Bend Transitional Care

Based on observation, interview and record review it was determined the facility failed to implement appropriate Enhanced Barrier Precautions (EBP) and Contact Precautions for 2 of 4 (#s 9 and 401) reviewed for infection control. This placed residents at risk for the spread of infection. Findings include:

The CDC's 4/2/24 Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) included to don gown and gloves when high-contact activities were performed.

The facility's undated Enhanced Barrier Precautions policy indicated the following:

-Staff must clean hands with sanitizer when entering room and leaving room.

-Staff must don gown and gloves before entering resident rooms during high contact resident care activities, including transferring (assisting residents to transfer/providing transfer assistance to residents).

1. Resident 401 was admitted to the facility on 6/20/25 with diagnoses including osteomyelitis (bone infection).

A review of Resident 401's 6/20/25 Care Plan indicated EBP interventions.

The facility's undated Enhanced Barrier Precautions policy indicated the following:

-Staff must clean hands with sanitizer when entering room and leaving room.

-Staff must donn gown and glove before entering resident rooms during high contact resident care activities, including transferring (assisting residents to transfer/providing transfer assistance to residents).

On 6/24/25 at 3:24 PM, Staff 5 (CNA) and Staff 6 (CNA) were observed to enter Resident 401's room with gloves and mask but without gowns. They transferred the resident out of bed to the shower chair.

On 6/24/25 from 3:27 PM to 3:35 PM, Staff 5 and Staff 6 stated they did not wear gowns to help Resident 401 transfer out of bed because they did not touch the resident's arm that had a PICC line (form of intravenous access to deliver medications directly into the bloodstream). Staff 5 and Staff 6 stated a staff nurse indicated donning gowns was not necessary.

On 6/25/25 at 1:43pm, Staff 7 (CNA) stated she did not wear PPE when residents were assisted to the bathroom who were on enhanced barrier precautions related to having a PICC line as she was not near the resident's PICC line.

On 6/27/25 at 9:10 AM, Staff 2 (Director Nursing Services) stated she expected staff to follow the CDC guidelines on enhanced-barrier and transmission-based precaution signs outside of resident rooms when high-contact activities were provided that included transferring.

2. Resident 9 was admitted to the facility on 6/23/25 with diagnoses including MRSA (bacterial infection that is resistant to several antibiotics).

A review of Resident 9's 4/18/25 Care Plan indicated to implement Contact Precautions.

On 6/24/25 at 8:42 AM, A Contact Precaution sign outside Resident's 9 door indicated residents, visitors, and staff must perform hand hygiene before entering and when leaving the resident's room.

On 6/24/25 at 10:34 AM and 10:43 AM Resident 9 was observed to leave her/his room and not perform hand hygiene. Resident 9 stated she/he never used the hand sanitizer outside of her/his room. Resident 9 stated she/he was not aware about performing hand hygiene prior to leaving her/his room and stated the doctors thought she/he had MRSA but she/he never believed them.

On 6/25/25 at 8:48 AM, Resident 9 was observed to leave her/his room and not perform hand hygiene. Resident 9 went to a table near the nurses station to complete her/his meal order. She/he used the staff's pen and returned it back to them after completing the form. No hand hygiene was completed by staff or the resident.

On 6/26/25 at 12:46 PM, Staff 8 (Infection Preventionist) stated staff were expected to remind Resident 9 to perform hand hygiene prior to leaving her/his room. Staff 2 stated staff were expected to follow the Contact Precaution sign outside of Resident 9's room and to remind the resident to perform hand hygiene.

Based on observation, interview and record review the facility failed to ensure an activity program was available at least 6 days a week for all residents to encourage residents to maintain normal activity and return to self-care for 1 of 1 facility reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include:

Resident 3 admitted to the facility on 6/6/25 with a diagnosis including cellulitis (infection) and was assessed as cognitively intact.

Resident 3's Activity Participation records from 6/6/25 to 6/24/25 indicated she/he was not available/refused one Exercise group offered on 6/6/25 with no other group participation or refusals indicated.

On 6/23/25 at 2:12 PM the Activity Calendar revealed a Coloring group was offered at 2:00 PM and no Coloring group was located in the facility with the search concluding at 2:39 PM.

On 6/23/25 at 2:24 PM Resident 3 stated she/he enjoyed group activities and was very active in groups at her/his home prior to admission. Resident 3 stated in this facility, she/he went to a group before and she/he was the only person at the group besides the manager. Resident 3 acknowledged a Coloring group was scheduled today but it did not interest her/him to color like a child as she/he wished for fun and challenging group activities.

On 6/25/25 the Activity Calendar revealed the following group activities were available and the following was observed:
- A Coffee and News group (no time listed), surveyor could not locate the group scheduled;
- At 10:30 AM an Exercise group. Resident 3 was observed to search for the Exercise group and staff directed her/him to the therapy room. At 10:40 AM another resident looked for the Exercise group and staff assisted her/him back to their room. The surveyor could not locate the scheduled Exercise group;
- At 10:51 AM Resident 3 self-propelled her/his wheelchair, looked at the Activity Calendar and stated the Exercise group never happened and the Uno group probably won't happen either;
- At 11:00 AM the Uno card group occurred in the dining room at 11:05 AM with three residents who participated and the group ended at 11:21 AM;
- At 2:00 PM a Craft group was scheduled, but no Craft group was found to occur in the facility. Staff 13 (Activity Director) was observed to read two residents a story from a book in the Bistro room.

On 6/25/25 at 11:50 AM Staff 7 (CNA) stated resident activities sometimes occurred during the week when the Activity Director worked Tuesday through Friday. Staff 7 stated no activities occurred on the weekends or on Mondays when the Activity Director was not there.

On 6/25/25 at 1:37 PM Staff 14 (CNA) stated in the past resident activities were canceled due to low staffing and because Staff 13 worked as a CNA instead of as the Activities Director.

On 6/26/25 at 10:05 AM Staff 4 (LPN) stated resident activities were canceled during the week and they did not always occur as scheduled.

On 6/26/25 the Activity Calendar revealed the following group activities were available and the following was observed:
- A Coffee and News group (no time listed), surveyor could not locate the group scheduled;
- At 10:00 AM an Exercise group, which started about 10:40 AM and ended by 10:57 AM;
- At 11:00 a Yahtzee dice game with two residents in attendance;
- At 2:00 PM Root Beer Floats activity with Music on the north nurses patio. Staff 13 was observed to served root beer floats in the hallway. Staff 13 stated it was not a group and she delivered the floats to the resident rooms and staff.

On 6/26/25 at 2:20 PM Staff 13 stated she was the only Activity Director for the facility, which almost always had over 50 residents and there was no system to have other staff cover resident activities. Staff 13 stated she was scheduled to work as an Activity Director 28 hours, four days a week on Tuesday through Friday. She stated she often worked less than 28 hours as the Activity Director and helped out as a CNA often. When asked about the scheduled group activities and the timeliness, she replied residents often needed ADL care, which she provided, and groups were often late. Staff 13 attributed the low level of resident activity participation to the lack of staff support, their lack of knowledge of the benefits of activities and the demand for her help as a CNA. Staff 13 confirmed the lack of group participation for Resident 3 from 6/6/25 to 6/24/25.

On 6/27/25 at 8:36 AM Staff 1 (Administrator) acknowledged the lack of resident group activity opportunities and confirmed the Activity Director worked four days a week. Staff 1 expected all residents to have the opportunity for meaningful and purposeful leisure, recreational and diversional activities daily.

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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880
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Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 19 out of 50 days reviewed for staffing. This placed residents, public and staff at risk for lack of accurate staffing information. Findings include:

On 3/3/23 at 3:30 PM the Direct Care Staff Daily reports were provided from 10/7/23 through 11/10/23 and from 2/2/24 through 3/1/24. The forms revealed 19 instances when portions of the form were left blank or were incomplete. The incomplete information included census, number of staff working and number of hours worked.

On 3/6/24 at 10:16 AM Staff 4 (CMA-Staffing Coordinator) and at 11:32 AM Staff 3 (RN-Assistant DNS) acknowledged the Direct Care Staff Daily reports forms were incomplete.

On 3/7/24 at 9:56 AM Staff 1 (Administrator) acknowledged the Direct Care Staff Daily reports were incomplete for 19 out of 50 days.

Based on interview and record review it was determined the facility failed to accurately document immunization choices for 1 of 5 sampled residents (#11) reviewed for immunizations. This placed residents at risk for resident vaccination choices not being followed. Findings include:

The facility's 10/2019 Influenza Vaccine Policy revealed:
-Employees hired and residents admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of the employee's job assignment or the resident's admission to the facility.
-A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical records.

The facility's 10/2019 Pneumococcal Vaccine Policy revealed:
-Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.
-Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission.
-Resident/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical records indicating the date of the refusal of the pneumococcal vaccination.

Resident 11 was admitted to the facility in 11/2023 with diagnoses including COVID-19.

A 12/1/23 Admission MDS revealed Resident 11 had a BIMS score of 15, which indicated the resident was cognitively intact.

Resident 11's Admission MDS dated 12/1/23 indicated Resident 11 was "not eligible" for both influenza and pneumococcal vaccinations.

Resident 11's Quarterly MDS dated 3/4/24 indicated Resident 11 was "not eligible" for both influenza and pneumococcal vaccinations.

Resident 11's immunization records listed on 3/6/24 reported Resident 11 as "not eligible" for influenza and pneumococcal vaccinations.

On 3/6/24 at 12:52 PM Staff 3 (Assistant DNS-Infection Preventionist) stated she recalled Resident 11 refused all immunizations and these immunization choices were not documented correctly. Staff 3 stated Resident 11's immunization records should have been updated to reflect Resident 11 refused influenza and pneumococcal vaccinations rather than not being eligible to receive vaccines.

On 3/6/24 at 1:27 PM Staff 2 (DNS) confirmed Resident 11's immunization choices were not correctly documented.

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

Refer to F732
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OAR-411-086-0140: Nursing Services: Problem Resolution & Preventive Care

Refer to F883
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Based on interview and record review it was determined the facility failed to ensure residents were provided information related to the formulation of an Advance Directive for 1 of 3 sampled residents (#24) reviewed for Advance Directives. This placed residents at risk for not having their treatment decisions honored. Findings include:

Resident 24 admitted to the facility on 1/18/23 with diagnoses including a below the knee amputation.

Resident 24 was listed as her/his own responsible party.

Resident 24's clinical record revealed no documentation to indicate the resident had an Advance Directive or was provided information concerning the right to formulate an Advance Directive prior to 2/6/23.

On 2/7/23 at 10:36 AM Staff 12 (Social Services) confirmed Resident 24 was not informed or provided written information concerning her/his right to formulate an Advance Directive until the information was requested by the Surveyor on 2/6/23.

3. Resident 8 was admitted to the facility on 1/10/23 with diagnoses including paraplegia.

Review of the resident's progress notes indicated the resident was alert and oriented.

Resident 18's 1/14/23 Admission MDS, Section C (cognitive assessment) indicated a Brief Interview for Mental Status (BIMS) was to be conducted. The subsequent assessment questions indicated "not assessed."

On 2/9/23 at 8:45 AM Staff 2 (DNS) acknowledged Section C was not completed as part of Resident 18's Admission MDS.

, Based on interview and record review it was determined the facility failed to ensure MDS assessments were comprehensive for 3 of 9 sampled residents (#s 8, 13 and 15) reviewed for skin, medications, and staffing. This placed residents at risk for inaccurate assessments. Findings include:

1. Resident 13 admitted to the facility in 1/2023 with diagnoses including diabetes.

Review of the resident's progress notes indicated the resident was alert and oriented.

Resident 13's 1/16/23 Admission MDS, Section C (cognitive assessment) indicated the BIMS was to be conducted. The subsequent assessment questions were marked "not assessed."

On 2/9/23 at 8:45 AM Staff 2 (DNS) acknowledged Section C was not completed as part of Resident 13's Admission MDS.

2. Resident 15 admitted to the facility in 1/2023 with diagnoses including Parkinson's disease.

Review of the resident's progress notes indicated the resident was alert and oriented.

The 1/12/23 Admission MDS, Section C (cognitive assessment) indicated the BIMS was to be conducted. The subsequent assessment questions were marked "not assessed."

On 2/9/23 at 8:45 AM Staff 2 (DNS) acknowledged Section C was not completed as part of Resident 15's Admission MDS.

Based on interview and record review it was determined the facility failed to code the MDS accurately for 1 of 1 sampled resident (#40) reviewed for hospitalization. This placed residents at risk for inaccurate assessments. Findings include:

1. Resident 40 was admitted to the facility on 1/13/23 with diagnoses including pneumonia and diabetes.

The 1/14/23 Discharge Return Not Anticipated MDS indicated Resident 40 discharged to an acute hospital.

The 1/14/23 progress note indicated Resident 40 elected to leave the facility AMA (against medical advice). The resident left the facility in stable condition via private vehicle.

On 2/9/23 at 12:27 PM Staff 2 (DNS) acknowledged the MDS was coded to reflect the resident discharged to an acute hospital, she stated she/he left AMA. Staff 2 acknowledged the MDS was not accurately coded to reflect the resident discharging home.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for adverse side effects. Findings include:

Resident 24 admitted to the facility on 1/21/23 with diagnoses including diabetes.

A 1/23/23 Physician Order indicated Resident 24 was to be administered Insulin Aspart Injection Solution (diabetic injection medication) and staff were to hold (not give) the medication for CBGs less than 120.

The 2/2023 MAR indicated Resident 24 experienced CBGs outside parameters and was administered insulin on the following dates:
-2/1/23: CBG 107.
-2/6/23: CBG 104.

Resident 24's clinical record did not indicate the resident experienced adverse outcomes due to receiving insulin on the identified dates.

On 2/9/23 at 10:43 AM Staff 2 (DNS) stated physician orders were expected to be followed and acknowledged Resident 24 received Insulin Aspart when the resident's CBGs were outside of physician ordered parameters on the identified dates.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's pressure ulcer was assessed and monitored to prevent worsening for 1 of 2 sampled residents (#13) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:

Resident 13 admitted to the facility on 1/12/23 with diagnoses including diabetes and COPD (chronic obstructive pulmonary disease) and utilized a BiPAP (bilevel positive airway pressure) machine.

Resident 13's 1/16/23 Admission MDS indicated the resident had no pressure ulcers upon admission.

A 1/24/23 Physician's Progress Note indicated Resident 13 developed a pressure ulcer on the bridge of her/his nose from her/his BiPAP machine.

A 1/24/23 Physician Order indicated staff were to place Duoderm (pressure ulcer dressing) on Resident 13's nasal bridge once daily to help with skin breakdown. 


The 1/2023 TAR indicated on 1/24/23 the Physician Order was implemented to place Duoderm on the resident's nasal bridge every night shift to help with skin breakdown and was completed as ordered.

A 2/1/23 Physician's Progress Note indicated Resident 13's pressure ulcer appeared to be healing and the resident told the physician she/he had a friend who was planning to bring in a new mask for the resident's BiPAP machine.

Prior to 2/7/23, there was no evidence in Resident 13's medical record to indicate the resident's pressure ulcer was assessed, measured, staged, and/or monitored after being identified by the physician on 1/24/23.

On 2/5/23 at 3:14 PM Resident 13 was observed with a bandage on her/his nose. Resident 13 stated the wound was due to her/his BiPAP machine because she/he did not have any more masks in the correct size.

On 2/7/23 at 8:16 AM Staff 6 (CNA) stated she worked with Resident 13 and believed the resident's nose wound was from the resident's BiPAP machine.

On 2/7/23 at 8:50 AM Staff 5 (RN) stated it was her first time working with Resident 13 and she was unsure why the resident had a bandage on her/his nose.

On 2/7/23 at 8:58 AM Staff 16 (CNA) told Staff 3 (RN) Resident 13's nose wound was from her/his BiPAP machine.

On 2/7/23 the Surveyor requested all skin evaluations for Resident 13's pressure ulcer.

A 2/7/23 Skin & Wound Evaluation indicated Resident 13 sustained a facility acquired, Stage II medical device pressure ulcer to her/his nose from the resident's BiPAP machine. The wound measured 0.2 cm x 0.7 cm x 0.5 cm with no reported pain. The evaluation indicated the wound was healing.

On 2/7/23 at 2:06 PM Staff 2 (DNS) stated Staff 7 (RNCM) was aware of Resident 13's pressure ulcer on the resident's nose but did not complete an investigation prior to 2/7/23 and did not have documentation for monitoring healing. Staff 2 further stated the wound was a medical device pressure ulcer from the resident's BiPAP machine mask not being the correct fit.

Based on interview and record review it was determined the facility failed to ensure residents were assessed after dialysis treatments for 1 of 1 sampled resident (#17) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include:

The Facility's 2020 Living Care of the Dialysis Resident policy indicated nursing staff were to complete the post dialysis assessment upon the resident's return to the facility.

Resident 17 admitted to the facility on 1/8/23 with diagnoses including renal dialysis.

Resident 17's 1/23/23 Care Plan indicated the resident went to dialysis three days a week on Monday, Wednesday, and Friday.

Review of Resident 17's 2/2023 Dialysis Communication forms indicated on 2/1/23, 2/3/23 and 2/6/23 the post-dialysis assessments were not completed.

On 2/7/23 at 8:54 AM Staff 7 (RNCM) acknowledged Resident 17's post dialysis assessments were not completed for the identified dates.

Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 4 of 5 halls (A, C, D, and E) reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include:

On 2/6/23 and 2/9/23 the facility provided lists of residents who:
-Required assistance with eating: 2.
-Required two-person assistance or a mechanical lift with transfers: 11.
-Required one or two-person assistance with dressing and toileting: 43.
-Were fully dependent on staff for toileting and dressing: 2.
- Required one or two-person assistance with bathing: 45.
-Were fully dependent on staff for bathing: 2.
-Had behavioral healthcare needs: 5.

Resident Council Notes were reviewed for 1/2023 and indicated residents requested more staff and more shower times and days. Residents indicated there were not enough staff to meet resident needs and residents did not always receive their scheduled showers or receive them timely.

A review of the facility Direct Care Staff Daily Reports from 1/6/23 through 2/6/23 revealed the facility had insufficient CNA staff for one or more shifts on the following dates:
-1/6/23: Day and Evening Shift.
-1/7/23: Day Shift.
-1/8/23: Day and Evening Shift.
-1/14/23: Day Shift.
-1/22/23: Evening Shift.
-2/5/23: Day Shift.

Interviews with residents revealed the following concerns:

On 2/5/23 at 2:50 PM Resident 17 stated she/he had "an accident" from having to wait so long for toileting assistance.

On 2/6/23 at 9:24 AM Resident 196 stated she/he felt the facility was understaffed and had to wait "a long time" to get toileting assistance.

On 2/6/23 at 9:56 AM Resident 24 stated staffing could be "good and then bad." Resident 24 stated at times she/he waited 15-20 minutes for her/his call light to be answered to use the restroom.

On 2/6/23 at 10:29 AM Resident 143 stated she/he waited 20 minutes for her/his call light to be answered to use the restroom and there were not enough staff at night.

On 2/6/23 at 10:56 AM Resident 192 stated she/he thought the facility needed more staff and waited up to 30 minutes for toileting assistance. Resident 192 stated she/he had incontinence episodes from waiting a long time for assistance.

On 2/6/23 at 12:10 PM Resident 32 stated she/he wanted more showers and was told she/he could only receive them twice a week due to staffing shortages. Resident 32 further stated she/he sometimes waited a long time for her/his call light to be answered and staff were "good but stretched thin."

Interviews with staff revealed the following concerns:

On 2/6/23 at 9:20 AM Staff 18 (CNA) stated the facility did not have enough staff, showers were difficult to complete for residents, and the facility was down two CNAs on 2/5/23. Staff 18 stated weekends were short staffed.

On 2/7/23 at 8:13 AM Staff 6 (CNA) stated the facility was short staffed on weekends and Mondays. Staff 6 stated when the facility was short staffed, weights and showers were more difficult to complete for residents.

On 2/8/23 at 6:03 PM Staff 19 (CNA) stated it was difficult to answer call lights on evening shift due to serving dinner and the facility was "always" short staffed on evening shifts. Staff 19 stated residents waited a long time for their call lights to be answered during evening shift.

On 2/8/23 at 6:07 PM Staff 21 (CNA) stated between 4:00 PM and 7:00 PM "it could be chaos" working on evening shift. Staff 21 stated staff were busy getting residents ready for dinner and there was only one CNA per each hall (five halls total).

On 2/8/23 at 6:14 PM Staff 20 (CNA) stated evening shifts were often short staffed and it was difficult to answer resident call lights due to multiple new admissions, serving dinner, and having to complete resident showers. Staff 20 stated there were times showers were unable to be completed and residents were unable to be toileted timely and had accidents due to staffing shortages.

On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the staffing concerns and stated the facility was working on staffing as it was their "biggest issue."

2. Resident 32 admitted to the facility on 12/9/22 with diagnoses including a stroke.

Resident 32's 12/15/22 Admission MDS indicated the resident was cognitively intact.

Resident 32's ADL Shower Task Sheet indicated Resident 32 received showers Mondays and Fridays. On 1/30/23 (Monday) the shower sheet completed by Staff 20 (CNA) indicated Resident 32 did not receive her/his shower due to the resident's refusal.

On 2/6/23 at 12:10 PM Resident 32 stated she/he wanted more showers and was told she/he could only receive them twice a week due to staffing shortages. Resident 32 further stated staff were "good but stretched thin."

On 2/8/23 at 6:14 PM Staff 20 stated there were days residents did not receive showers due to staffing shortages. Staff 20 stated he was unable to provide Resident 32 a shower "last week" due to not enough staff and had marked "resident refused" because there was no other option to mark on the shower task sheet.

On 2/9/23 at 10:32 AM Staff 2 (DNS) stated the expectation was if staff could not provide a resident a shower to report it to the next shift and offer the resident a shower the next day. Staff 2 acknowledged there was no indication the resident was re-offered a shower the next day (1/31/23). Staff 2 stated staff were not to document "refused" if the resident did not refuse their shower. Staff 2 further acknowledged staffing concerns related to providing residents with showers.

3. Resident 15 admitted to the facility in 1/2023 with diagnoses including Parkinson's disease.

Resident 15's 1/12/23 Admission MDS indicated the resident required extensive, one-person assistance with dressing.

On 2/8/23 at 6:00 PM Resident 15's call light was observed to be initiated for 16 minutes per the call log at the nurses' station. Resident 15 was observed in bed and stated she/he had been waiting "awhile" for assistance with toileting and getting into her/his pajamas prior to dinner. When asked if call lights often took a long time to be answered by staff, Resident 15 stated it occurred "enough."

On 2/8/23 at 6:01 PM Staff 19 (CNA) was observed to deliver Resident 15's dinner meal tray and asked Staff 20 (CNA) to assist her with pulling the resident up in bed. Resident 15's call light was turned off.

On 2/8/23 at 6:03 PM Staff 19 (CNA) stated staff were unable to assist Resident 15 with toileting/dressing due to passing meal trays down another hall but would come back. Staff 19 confirmed Resident 15 had been waiting 17 minutes and did not receive assistance. Staff 19 stated residents waited "a long time" for assistance from staff but was unable to state any outcomes to residents due to long call light times.

On 2/8/23 at 6:10 PM Resident 15 was observed eating her/his meal in the same clothes as prior and stated she/he wanted to get into her/his pajamas. Resident 15 stated she/he did not need to use the restroom. Resident 15 stated staff did not tell her/him why she/he could not be changed prior to dinner and just turned off her/his call light. When asked if staff often turned off the call light prior to assisting the resident, the resident stated it occured "enough."

On 2/8/23 at 6:14 PM Staff 20 (CNA) stated staff were unable to assist Resident 15 as staff were busy passing the dinner meal and there were three new admission residents, which made it difficult to answer call lights.

On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the staffing concerns and stated the facility was working on staffing as it was their "biggest issue."

4. Resident 24 admitted to the facility on 1/21/23 with diagnoses including a leg amputation.

On 2/6/23 at 9:56 AM Resident 24 stated staffing could be "good and then bad." Resident 24 stated at times she/he waited 15-20 minutes for her/his call light to be answered to use the restroom.

Call Light Logs were reviewed for Resident 24 from 1/21/23 through 2/7/23 and indicated four instances when the resident waited 15 minutes or longer for her/his call light to be answered by staff:
-1/21/23, 16 minutes.
-2/1/23, 15 minutes.
-2/2/23, 16 minutes.
-2/4/23, 29 minutes.

On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the identified long call light wait times.

5. Resident 192 admitted to the facility on 1/24/23 with diagnoses including a UTI and a hip fracture.

Resident 192's 1/28/23 Admission MDS indicated the resident was cognitively intact.

On 2/6/23 at 10:56 AM Resident 192 stated she/he thought the facility needed more staff and waited up to 30 minutes for toileting assistance. Resident 192 stated she/he had incontinence episodes from waiting a long time for toileting assistance.

Call Light Logs Were Reviewed for Resident 192 from 1/24/23 through 2/7/23 and indicated four instances when the resident waited over 15 minutes for her/his call light to be answered by staff:
-1/29/23, 16 minutes, 18 minutes, and 30 minutes.
-2/5/23, 24 minutes.

On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the identified long call light wait times.

6. Resident 143 admitted to the facility on 1/31/23 with diagnoses including sepsis.

Resident 143's 2/2/23 Admission MDS indicated Resident 143 was cognitively intact.

On 2/6/23 at 10:29 AM Resident 143 stated she/he waited 20 minutes for her/his call light to be answered to use the restroom and there were not enough staff at night.

Call Light Logs Were Reviewed for Resident 143 from 1/31/23 through 2/7/23 and indicated two instances when the resident waited over 15 minutes for her/his call light to be answered:
-2/3/23, 16 minutes.
-2/4/23, 26 minutes.

On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the identified long call light wait times.

Based on interview and record review it was determined the facility failed to provide prescribed medications for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for medication-related adverse consequences. Findings include:

Resident 24 admitted to the facility on 1/21/23 with diagnoses including diabetes and hyperlipidemia (high cholesterol).

Resident 24 had physician orders for the following:
-1/18/23: simvastatin oral tablet (cholesterol medication) to be administered once daily.
-1/24/23: Phos-NaK oral packet (medication to treat low phosphorus levels) to be administered twice daily.

A review of Resident 24's 1/2023 and 2/2023 MARs revealed the following medications were not administered because they were not available:
-Phos-NaK Oral Packet from 1/25/23 through 1/28/23.
-simvastatin from 2/5/23 through 2/6/23.

Resident 24's Progress Notes reviewed from 1/25/23 through 2/6/23 indicated the following:
-1/25/23 at 5:13 PM: Note indicated "med not in cart" regarding Phos-NaK. There was no follow-up notes.
-1/26/23 at 8:07 AM and 3:55 PM: Notes indicated "med not in cart" and "OUT OF MED WILL CONTACT PHARMACY" regarding the resident's Phos-NaK.
-1/27/23 at 8:48 AM and 4:39 PM: Notes indicated "have not received will call pharmacy" and "pharmacy contacted" regarding the resident's missed Phos-NaK.
-2/5/23: The resident's dose of simvastatin on 2/5/23 was unavailable and was ordered from the pharmacy on 2/5/23 and the provider was notified. There was no follow-up notes regarding the resident missing simvastatin on 2/6/23.

On 2/9/23 at 10:43 AM Staff 2 (DNS) acknowledged the medications were not administered due to not being available and the expectation was for staff to re-order medication prior to running out. Staff 2 stated if the issue was related to the pharmacy, staff were expected to let the physician know of the missed medication.

Based on interview and record review it was determined the facility failed to ensure reference checks were completed for 1 of 5 sampled staff (#8) reviewed for reference checks. This placed residents at risk for care from unqualified staff. Findings include:

Reference Checks were requested from Staff 11 (Human Resources) on 2/7/23 for Staff 8 (Dietary Aide).

On 2/7/23 at 1:11 PM Staff 11 stated reference checks were not completed for Staff 8.

Based on interview and record review it was determined the facility failed to ensure background checks were completed for newly hired staff for 3 of 5 sampled staff (#s 8, 9 and 10) reviewed for background checks. This placed residents at risk for abuse. Findings include:

Background Checks were requested from Staff 11 (Human Resources) on 2/7/23 for Staff 8 (Dietary Aide), Staff 9 (LPN) and Staff 10 (RN).

On 2/7/23 at 1:11 PM Staff 11 stated background checks were not completed for Staff 8, Staff 9 and Staff 10. Staff 11 further stated Staff 8, Staff 9 and Staff 10 were under active supervision.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 6 of 32 days reviewed for minimum CNA staffing. This placed residents at risk for delayed care and unmet care needs. Findings include:

A review of the facility Direct Care Staff Daily Reports from 1/6/23 through 2/6/23 revealed the facility had insufficient CNA staff for one or more shifts on the following dates:
-1/6/23: Day and Evening Shift.
-1/7/23: Day Shift.
-1/8/23: Day and Evening Shift.
-1/14/23: Day Shift.
-1/22/23: Evening Shift.
-2/5/23: Day Shift.

On 2/7/23 at 1:49 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the facility did not meet minimum CNA staffing requirements for the identified dates.

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OAR 411-086-0040 Admission of Residents [Advanced Directive]

Refer to F578
*************************
OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F636 and F641
*************************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684 and F698
*************************
OAR 411-076-0140 Nursing Services: Problem Resolution & Preventative Care

Refer to F686
*************************
OAR 411-086-0100 Nursing Services: Staffing

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

Refer to F755
*************************

Based on observation, interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 81 out 122 days reviewed for minimum CNA staffing. This placed residents at risk for unmet needs. Findings include:

A review of the facility's Direct Care Staff Daily Reports from 12/31/20 through 6/30/20 revealed the following dates when the required state minimum CNA staff to resident ratios were not met for one or more shifts:

-4/1/20
-4/2/20
-4/4/20
-4/6/20
-4/7/20
-4/8/20
-4/9/20
-4/10/20
-4/11/20
-4/12/20
-4/13/20
-4/16/20
-4/17/20
-4/18/20
-4/19/20
-4/20/20
-4/24/20
-4/25/20
-4/27/20
-4/29/20
-4/30/20
-5/2/20
-5/7/20
-5/8/20
-5/10/20
-5/11/20
-5/15/20
-5/16/20
-5/17/20
-5/18/20
-5/19/20
-5/21/20
-5/22/20
-5/23/20
-5/25/20
-5/26/20
-5/28/20
-5/29/20
-5/30/20
-5/31/20
-6/1/20
-6/2/20
-6/4/20
-6/5/20
-6/6/20
-6/7/20
-6/8/20
-6/9/20
-6/15/20
-6/16/20
-6/19/20
-6/20/20
-6/21/20
-6/22/20
-6/23/20
-6/25/20
-6/26/20
-6/28/20
-6/29/20
-6/30/20        

-12/1/20
-12/2/20
-12/3/20
-12/4/20
-12/5/20
-12/7/20
-12/8/20
-12/10/20
-12/12/20
-12/13/20
-12/15/20
-12/16/20
-12/17/20
-12/18/20
-12/19/20
-12/29/20
-12/21/20
-12/22/20
-12/24/20
-12/29/20
-12/30/20
-12/31/20

On 6/15/21 at 2:08 PM Staff 23 (HR/Staffing Coordinator) stated when she completed the Direct Care Staff Daily Report she did not count the NAs (Nursing Assisstant) working as part of the CNA count but did count them on the report which was sent to the state.

On 6/15/21 at 5:04 PM Staff 2 (DNS) acknowledged the lack of required CNAs on duty on the identified dates.

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 06/14/2021 and 06/20/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to provide adaptive equipment for 1 of 3 sampled residents (#2) reviewed for skin breakdown. This placed residents at risk for skin breakdown. Findings include:

Resident 2 was admitted to the facility in 5/2020 with diagnoses including a fractured pubis, chronic heart failure and vasculitis (inflammation of blood vessels).

An Admission MDS dated 5/18/20 indicated Resident 2 was at risk for developing pressure ulcers and had one unstageable DTI (a deep tissue injury [Intact skin with localized area of persistent non-blanchable deep red, maroon or purple discoloration due to damage of underlying soft tissue]) to the tailbone upon admission.

A care plan initiated on 5/13/20 revealed Resident 2 had potential and actual impairment to skin integrity related to multiple pelvic fractures, medications, vasculitis neuropathy, incontinence, foley catheter, deconditioning and decline in mobility. Resident 2 was at high risk for pressure ulcer. Staff were to evaluate skin integrity, perform objective pressure ulcer risk tool such as Braden/Norton scale. A revision on 5/19/20 directed staff to float heels always. A revision on 5/21/20 directed staff to float Resident 2's heels while in bed, monitor suspected DTIs to both bilateral heels, offer to reposition the resident in bed as needed and to reposition the resident so her/his heels were not on the resident's mattress.

A 5/19/20 Pressure Injury report revealed the following:

-Staff 14 (RN) assessed legs bilaterally and noted edema, skin was cool to the touch and assessed pedal pulses. Staff 14 lifted the patient's heels and identified Resident 2 had deep tissue injuries to both her/his bilateral heels, and Resident 2 denied pain at the site.
-The patient was informed there was one bruise on each heel and was educated to keep her/his heels off the bed and a heel float would be provided to support her/his legs/feet.
-Staff interviews were conducted and revealed staff did not identify any bilateral deep tissue injuries on 5/13, 5/15, 5/16, 5/17 and 5/18/20. Staff indicated Resident 2 did not always like to be repositioned in bed.
-The conclusion of the investigation determined Resident 2 appeared to have DTIs to her/his bilateral heels. Resident 2's heels noted to be resting on the edge of the mattress due to her/his height and the mattress length. Nurse assessed and noted purple, non-blanching areas to both bilateral heels that were not present on admission. Resident 2 denied pain.
-Interventions were Resident 2 was at risk for skin impairment related to decreased mobility, height of six foot four, history of pressure injury and vasculitis. Heel floats would be utilized when the resident was in bed. Staff were to ensure Resident 2 was repositioned in bed with heels not on the edge of the mattress. Resident was added to weekly wound rounds. The provider and family was notified.
-The Interdisciplinary team felt the DTIs were "brewing" many days prior to admission (Resident 2 admitted to the facility on 5/11/20), The DTIs probably started at her/his assisted living facility after she/he fell and continued through her/his extended hospitalization (two weeks) and became visible at the facility on 5/18/20.
-Abuse and neglect were ruled out.

On 6/17/20 Resident 2 discharged back to her/his assisted living facility.

On 3/9/21 at 9:29 AM Staff 19 (RN) stated she remembered Resident 2 and stated the DTIs were discovered roughly two weeks after her/his admission. Staff 19 stated the resident was tall and she thought the end of her/his bed was open and Resident's 2's feet were toward the edge of the bed due to her/his height. Staff 19 stated the resident had limited mobility, did not like to be repositioned and did not complain of pain to her/his bilateral feet.

On 3/10/21 at 11:11 AM Staff 14 (RN) stated she recalled Resident 2 and discovered her/his bilateral DTIs when doing a wound treatment to the resident's coccyx. Resident 2 did not complain of pain or discomfort to the area and she recalled her/him being very hesitant about getting in and out of bed. Staff 14 stated she did not work with Resident 2 much and could not recall if the resident's bed had a foot board at the end or not. Staff 14 stated she reported her findings to Staff 7 (Infection Preventionist/Assistant Director of Nursing) and Staff 15 (DNS) immediately and the resident was assessed, and interventions put into place.

On 3/10/21 at 1:45 PM Staff 15 stated Resident 2 was assessed upon admission and weekly skin checks were completed to identify any new skin conditions. Staff 15 stated Resident 2 had multiple co-morbidities and the DTI's were unavoidable. Staff 15 stated she could not recall if there was a foot board at the end of her/his bed or if it was open. When asked how you would address residents who were tall and needed a longer bed Staff 15 replied due to Resident 2's height they would have had to order special equipment to accommodate for her/his size. Staff 15 stated she did not recall the facility ordering any additional equipment for Resident 2's bed.

Based on interview and record review it was determined the facility failed to timely report allegations of neglect to the State Survey Agency for 1 of 3 sampled residents (#3) reviewed for incontinence care, treatment of a rash and dignity and respect. This placed residents at risk for unmet needs. Findings include:

Resident 3 was admitted to the facility in 2020 with diagnoses including diabetes, cancer and adult failure to thrive.

A 2/2/20 Admission MDS revealed Resident 3's BIMs score was nine indicating moderately cognitive impairment.

On 3/3/2020 at 1:47 PM a facility reported incident was received by the State Survey Agency which indicated Resident 3 had discharged with multiple complaints related to her/his care. On 3/10/20 the facility sent copies of Resident 3's call light records and her/his care plan to the State Survey Agency. On 3/16/20 the facility had not submitted the State Survey Agency requested investigations to the allegations, and a few of the allegations were too vague to triage. The allegations that were triaged were as followed:
-The facility failed to ensure Resident 3's rash was treated timely.
-The facility failed to provide necessary care and services related to incontinent care.
-The facility failed to ensure the resident was treated with dignity and respect.

On 3/1/21 at 2:00 PM Staff 16 (Administrator) stated they initiated and submitted the facility reported incident (FRI) 3/3/20 however, they turned the FRI into a grievance report related to the three allegations and Staff 17 (Regional Director of Operations) completed the grievance/investigation.

On 3/10/21 at 2:02 PM Staff 17 stated Staff 16 initiated the FRI however, he completed the grievance form which was his investigation. Staff 17 was not aware the completion of his grievance was not submitted to the State Survey Agency within the 5 day time period.

Based on interview and record review it was determined the facility failed to thoroughly investigate incontinence care, dignity and respect and appropriate treatment of a skin rash for 1 of 3 sampled residents (#3) reviewed for incontinence care, dignity and respect and appropriate treatment of a skin rash. This placed residents at risk for unmet needs. Findings include:

Resident 3 was admitted to the facility in 2020 with diagnoses including diabetes, cancer and adult failure to thrive.

A 2/2/20 Admission MDS revealed Resident 3's BIMs score was nine indicating moderately cognitive impairment.

On 3/3/2020 at 1:47 PM a facility reported incident (FRI) was received by the State Survey Agency and indicated Resident 3 had discharged with multiple complaints related to her/his care to the State Survey Agency. On 3/10/20 the facility sent copies of Resident 3's call light records and her/his care plan. On 3/16/20 the facility had not submitted State Survey Agency requested investigations to the allegations, and a few of the allegations were too vague to triage. The allegations that were triaged are as followed:
-The facility failed to ensure Resident 3's rash was treated timely.
-The facility failed to provide necessary care and services related to incontinent care.
-The facility failed to ensure the resident was treated with dignity and respect.

A Grievance Summary Form initiated 3/2/20 revealed the following:

-3/2/20 Witness 11 (Family Member) had concerns regarding Resident 3's care at the facility and it was "horrible".
-3/3/20 Staff 17 (Regional Director of Operations) spoke with Witness 11 and she stated call lights were not answered timely, Resident 3 was left soiled briefs for long periods of time, a rash not dealt with in a timely manner and two staff members being "rude" when assisting Resident 3 with her/his tube feeding.
-3/4/20 responses to the above concerns were as followed:

-Call lights and incontinences care not being completed timely Staff 19 (LPN/RCM) indicated Resident 3 had a couple of falls and was wet both of those instances however, she could not recall any other instance. Call logs were reviewed, and three times call lights were greater than 15 minutes from 1/28/20 through 2/23/20. Overall call lights did not look too bad. There are three that Staff 17 would investigate further.

-Rash not being dealt with timely Staff 19 stated the rash was identified however, the order from the physician took two days to receive and implement.

-Staff being rude when assisting Resident 3 with her/his tube feeding "something around the bags." Staff 16 (Administrator) was unsure of this allegation and family members had asked her about Resident 3's tube feeding she recalled stepping out of the room to close the door and the family was right behind her and Staff 16 opened the door up. Staff 16 stated she told the family members when leaving Resident 3's room she needed to ask Staff 19 a question about her/his tube feeding and did not recall it being a funny conversation.

-3/4/20 Staff 17 reviewed progress notes and risk management for Resident 3 and no concerns were noted, and abuse and neglect were ruled out. Staff 17 called and spoke with Witness 11 regarding his findings and Witness 11 appreciated the callback but voiced her frustration with the findings and the facility.

The Grievance form did not include any other interviews with staff members, no follow up regarding the long call light wait times, delay in physician orders and no CNA interviews regarding incontinence care or call light response times were included in the grievance.

On 3/1/21 at 2:00 PM Staff 16 (Administrator) stated they initiated and submitted the FRI to the State Survey Agency on 3/3/20 however they turned the FRI into a grievance report related to the three allegations and Staff 17 (Regional Director of Operations) completed the grievance/investigation.

On 3/10/21 at 2:02 PM Staff 17 stated he had Staff 16 initiate the FRI however, he completed the grievance form which was his investigation. Staff 17 stated he should have included more interviews with staff regarding the above allegations and could not recall if he spoke with any other staff members regarding the concerns.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (# 1) reviewed for diabetic management. This placed residents at risk for adverse side effects. Findings include:

Resident 1 admitted to the facility in 12/2019 with a diagnoses including diabetes.

A 4/8/20 physician order directed staff to administer 10 units of Insulin aspart (generic brand for Novolog) before meals and at bedtime related to diabetes with neuropathy. Staff were to hold insulin if blood sugar was less than 120 or if Resident 1 was not going to eat a meal.

A review of the MARs from 10/2020 through 12/2020 revealed the following:

-10/2020: There were seven instances at 7:00 AM when Resident 1's blood sugar was less than 120 and the resident was administered insulin. On two instances one at 7:00 AM and one at 6:00 PM there was no documentation inputted.

-11/2020: There were nine instances at 7:00 AM when Resident 1's blood sugar was less than 120 and the resident was administered insulin.

-12/2020: There were nine instances at 7:00 AM when Resident 1's blood sugar was less than 120 and the resident was administered insulin.

On 2/19/21 a public complaint was received which alleged care and service were not provided regarding Resident 1's diabetic management.

On 3/8/21 at 11:47 AM Staff 10 (LPN) stated she was aware Resident 1 was a diabetic and her/his blood sugar was taken often. Staff 10 stated she would hold administering insulin based on the physician order and what blood sugar parameters were indicated. Staff 10 was unaware Resident 1 received insulin when she/he was supposed to have the insulin medication held.

On 3/9/21 at 9:17 AM Staff 13 (RN) stated she was aware of Resident 1 and the physician order indicated if Resident 1's blood sugar was less than 120 or if the resident had not eaten breakfast the insulin should not have been administered. Staff 13 was unaware Resident 1 received insulin when it should have been held.

On 3/10/21 at 1:04 PM and 3/12/21 at 8:11 AM Staff 15 (DNS) stated she would expect her staff to follow and implement physician insulin orders, and acknowledged staff administered insulin when the insulin should have been held.

OAR-411-086-0360: Residents Furnishings, Equipment

Refer to F558
*****
OAR-411-085-0360: Abuse

Refer to F609, F610
*****
OAR-411-086-0110: Nursing Services: Resident Care

Refer to F684