents will be urine soaked which were not taken care of from the previous shift. Staff 5 stated the NA were not trained properly and residents are laying in their incontinence and not being changed properly.

On 10/6/22 at 11:27 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would like to review and provide additional information. Staff 2 sated there were aides who were documenting activity did not occur for incontinent residents at one time and they provided education at the last CNA meeting.

5. Resident 13 was admitted to the facility in 6/2022 with diagnoses including dementia and muscle weakness.

A 6/4/22 care plan indicated Resident 13 required assistance with his daily care needs and required two-person assistance with toileting needs. Staff may offer to assist with a bedpan for bowel movement and she/he has an indwelling catheter which required care every shift and PRN.

A 6/28/22 Admission MDS and Urinary Incontinence Indwelling Catheter CAA revealed Resident 13's BIMS was eight indicating she/he was moderately impaired. Resident 13 required total dependence of two people physical assist for toilet use. The CAA indicated Resident 13 was always incontinent of bladder and bowel and was dependent on staff for brief changes and peri care. Staff were to help with toileting frequently to help maintain and improve continence level, maintain skin integrity. Staff were to check and change her/his brief frequently and provide peri-care with each incontinent episode to maintain skin integrity.

An 8/17/22 Occurrence Investigation Final Summary indicated Staff 8 (CNA) documented that staff had toileted, fed and provided a partial bed bath for Resident 13. At 11:15 AM Staff 2 (DNS) was notified from another staff member that Resident 13 was not changed all shift. A few minutes after 11:00 Resident 13 was provided incontinent care and reported she/he had dried bowel movement stuck to her/his buttocks and groin area which was reddened. Staff 8 reported she provided a partial bed bath before breakfast and before the family's arrival. Family reported arriving at the facility around 7:00 AM. Video footage reviewed from time Staff 8 assigned from 6:00 to 6:51 AM and the CNA did not enter Resident 13's room. Staff 8 indicated she provided the documented care prior to family arrive and CNA was suspended pending investigation. Staff 8 was terminated on 8/18/22. Resident 13 was unable to remember if she/he had incontinent care.

Point of Care History for 8/17/22 revealed Staff 8 documented Resident 13 was incontinent of bowel function at 8:58 AM.

An 8/2022 MAR instructed staff to complete the following on 8/17/22:
- monitor pain every shift and indicate pain level and location on a 0-10 pain scale. On 8/17/22 was documented as zero in the morning.
-administered acetaminophen tablet three times a day documented as administer at the 7:00 AM time by Staff 32 (CMA).

On 9/21/22 at 10:11 AM Staff 8 stated she provided Resident 13 a partial bed bath and did not provide peri care as she/he was in too much pain and she reported it to the CMA and let her know she would wait to provide incontinent care later to let the pain medication take effect. At 6:00 AM Staff 8 checked Resident 13 and she/he was not incontinent of bowel she wiped the front part as she/he was prone to inventions. Staff 8 stated she documented bowel incontinent care because she knew she/he had a bowel movement and she was sent home before she could provide incontinent care.

On 9/28/22 at 8:18 AM Staff 32 stated she did not remember if any staff came and informed her the morning of 8/17/22 that Resident 13 was in pain. Staff 32 stated since the facility was short staffed a lot she would get through her medications as quickly as possible then help CNAs with the residents and she was usually able to get morning medications completed by 9:00 AM but that did not always occur. Staff 32 stated she had until 10:30 AM in the system before she must mark what the reason was for a late entry or administration.

On 10/6/22 at 11:37 AM Staff 1 (Administrator) and Staff 2 (DNS) stated it was the expectation of staff to provide timely incontinent care.

Based on interview and record review the facility failed to provide hydration care and services for 1 of 3 residents (#5) a reviewed for hydration. This placed residents at risk for dehydration. Findings include:

The facility's 9/2017 Hydration Clinical Protocol indicated:
The physician and staff will define the resident's current hydration status.
The staff with physician's input, will identify and report residents with signs and symptoms (for example, delirium, lethargy, increased thirst) or lab test results.
The physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance.

Resident 5 was admitted to the facility in 3/2022 with a diagnosis of bladder cancer and dehydration.
A 3/17/22 comprehensive care plan indicated Resident 5 was a potential for alteration in nutrition and dehydration. With goal of eating 75 to 100 percent of meals, adequate fluid intake, and no signs or symptoms of dehydration. Interventions included speech therapy and occupational therapy to screen and treat if indicated, assist with dining as needed, follow swallow precautions if indicated, supplements and labs per physician orders, monitor input and output if indicated, monitor meal and fluid intakes and record. Registered dietitian's consult on admission and as needed.

A 3/18/22 SOAP Note (physician visit) indicated Resident 5 had an acute kidney injury and needed to follow up with labs including CBC, (Complete blood count) and CMP (comprehensive metabolic panel which measures 14 different substances in the blood.)

A 3/19/22 Progress Note indicated Resident 5 was very lethargic.

A 3/21/22 Progress Note Indicated Resident 5 continued to be lethargic and her/his Foley catheter was patent and draining concentrated yellow urine (urine becomes more concentrated when an individual is less hydrated).

A 3/22/22 Admission MDS revealed Resident 5's was severely cognitively impaired, had coughing and choking during meals or when swallowing medications.

A 3/31/22 Resident 5 Dietician Review and Recommendations revealed continued lethargy and recommended a medication to be held to see if it would improve her/his wakefulness. Resident 5 had decreased oral intake and need for mechanically altered diet.

A 4/3/22 at 1:46 AM and 1:35 PM Progress Notes indicated Resident 5's urine was amber in color [which can be an indicator of severe dehydration].

A review of fluid intake records from 3/16/22 to 4/17/22 revealed fluid intake records lack documented monitoring for 44 shifts out of 99 shifts reviewed.

A review of urine output records from 3/17/22 to 4/17/22 revealed no documented monitoring for 64 shifts out of 99 shifts reviewed.

On 9/14/22 at 8:11 AM Witness 4 confirmed the public complaint that staff did not provide Resident 5 with adequate fluids, and the family had to request staff to provide her/his fluids.

On 9/26/22 Staff 11 (Former CNA) stated it was difficult to make sure all the residents received enough fluids when the facility was short staffed in 3/2022 and 4/2022. Staff 11 stated Resident 5 was not capable of drinking on her/his own and staff needed to hand fluids to Resident 5 while she/he drank.

On 10/6/22 at 11:09 AM Staff 1 (Administrator) and Staff 2 (DNS) stated Resident 5 had days she/he could drink on her/his own and other days when she/he could not drink without assistance. Staff 2 stated it was expected of the staff to document input and output for Resident 5.

Based on interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 10 of 20 sampled residents (#s 1, 3, 4, 5, 6, 7, 8, 9, 12 and 16) and of 4 halls reviewed for call light wait times, staffing, verbal abuse, ADLs and respiratory. This placed residents at risk for unmet needs. Findings include:

1. A review on 9/21/22 of an updated 11/7/19 Facility Assessment revealed the assessment was not updated, as necessary, or at least annually. The assessment was not comprehensive and did not include any changes in staffing acuity since 2019.

A review of DCSDRs (Direct Care Staff Daily Report revealed the facility was not staffed at minimum requirements for CNAs for the following:
-4/9/22 through 4/17/22 for 19 out of 27 shifts.
-6/4/22 through 6/12/22 for 24 out of 27 shifts.
-7/3/22 through 7/31/22 for 64 out of 87 shifts.
-8/1/22 through 8/21/22 for 36 out of 63 shifts.
-9/3/22 through 9/11/22 for 8 out of 27 shifts.

On 8/2/22 a public complaint was received which indicated the facility was short staffed on all shifts which was a concern for over a month. On 8/4/22 there was only one CNA for 27 residents. On 8/5/22 the scheduled indicated there would only be two CNAs scheduled. Earlier in 8/2022 a NA received one day of training and then was working with residents on her own.

On 9/14/22 at 8:10 AM Witness 2 (Family Member) stated the facility was short staffed often. Witness 2 stated she would hear residents yelling out for help "all the time." Residents would wave Witness 2 down when walking the halls to get assistance because no one came. Witness 2 would have to go find someone. At times staff were at the nursing station just standing there. Witness 2 stated she saw residents with dirty clothes on.

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated there were staffing concerns in the facility from 2/2022 through the end of 8/2022. Staff 8 was a NA and then became a CNA and while she was a NA, she was scheduled to work quite often with no CNAs scheduled. In 8/2022 Staff 8 came on shift and the previous shift told her they were too busy to provide incontinent care. Staff 8 was the only CNA scheduled for evening shift and the following rooms needed assistance when she arrived on shift:
-Room 33 a staff member was feeding her/him dinner and did not see the large wet spot on her/his sheet and the soaked sheet was leaking "everywhere."
-Room 29 was wet [incontinent of urine]
-Room 3 was wet
-Room 25 was wet
-Room 36 needed to use the bed pan and her/his light was on
-Room 39 wet and was prone to UTIs
Staff 8 stated it took her four hours to get caught up and to get the residents calmed down. Staff 8 stated she was "running around like a chicken with head cut off". Staff 8 stated she had all 25 residents. Staff 6 (RN) did assist her with the two-person transfers. Staff 8 stated she did not have enough time to complete all her assigned tasks and she would not complete charting and did not always have time for showers. Residents complained of long call light wait times "all the time".

On 9/26/22 at 9:14 AM Staff 14 (CNA) stated in 7/2022 the facility was short staffed and evening shifts were always short as well as the weekends. At times NAs would be assigned with no CNAs. Staff 14 stated it was difficult to make sure all the residents were hydrated as there were not enough staff. Staff 14 also stated because of lack of staff residents were being left in bed all day and were not getting up for meals.

On 9/27/22 at 12:47 AM Staff 12 (Former NA) stated there were instances she would be the only person on shift from 6:00 PM to 10:00 PM and every resident would need incontinent care and be wet. Staff 12 stated she would have to do five to six full bed linen changes because residents would be soaked through including their bed linen. Staff 12 stated by the time she was able to assist the residents they would be so "pissed".

On 9/28/22 Staff 35 (CNA) stated residents would call out for help because of long waits for care. Residents had incontinent episodes because they could no longer wait for assistance to use the toilet. Residents were upset and went days without showers.

On 10/3/22 at 9:26 AM Staff 28 (Former CNA) stated from 4/2022 through middle of 6/2022 the facility was understaffed. Staff 28 stated one day on day shift when she arrived at work, she was the only CNA scheduled for the whole facility and the Activities Director and the outreach coordinator had to assist. Not all care was provided to the residents. Staff 28 stated she quit because the facility was historically short staffed. There would be 15 to 16 residents assigned on evening shift and they did not have time to get them up for meals. Showers were commonly differed to the next shift, residents had incontinent episodes because staff could not get to them in a timely manner. One resident had two falls and her/his face was black and blue as staff could not get to her/him in a timely manner. One resident was a three-person transfer and was not given the opportunity to get out of bed because there were not enough staff to provide a transfer. Staff 28 stated "It was a nightmare."

On 10/3/22 at 11:48 AM Staff 33 (Former NA) stated she quit working at the facility because of the short staffing. Staff 33 stated there were many instances she would come onto her shift and residents would be soaked from lack of incontinent care.

On 10/4/22 at 10:03 AM Staff 19 (Agency LPN) stated the resident in room 12 had greasy hair, body odor and smelled of urine. Staff 19 stated she gave her/him a complete bed bath as it seemed like she/he never got showered. Staff 19 stated she usually worked the night shift and many instances she would have just one NA and one nurse and no other staff in the building. Staff 19 stated there instances she had a hospitality aid who could not provide any type of hands-on care with the residents and she would have to provide the care. Staff 19 stated she was very concerned and one night refused to come on to shift because she could not do it anymore. Staff 19 stated there were a lot more UTIs in the facility because resident were being left in wet briefs for long periods of time.

On 10/4/22 at 2:42 PM Staff 13 (Former NA) stated she had worked both evening shift and night shift alone with no other CNAs or NAs to assist. Staff 13 had come on shift and found resident's needs were not met the previous shift.

On 10/5/22 at 8:35 AM Staff 20 (NA) stated he recently worked the night shift two nights in a row by himself with no other CNAs or NAs to assist him and had to care for approximately 26 residents. Residents complain of long call light wait times and a resident recently told him thank you for responding quickly to a call light as they had just waited during the day for 40 minutes for a staff member to come into the room.

On 10/5/22 at 12:13 PM Staff 5 (CNA) stated she did not have enough time each day to complete all her required assignments, she usually could not complete all the showers or charting. Staff 5 stated if a resident did not have to get out of bed for therapy or an appointment they would stay in bed. Residents complain about long call light wait times, not being able to wait for toileting assistance and had incontinent episodes. Staff 5 stated she had come onto shift and residents would be urine soaked because the previous shift did not provide ADL care. Staff 5 stated the NA were not trained properly and residents were not provided appropriate incontinence care.

On 10/6/22 at 8:30 AM Staff 15 (LPN) stated he was not sure if weekly wound assessments were being completed due to lack of staff.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to work with outside agencies and provide bonuses but continued to have difficulty with finding and retaining staff.

2. Resident 1 was admitted to the facility in 2018 with diagnoses including low back pain, diabetes and glaucoma.

An 8/11/21 comprehensive care plan indicated Resident 1 used her/his call light incessantly for different reasons. With the goal of tending to her/his needs on a scheduled basis, interventions included to answer Resident 1's call light and ask what her/his need were and if they could provide anything else. Resident 1 was to be reminded she/he would be checked on by staff every 15 to 30 minutes to inquire about future needs.

An 8/15/22 ADL CAA indicated Resident 1 was encouraged to use her/his call light for assistance.

An "Alarm History since Aug 2021" report was reviewed for the following dates: 8/13/22, 9/5/22 and 9/11/22. The report revealed the following call light response times over 20 minutes for Resident 1's room.
8/13/22:
-7:28 AM 27 minutes, 34 seconds.
-8:08 AM 28 minutes, 15 seconds.
-9:38 AM 58 minutes, 26 seconds.
-11:44 AM 29 minutes, 28 seconds.
-12:30 PM one hour, seven minutes, 49 seconds.
-2:06 PM one hour, nine minutes, 39 seconds.
-3:21 PM one hour, one minute, 24 seconds.
-5:23 PM 46 minutes, 48 seconds.
-6:39 PM 30 minutes, 39 seconds.
-7:35 PM 35 minutes 36 seconds.
-8:51 PM 24 minutes 36 seconds.
9/5/22:
-10:02 AM 23 minutes 58 seconds.
-11:20 AM 20 minutes, 51 seconds.
-8:50 PM 40 minutes, 36 seconds.
9/11/22:
-8:13 AM 29 minutes, 17 seconds.
-6:01 PM 31 minutes 47 seconds.

On 9/15/22 at 12:39 AM Resident 1 stated the staff were not timely in meeting her/his needs and concerns. Resident 1 stated she/he has had incontinent episodes of her/his bowels multiple times and had to lay in soiled briefs. One instance in 8/2022 she/he sat in a bowel movement for over an hour waiting for assistance. Resident 1 stated sometimes medications would be two to three hours late and her/his pain levels would be out of control.

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated in 6/2022 Resident 1 sustained a fall due to long call light wait times when the resident attempted to transfer herself/himself to the toilet. In 8/2022 Staff 8 came onto her shift and the previous shift told her they were too busy to provide incontinent care. Staff 8 was the only CNA scheduled for evening shift and Resident 1 sat in her/his fecal matter for over an hour.

On 9/26/22 at 9:14 AM Staff 13 (Former CNA) stated because the facility was short staffed, Resident 1 did not receive showers, or assistance out of bed. Resident 1 yelled out at times to receive assistance and fell out of her/his wheelchair at one time because she/he waited for staff to come and assist her/him.

On 10/6/22 at 10: 38 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they were not aware Resident 1 had sat in her/his bowel movement for over an hour. Staff 2 stated the expectation was call light wait times not to go over 10 minutes.

3. Resident 3 was admitted to the facility in 11/2021 with diagnoses including generalized anxiety disorder, acute kidney failure and pain

A 12/16/21 care plan indicated Resident 3 was at risk for falls with a history of repeated falls, immobility, and behaviors with interventions including ensure Resident 3's call light was in reach and encourage her/him to use the call light when assistance was needed.

A 4/18/22 Quarterly MDS indicated Resident 3's BIMS was 14 indicating she/he was cognitively intact and required two-person physical assist with bed mobility and toilet use and one person assist with dressing and personal hygiene.

An "Alarm History since Aug 2021" report was reviewed for 6/4/22, 6/12/22, 9/5/22 and 9/9/22. The report revealed the following call light response times over 20 minutes for Resident 3's room.
6/4/22: call light was activated 13 times
-6:31 AM 49 minutes, 16 seconds
-3:02 PM 39 minutes, 45 seconds
-4:48 PM 48 minutes 59 seconds
-5:58 PM 37 minutes 43 seconds
6/12/22: call light was activated 20 times
-8:15 PM one hour, four minutes and 59 seconds
9/5/22: call light was activated 20 times
-2:37 AM 37 minutes
-7:38 AM 25 minutes 25 seconds
9/9/22: call light was activated 16 instances
-3:29 PM 27 minutes 41 seconds
-4:36 PM 21 minutes 10 seconds
-11:06 PM 24 minutes 6 seconds

On 9/15/22 at 12:20 PM Resident 3 stated she/e did not feel there was enough staff to meet her/his needs in a timely manner. Resident 3 stated she/he waited up to 45 minutes for a call light to be answered and then staff would be in and out quickly.

On 9/21/22 at 9:54 AM Staff 8 (CNA) stated on 8/13/22 she came on to her shift and the previous shift told her they were too busy to provide incontinent care. Staff 8 was the only CNA scheduled for evening shift and Resident 3 was one of the many residents who needed incontinent care and was wet.

On 10/6/22 at 10: 55 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation was call light wait times should not be over 10 minutes.

4. Resident 4 was admitted to the facility in 5/2022 with diagnoses including hip fracture and pain.

A 5/15/22 Admission MDS indicated Resident 4 was cognitively intact with a BIMS score of 14. Resident 4 required limited assistance with one-person physical assist and was always continent of bowel and bladder.

A 6/6/22 Direct Care Staff Daily Report indicated revealed the facility was not staffed at minimum state requirements on the night shift.

A 6/8/22 public complaint revealed on 6/6/22 between 10:00 PM and 6:00 AM Resident 4 activated her/his call light and Staff 4 (CNA) stated "I can't do that for you" Resident 4 had to urinate all night and was upset and in pain the next morning. Staff 4 came into the room several times throughout the night but did not assist Resident 4 to the toilet. When Staff 5 (CNA) came on shift at 6:00 AM Resident 4 was assisted to the toilet.

A 6/9/22 Occurrence Investigation Final Summary indicated on the night of 6/6/22 Resident 4 was told by Staff 4 that Resident 4 could not be assisted to the toilet. Resident 4 stated Staff 4 came into the room several times and checked her/his incontinent product and offered to change her/his incontinent product if needed. Staff 4 reported Resident 4 had requested "to be toileted" and she stated she would be right back. When Staff 4 returned Resident 4 stated she was "fine" and "dry". Staff 4 was issued a written warning and was provided a copy of the facility's abuse and neglect policy and procedure. Resident 4 was educated on the importance of notifying the charge nurse, DNS, or administrator if she/he was experiencing any difficulty with staff.

A 6/10/22 handwritten witness statement from Staff 4 (CNA) stated on 6/6/22 she completed a check on all residents to make sure they were safe and dry when she started her shift. Resident 4's call light came on with several other call lights and she answered Resident 4's light. Resident 4 requested "to be toileted" at the time. Staff 4 indicated she would be right back as she had to finish her "safety walk through" and when she returned to Resident 4's room Resident 4 stated "[she/he] was fine and dry." Staff 4 continued to check on her and Resident 4 continued to say she/he was fine and dry each instance. Staff 4 checked her/his brief and it was dry.

A Point of History Report from 6/1/22 through 6/30/22 revealed eight instances it was documented Resident 4 was continent and no documentation of incontinence in the month of 6/2022.

On 9/26/22 at 9:14 AM Staff 11 (Former CNA) stated there was only one CNA on night shift on 6/6/22 and Staff 4 told Resident 4 to wet in her/his brief and Staff 4 would provide incontinent care because she was the only CNA working that night.

On 10/5/22 at 5:09 AM Staff 4 stated she confirmed the above 6/10/22 handwritten statement and stated she did not tell Resident 4 to wet her/his brief and then she would change her/him. Staff 4 stated the new aides were telling residents to go in their incontinent product now as it is quicker to change a brief then take a resident to the toilet. Staff 4 stated the night of 6/6/22 to 6/7/22 was the last night she worked alone on night shift with no additional CNA staff to assist. As now Staff 4 will call the facility before each shift she works to make sure there is an additional qualified person to work with her.

On 10/6/22 at 10: 57 AM Staff 2 (DNS) stated it was the expectation of the staff to assist a resident who was continent to the toilet. Staff 1 (Administrator) stated it was her understanding Resident 4 did not ask Staff 4 to use the toilet and assumed Resident 4 did not need to use the toilet.

5. Resident 5 was admitted to the facility in 3/2022 with diagnoses including acute kidney failure and muscle weakness.

A 3/18/22 bedside care plan indicated Resident 5 required two-person for bed mobility and to reposition every two hours.

A review of DCSDRs (Direct Care Staff Daily Report revealed the facility was not staffed at minimum requirements for CNAs for the following:
-4/9/22 through 4/17/22 for 19 out of 27 shifts.

On 6/16/22 a public complaint was received which indicated Resident 5 was re-admitted to the hospital on 4/17/22 and Resident 5 diagnosed with a Stage 4 (Full-thickness skin and tissue loss.) pressure ulcer to her/his lower back. Resident 5 had a bladder infection which resulted in sepsis and a staph infection on the right leg.

On 9/26/22 Staff 11 (Former CNA) stated Resident 5 did not get repositioned as frequently as care planned because of short staffing in 3/2022 and 4/2022.

On 10/6/22 at 10: 02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to work with outside agencies and provide bonuses but continued to have difficulty with finding and retaining staff.

6. Resident 6 was admitted to the facility in 7/2022 with diagnoses including irritable bowel syndrome with diarrhea.

A 7/2022 Point of Care History revealed on 7/23/22 for evening and night shift there was no documented evidence the resident was toileted.

A 7/7/22 bedside care plan indicated transfers "not until seen by therapy."

An event date "7/23-7/24" Occurrence Investigation Final Summary report indicated Resident 6 reported she/he was not checked on all night shift and stated she/he did not have her/his call light or phone and was left with only a sheet as a cover. Resident 6 also reported her/his window was left open all night.

-According to the investigation Staff 14 (NA) reported at approximately 9:00 PM Resident 6 was assisted with using a bed pan and incontinent care. Staff 14 stated she provided Resident 6 with her/his bed controller. Staff 33 (NA) stated Resident 6 did not like her/his main door open because it was loud so Staff 33 checked on her through the adjoining bathroom. Staff 33 indicated Resident 6 appeared to be asleep with her/his eyes closed during "this safety check." Plan to prevent recurrence was all staff to ensure call light and bed controllers are attached prior to leaving the room, frequently used items to be always in reach. Staff 33 reported she completed at least four safety checks during her shift.

-Handwritten statement attached to the investigation by Staff 33 indicated when she arrived on shift, she was told Resident 6 was fine and she/he would activate her/his call light if she/he needed anything. In total Resident 6 was checked four times "maybe".

A 7/24/22 signed handwritten statement by Staff 14 indicated she assisted Resident 6 at 9:00 PM on 7/23/22 and assisted with bedpan and incontinent care. Staff 14 stated Resident 6 was holding her/his bed controls when she left her/his room at 9:15 PM.

A 7/24/22 Direct Care Staff Daily Report revealed on night shift there was a census of 28 residents with one NA scheduled and no CNA scheduled for night shift.

A 7/28/22 care plan indicated Resident 6 expressed she/he was unattended and unchecked during the night. With interventions including safety checks, ensure call lights and bed controllers were attached prior to leaving room, frequently used items such as bedside table, and cell phone within reach and ensure CPAP (continuous positive airway pressure) was on at night.

On 9/22/22 at 9:41 AM and 2:56 PM Witness 11 (Family Member) stated on 7/24/22 Resident 6 did not receive any type of care or safety checks throughout the night. Witness 11 stated at 9:30 PM on 7/23/22 she/he was provided incontinent care and her/his bed was left in the highest position with all her/his bed controls left on the floor. Resident 6's window was left open and by 11:30 PM she/he stated Resident 6 was cold. Resident 6 was up all night with just a sheet and her window open. Resident 6 had an incontinent episode and her/his bed was soaked. At 7:30 AM the nurse came in to administer her/his medications and Resident 6's teeth were chattering. Witness 11 stated they filed a grievance. Witness 11 stated they had a video of the hallway and they were going to review to see if staff ever went into Resident 6's room. Witness 11 stated she requested to view the video but never saw it.

On 10/3/22 at 10:57 AM (RN) Staff 6 stated she worked the night of 7/24/22 and Staff 33 told Staff 6 that the main door of Resident 6's room closed loudly so she went in through the bathroom of the adjoining room and stated Resident 6 was sleeping and Staff 33 assumed Resident 6's call light had fallen out of reach and Staff 33 did not observe it happened. Resident 6 had difficulty sleeping and requested not to have staff wake her/him if she/he was sleeping.

On 10/3/22 at 11:48 AM Staff 33 (NA) stated on night shift of 7/23/22 to 7/24/22 she was the only NA on shift that night. Staff 33 stated she would peek in on Resident 6 from the adjoining bathroom door. Staff 33 stated she thought she saw Resident 6's cords within reach but she was all alone and did not have a hospitality aide that night to assist her and she was "on the run" to make sure resident's needs were met. Staff 33 stated she did remember Resident 6's bed was in a higher position that night.

On 10/6/22 at 11:14 AM Staff 1 (Administrator) and Staff 2 (DNS) stated Resident 6 did not like staff coming through her/his main room door and they could see staff looking at Resident 6 through the bathroom door. The expectations were for Resident 6 to have her/his controls within reach and she/he was doing okay. Resident 6 was alert and oriented and would ask where her/his call light and bed controller were and she/he could call out and she/he would have received an "immediate" response.

7. Resident 7 was admitted to the facility in 2019 with diagnoses including Parkinson's disease.

A 10/29/21 bedside care plan indicated staff may offer a bed pan to Resident 7 for toileting.

A 7/5/22 Quarterly MDS indicated Resident 7 was frequently incontinent of bowel and bladder.

A review of Direct Care Staff Daily Reports revealed the facility was not staffed at minimum requirements for CNAs for the following:
-7/3/22 through 7/31/22 for 64 out of 87 shifts.
-8/1/22 through 8/21/22 for 36 out of 63 shifts.
(8/4/22: Day shift census of 26 with two CNAs, Evening shift census of 25 with one CNA and on NA.)
(8/5/22: Census of 25 with one CNA and two NAs, Evening shift no CNAs and one NA scheduled.)

On 8/2/22 a public complaint was received which indicated the facility was short staffed on all shifts which was a concern for over a month. On 8/4/22 there was only one CNA for 27 residents. On 8/5/22 the scheduled indicated there would only be two CNAs scheduled. Earlier in 8/2022 a NA received on day of training and then was working with residents on her own. Resident 7 waited for over 45 minutes for a bed pan because there were only two CNAs.

An 8/2022 Point of Care History report indicated on 8/4/22 Resident 7 was dependent or required extensive assist from staff for toileting. On 8/5/22 there was no documentation on the report for day and evening shift and toileting was documented as "did not occur" for night shift.

An Alarm History Since "Aug 2021" report indicated on 8/4/22 at 10:06 AM Resident 7's call light was activated with a response time of 46 minutes and 27 seconds.

On 10/6/22 at 11:17 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they were not aware Resident 7 was on a bed pan for 45 minutes.

8. Resident 8 was admitted to the facility in 2010 with diagnoses including spinal cord injury and muscle weakness.

A 7/13/22 Significant Change MDS and Urinary Incontinence and Indwelling Catheter indicated Resident 8 was occasionally incontinent of urine and required extensive assistance with setup only for toilet use.

Review of the "Alarm History since Aug 2021" report from 6/1/22 through 6/16/22 revealed 34 out of 192 activations of Resident 8's call light with over 20 minutes wait with two wait times over an hour.

An 8/26/22 care plan indicated Resident 8 required one-person for transferring to the toilet as she/he sits for long periods of time in her/his bathroom. Resident 8 required one-person assistance for bowel care.

A review of "Alarm History since Aug 2021" report for Resident 8's room revealed the following call light response times over 20 minutes.
9/1/22:
-12:38 AM 21 minutes 46 seconds
-5:24 PM 48 minutes 50 seconds
9/6/22:
-8:47 PM 26 minutes
9/9/22:
-7:05 PM 25 minutes 10 seconds
9/10/22:
-7:55 PM 40 minutes 23 seconds
9/11/22:
5:43 PM 20 minutes 54 seconds
-7:37 PM 22 minutes 25 seconds
9/12/22:
-9:11 AM 20 minutes 11 seconds.
9/14/22:
-5:53 AM 49 minutes 48 seconds
9/15/22:
-4:36 AM 23 minutes 44 seconds
-10:44 AM 22 minutes 26 seconds
-6:41 PM 46 minutes 52 seconds

On 9/15/22 at 12:52 PM Resident 8 stated when agency staff were not in the facility the call light wait time was about an hour and a half. Resident 8 stated she/he had incontinent episodes quite often because of waiting. Resident 8 stated on 6/16/22 she/he had not activated her/his call light as she/he was tired of it not being answered and on 6/16/22 she/he fell and broke her/his ribs and hip.

On 10/6/22 at 11:20 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation was call light wait times not to go over 10 minutes.

9. Resident 9 was admitted to the facility in 10/2021 with diagnoses including retention of urine.

The facility's Direct Care Staff Daily Reports revealed the following:
-8/1/22 through 8/21/22 there were eight out of 21 days without eight consecutive hours of RN coverage between the start of day shift and the end of evening shift as follows: 8/2/22, 8/3/22, 8/4/22, 8/7/22, 8/8/22, 8/12/22, 8/14/22, and 8/17/22.

A review of Direct Care Staff Daily Report revealed the facility was not staffed at minimum State requirements for CNAs for the following:
-8/1/22 through 8/21/22 for 36 out of 63 shifts.

An 8/19/22 care plan indicated Resident 9 was frequently incontinent of bladder and the goal was to keep her/him clean, and dry. Interventions included frequent incontinence checks for Resident 9 to be free of UTIs. Resident 9 required one-person maximum assistance with toileting.

An 8/2022 Point of Care History revealed Resident 9's documentation for bladder, 8/1/22 through 8/7/22 and 8/20/22 through 8/31/22 there was no documentation of bladder or bowel function, 8/8/22 through 8/19/22 there were 21 instances of no documentation or unanswered and 12 instances of incontinence. (On 8/13/22 day and evening shift "unanswered" and night shift incontinent for bowel and bladder)

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated there were staffing concerns in the facility from 2/2022 through the end of 8/2022. Staff 8 was a NA and then became a CNA and while she was a NA, she was scheduled to work quite often with no CNAs scheduled. In 8/2022 Staff 8 was told by the previous shift they were too busy to provide incontinent care. Staff 8 was the only aide scheduled for evening shift and Resident 9 was one of many residents who were "soaking wet." Staff 8 stated it took her four hours to get caught up and the residents calmed down. Staff 8 stated she was "running around like a chicken with head cut off". Staff 8 stated she had all 25 residents.

On 10/6/22 at 11:27 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would like to review Resident 9's information. Staff 2 stated there were aides who were documenting activity did not occur for incontinent residents at one time and they provided education at the last CNA meeting. No additional information was provided.

Refer to F690

10. Resident 12 was admitted to the facility in 7/2022 with diagnoses including UTI and repeated falls.

A 7/26/22 Admission MDS and Urinary Incontinence and Indwelling Catheter CAA revealed Resident 12 was cognitively intact with a BIMs of 15. Resident 12 required extensive two-person physical assist for toilet use. Resident 15 was frequently incontinent of bowel and bladder. Staff were to help with toileting frequently to maintain or improve continence level and maintain skin integrity.

An "Alarm History since Aug 2021" report revealed the following call light response times over 20 minutes for Resident 12's room.
-8/13/22:
9:24 PM 28 minutes, 32 seconds
-9/3/22:
2:08 PM 37 minutes 10 seconds
-9/4/22:
9:35 PM 22 minutes 53 seconds
-9/12/22:
9:36 AM 24 minutes, 21 seconds
1:14 PM 23 minutes, 31 seconds

A 9/4/22 Direct Care Staff Daily Report revealed a census of 24 on the night shift no CNAs scheduled.

Review of the 9/4/22 through 9/5/22 Point of Care History revealed on the night shift of 9/4/22 staff documented "activity did not occur."

A 9/5/22 Grievance or Concerns Problem Identification and Follow up Form revealed Resident 12's was provided incontinent care at 10:00 PM on 9/4/22 and at 3:00 AM on 9/5/22 Resident 12 activated her/his call light but no staff came. Resident 12 stated she/he was not provided incontinent care until after 8:00 AM when she/he activated the call light again. Resident 12 was interviewed and indicated she/he did not know if someone came in while she/he was asleep and did not wake her/him. Resident 12 was upset with administration for understaffing of the facility. Resident 12 indicated she/he "dozed on off" until about 6:30 AM and day shift informed her/him she/he would have to wait until after breakfast for incontinent care.

On 9/14/22 at 11:05 AM Resident 12 stated call light wait times go over 20 to 30 minutes a couple of times a week. Resident 12 stated evening was usually the worse and Sundays the facility would only have one CNA and one hospitality aid. Resident 12 stated one evening in 9/2022 she gone with no assistance between 10:00 PM and 3:00 AM. Resident 12 stated she/he activated her/his call light and no one came to assist her/him so she/he filed a grievance.

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated there were staffing concerns in the facility from 2/2022 through the end of 8/2022. On 8/13/22 Staff 8 came onto her shift and the previous shift told her they were too busy to provide incontinent care. Staff 8 was the only CNA scheduled for evening shift and Resident 12 which was one of many residents "was soaking wet".

On 10/6/22 at 10: 38 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation was call light wait times not to go over 10 minutes.

11. Resident 16 was admitted to the facility in 2014 with diagnoses including stroke and anxiety.

A 7/27/22 Annual MDS Resident 16's BIMS score was a 15 indicating she/he was cognitively intact and was frequently incontinent of bowel and bladder.

An 8/30/22 care plan indicated Resident 16 required assistance for toileting and would activate call light for use of bed pan. Staff were to assist with bed mobility during toileting with one person assist.

An "Alarm History since Aug 2021" reports revealed the following call light wait times over 20 minutes for the following days reviewed:
-9/1/22: 10:58 AM 22 minutes 29 seconds.
-9/4/22: 8:23 AM 26 minutes 16 seconds, 2:13 PM 44 minutes 3 seconds, 7:43 PM 26 minutes 54 seconds.
-9/8/22: 3:29 AM 39 minutes 27 seconds, 10:29 PM 27 minutes 27 seconds.
-9/10/22: 2:40 PM 23 minutes 3 seconds, 6:41 PM 29 minutes 55 seconds.

On 9/14/22 at 7:44 AM Resident 16 stated call light wait times were "lately lousy". Resident 16 stated she/he usually waited 30 to 40 minutes twice a week usually on weekends for staff to answer her/his call light. Resident 16 stated she/he often had incontinent episode because she/he could not wait. Resident 16 stated staff are usually shorthanded on shower days and she/he was "lucky" if she/he could get a shower once a week.

On 9/21/22 at 9:54 AM Staff 8 (NA/CNA) stated there were staffing concerns in the facility from 2/2022 through the end of 8/2022. On 8/13/22 Staff 8 came onto her shift and the previous shift told her they were too busy to provide incontinent care. Staff 8 was the only CNA scheduled for evening shift and Resident 16 was one of many residents who were "soaking wet".

On 10/6/22 at 10: 38 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation was call light wait times not to go over 10 minutes.

Based on interview and record review it was determined the facility failed to ensure the DCSDR (Direct Care Staff Daily Reports) were complete for 31 of 59 days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information. Findings include:

A review of DCSDRs revealed the following missing information:
7/3/22 through 7/31/22 (14 out of 29 days)
-7/6/22 no documented census on night shift.
-7/8/22 no documented census all three shifts.
-7/9/22 no documented census all three shifts.
-7/12/22 no documented census evening and night shift and no hours worked for CNA, NA day shift all staff hours for evening and night shift.
-7/14/22 No hours worked documented for evening and night shift. .
-7/18/22 no census, no number of staff and hours worked or authorized signature for night shift.
-7/19/22 No census for evening shift, no census, no number of staff, no hours worked and no authorized signature for night shift.
-7/21/22 No number of staff, no hours worked.
-7/22/22 No census for all three shifts.
-7/24/22 no census for evening shift and night shift.
-7/28/22 no census on evening shift and night shift.
-7/29/22 no census for all three shifts.
-7/30/22 no census for all three shifts.
-7/31/22 no census for all three shifts.

8/1/22 through 8/21/22 (11 out of 21 days)
-8/2/22 no census for all three shifts.
-8/4/22 no census all three shift.
-8/5/22 no census night shift.
-8/6/22 no number of staff, no hours for day shift. No census for evening and night shift.
-8/7/22 No census all three shifts.
-8/15/22 No census on evening and night shift. No number of staff, no hours worked and no authorized signature for night shift.
-8/16/22 No census for all three shifts.
-8/17/22 no number of staff, no hours worked and no authorized signature for day shift. No CNA staff and hours worked for evening shift.
-8/18/22 No census for evening and night shift.
-8/20/22 No number of staff, no hours worked for day shift. No census for evening and night shift.
-8/21/22 no census for evening and night shift.

9/3/22 through 9/11/22 (six out of nine days)
-9/3/22 No census for all three shifts.
-9/4/22 no census for all three shifts.
-9/6/22 no census for night shift.
-9/8/22 no census for evening and night shift.
-9/9/22 no census for all three shifts.
-9/11/22 no census for all three shifts.

On 10/6/22 at 10:20 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the charge nurses were responsible for filling out the DCSDRs. Because of staffing issues, the nurses were not completely trained and there was a Human Resources person supposed to pick up every morning and review and that staff member was not completing and was throwing away the daily scheduling sheets.

Based on interview and record review it was determined the facility failed to annually update facility assessment to include current staffing needs and references to facility resources related to COVID-19 requirements. This placed residents at risk for unmet needs. Findings include:

The Facility Assessment dated 11/7/19 revealed the assessment was not updated, as necessary, or at least annually. The assessment was not comprehensive and did not include any changes in staffing since 2019 or reference to facility resources related to COVID-19 requirements.

On 10/6/22 at 10:23 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they had an updated facility assessment and would provide the assessment. No additional information was provided.

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 seven days a week for 22 of 68 days reviewed for staffing. This placed residents at risk for unmet assessment and care needs. Findings include:

The facility's Direct Care Staff Daily Reports revealed no RN coverage between day shift and end of evening shift as followed:
-6/4/22, 6/5/22, 6/6/22 and 6/11/22.
-7/8/22, 7/13/22, 7/15/22, 7/20/22, and 7/27/2.
-8/2/22, 8/3/22, 8/4/22, 8/7/22, 8/8/22, 8/12/22, 8/14/22, and 8/17/22.
-9/6/22, 9/7/22, 9/8/22, 9/10/22, and 9/11/22.

On 10/6/22 at 10:26 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they were usually short on weekends for RN coverage.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 70 of 77 days and the use of NAs exceeded 25% of the CNA staffing ratios for 59 of 77 days reviewed for staffing. This placed residents at risk for delayed assistance and unmet care needs. Findings include:

A review of DCSDRs (Direct Care Staff Daily Report revealed the following:
The facility was not staffed at minimum requirements for CNAs.
-4/9/22 through 4/17/22 for 19 out of 27 shifts.
-6/4/22 through 6/12/22 for 24 out of 27 shifts.
-7/3/22 through 7/31/22 for 64 out of 87 shifts.
-8/1/22 through 8/21/22 for 36 out of 63 shifts.
-9/3/22 through 9/11/22 for 8 out of 27 shifts.

The facility exceeded the 25 percent maximum ratio of NAs.
-6/4/22 through 6/12/22 for 12 out of 27 shifts.
-7/3/22 through 7/31/22 for 57 out of 87 shifts.
-8/1/22 through 8/21/22 for 30 out of 63 shifts.
-9/3/22 through 9/11/22 for 14 out of 27 shifts.

On 10/6/22 at 10:02 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continues to work with outside agencies and provide bonuses but continues to have difficulty with finding and retaining staff.

*****************************************
OAR 411-086-0130 Nursing Services: Notification

Refer to F580
****************************************
OAR 411-085-0360 Abuse

Refer to F600
***************************************
OAR 411-086-0110 Nursing Services: Resident Care

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

Refer to F686, F689, F690 and F692
***************************************
OAR 411-086-0100 Nursing Services: Staffing

Refer to F725
***************************************
OAR 411-085-0030 Required Postings

Refer to F732
***************************************
OAR 411-086-0010 Administrator

Refer to F838
***************************************

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 07/25/2022 and 07/31/2022, 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 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 06/20/2022 and 06/26/2022, 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.