Secora Rehabilitation of Cascadia

The facilityGÇÖs 10/15/22 Medical Record Policy and Procedure revealed the following:-á-á -á -á-The resident may have access to their medical record upon request to nursing leadership.-á-á -á -á-The resident and/or responsible party request for medical record documents may be made orally or in writing. It will be provided in the form and format requested, if it is readily producible in such format within two business days.-á-á-á1. Resident 801 was admitted to the facility in 6/2024 with diagnoses including morbid obesity and chronic pain.-á-á-áThe 7/5/25 Annual MDS indicated Resident 801 was cognitively intact.-á-á-áRecord review revealed on 4/21/25 Resident 801GÇÖs attorneyGÇÖs office had requested the facility ""Please: Provide Medical Records and Billing from 12/3/24 to Present.GÇ¥-áOn 7/28/25 a public complaint was received which alleged Witness 1 (Complainant) stated Resident 801GÇÖs attorney had requested medical records on 4/21/25 and did not receive the completed list of medical records until 7/29/25.On 7/31/25 at 12:24 PM Witness 2 (Case Manager) stated the attorneyGÇÖs office had initially sent the request for Resident 801GÇÖs medical records to the facility on 4/21/25. Witness 2 stated the facility sent Resident 801GÇÖs Progress Notes on 4/29/25 but no billing documentation was included. From 5/6/25 through 7/21/25, eight follow-up requests were made for Resident 801GÇÖs records. All requested records were not released by the facility until 7/29/25, approximately four months later.-á-áOn 7/31/25 at 2:25 PM Staff 10 (Business Office Manager) stated she had received voicemails and phone calls from Resident 801GÇÖs attorneyGÇÖs office but had not followed up with the attorneyGÇÖs office because she was too busy.-á-áOn 7/31/25 at 11:05 AM Staff 1 (Administrator) acknowledged a portion of Resident 801GÇÖs requested medical records were provided/released to Resident 801GÇÖs attorney on 4/29/25. Staff 1 acknowledged the requested billing documentation was omitted from the medical records and the billing records were subsequently received by the attorneyGÇÖs office on 7/29/25.a. On 7/28/25 a public complaint was received which alleged Resident 801 requested her/his medical records on 7/24/25 and had not received them in a timely manner.-áA review of Resident 801's medical records revealed no documentation indicating the resident received her/his requested medical records. Additionally, there was no evidence found in the medical record of a third-party request for medical records.-á-áA Disclosure/Release of Protected Health Information form dated 7/24/25, signed by Resident 801, included a request for her/his history and physical, progress notes, medication list, care plan, all financial data, foot wound care documentation, and notes from a transportation ride to be provided to the resident.On 7/30/25 at 10:10 AM Resident 801 stated she/he had not yet received the records she/he had requested and signed for on 7/24/25, approximately one week earlier.-áOn 7/31/25 at 12:01 PM Staff 1 (Administrator) acknowledged Resident 801 was not provided a copy of her/his medical records which were formally requested on 7/24/24. Staff 1 stated the medical records were not delivered or made available to Resident 801 in the required timeframe. -á-á-á-á

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#28) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration and adverse medication side effects. Findings include:

The facility's Self-Administration of Medications policy, dated 11/28/17, revealed the resident may self-administer drugs if the interdisciplinary team (IDT) determined the practice was safe as follows:
-The resident had the capacity to follow directions.
-The resident had comprehension of instructions for the medications they were taking.
-The resident had the ability to store medications securely and safely.
-Appropriate notation of determinations were documented in the resident's medical record and care plan.

Resident 28 was admitted to the facility in 1/2024 with diagnoses including major depressive disorder.

Resident 28's 1/31/25 Annual MDS indicated the resident had no cognitive impairment.

During multiple observations from 3/24/25 through 3/26/25 between the hours of 9:00 AM and 4:00 PM, mycostatin (a medication used to treat infections caused by fungi) and trimincolone acetonide (a potent corticosteroid medication used to treat inflammatory conditions of the skin) were observed on the resident's nightstand, within the resident's reach. Multiple staff, residents and resident visitors were observed going in and out of the room. Resident 28 reported that she/he self-administered the medications at times.

Review of Resident 28's health record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer the mycostatin or trimincolone acetonide and there were no physician orders for either medication.

On 3/26/25 at 8:49 AM, Staff 11 (CMA) stated when any medications were left at the bedside, a self-administration of medication assessment needed to be completed before allowing the resident to self-administer medications.

On 3/26/25 at 10:14 AM, Staff 10 (CNA) stated no medications were to be left at a resident's bedside and if medications were left at the beside, the nurse should be notified. Staff 10 confirmed mycostatin and trimincolone acetonide were on Resident 28's nightstand within reach of the resident.

On 3/26/25 at 10:16 AM, Staff 4 (DNS) observed Resident 28's medications within the resident's reach. Staff 4 confirmed the resident was not assessed to safely self-medicate and the medications should not be left in her/his room.

Based on interview and record review it was determined the facility failed to assist residents to formulate an advance directive for 1 of 2 residents (#21) reviewed for advance directives. This placed residents at risk for healthcare decisions to conflict with resident wishes. Findings include:

The facility's Advance Directives/Health Care Decisions Policy dated 10/1/17 states:
If a resident has not executed an advance directive, the facility advises the resident and family of the right to establish an advance directive, including but not limited to:
- Offering assistance if the resident wishes to execute one or more directives.

Resident 21 admitted to the facility in 9/2024 with diagnoses including pneumonia and anxiety.

A 9/16/24 Advance Directive Review form signed by Resident 21 stated Resident 21 would like assistance with formulating an advance directive plan.

A review of Resident 21's clinical record revealed no advance directive on file.

On 3/26/25 at 8:27 AM Resident 21 reported she/he had not received assistance with establishing an advance directive.

On 3/25/25 at 2:47 PM Staff 5 (Social Services Director) stated she had discussed advance directives with Resident 21 after she/he arrived at the facility, but no follow-up occurred with assisting Resident 21 with formulating an advance directive.

On 3/28/25 at 12:55 PM Staff 1 (Administrator) confirmed no follow-up had be completed to assist Resident 21 with formulating an advance directive.

Based on observation and interview it was determined the facility failed to maintain a clean and homelike environment for 1 of 1 facility reviewed for homelike environment. This placed residents at risk for adverse health conditions related to an unclean environment. Findings include:

Observations of the air intake floor vents in the north and south residents' hallways and the entrance hallway from 3/24/25 through 3/28/25 between the hours of 7:45 AM and 4:30 PM revealed accumulations of dust, fuzz and paper debris on and below the grates covering them.

On 3/24/25 at 1:47 PM Resident 14 stated staff swept the dust from the floors into the vents on the floor which made them "filthy."

On 3/26/25 at 2:17 PM Staff 25 (Maintenance Manager) stated cleaning the floor vents was part of housekeeping's duties and he was involved if they needed to be fixed.

On 3/27/25 at 10:11 AM Staff 24 (Housekeeping Manager) stated the floor vents were cleaned every quarter and their most recent cleaning was 11/21/24. She acknowledged the vents were "filthy."

On 3/28/25 at 12:39 PM Staff 2 (Administrator in Training) acknowledged the vents were dirty and needed to be cleaned. Staff 2 stated he expected the floor vents to be cleaned weekly by housekeeping and more frequently if staff noticed the vents were dirty.

Based on interview and record review it was determined the facility failed to ensure dependent residents received showers for 1 of 5 sampled residents (#16) reviewed for ADLs. This placed residents at risk for a lack of personal hygiene and loss of dignity. Findings include:

Resident 16 was admitted to the facility on 2/28/25 with diagnoses including diabetes and morbid obesity (having a body mass index greater than 40).

Resident 16's 3/7/25 Admission MDS indicated the resident had moderate cognitive impairment and required partial to moderate assistance with bathing/showering.

Resident 16's 3/13/25 bladder and bowel care plan indicated the resident was incontinent of urine and frequently incontinent of bowel.

Resident 16's 2/2025 and 3/2025 bathing task logs indicated the resident received bathing on the following days:
- 3/8, 3/12, 3/19, 3/22 and 3/26/25. Resident 16 was not showered until eight days after being admitted and received only one shower between 3/9/25 and 3/15/25.

On 3/24/25 at 10:40 AM and 3/26/25 at 9:14 AM, Resident 16 stated she/he was scheduled for showers on Wednesday and Saturday, she/he did not receive showers as scheduled and if she/he missed a shower, the shower was not made-up on another day. Resident 16 stated she/he was incontinent of urine and bowel and, as a result, needed more than one shower a week.

On 3/27/25 at 9:09 AM and 9:43 AM, Staff 12 (CNA) and Staff 15 (CNA) stated Resident 16 liked taking showers and rarely refused. Staff 15 stated if a resident refused showers the nurse was notified. Staff 15 stated they tried to make-up refused or missed showers on another day but that only occurred if the shower aid had time.

On 3/27/25 at 9:53 AM, Staff 9 (CNA) stated Resident 16 typically showered on evening shift but the resident recently asked for a shower during the day and the resident's request could not be accommodated because she could not "get to it." Staff 9 stated if a resident refused or missed a shower, the resident usually had to wait until their next shower day unless a "slot" opened up with the shower aid.

On 3/27/25 at 1:18 PM, Staff 6 (LPN-Care Manager) stated residents should receive at least two showers a week, more if they wanted. Staff 6 stated CNA staff should make-up any refused or missed showers.

On 3/28/25 at 9:37 AM, Staff 4 (DNS) reviewed Resident 16's shower task logs and stated her expectation was residents received a minimum of two showers a week, more if that was their preference. Staff 4 confirmed Resident 16 did not receive showers twice a week.

Based on observation, interview and record review it was determined the facility failed to implement an activity care plan and failed to include residents in group and individual activities for 1 of 3 sampled residents (# 302) reviewed for activities. This placed residents at risk for isolation, lack of social interaction and engagement. Findings include:

The facility's 11/2017 Activities Policy included the following information:
- The facility provides, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in the choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
- The recreation program provides stimulation or solace, promotes a sense of usefulness, and provides a sense of belonging.
- The facility considers accommodations in schedules, supplies and timing in order to optimize a resident's ability to participate in an activity of choice. Examples of accommodations may include, but are not limited to: assisting residents, as needed, to get to and participate in desired activities; providing supplies (i.e. books/magazines, music.).
- For the resident who has withdrawn from previous activity interests/customary routines and isolates self in room/bed most of the day: provide in-room volunteer visits, music or videos of choice; invite to special events; invite resident to participate on facility committee; invite the resident outdoors.

Resident 302 was admitted to the facility in 1/2024 with diagnoses including metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly) and Cerebral Palsy (neurological disorder affecting movement).

Resident 302's 10/5/24 Significant Change MDS indicated Resident 302 had impaired communication related to being non-verbal and was dependent on staff for care and mobility.

Resident 302's 10/2024 Activity Profile revealed Resident 302 preferred to watch action movies, enjoyed exercise/sports, gardening/plants, music, pet visits, and spiritual/religious activities. Resident 302 also preferred talking books in the afternoon.

Resident 302's 1/9/25 Care Plan indicated for Resident 302 to be invited, encouraged, and assisted to activities. Resident 302 also enjoyed non-group activities including listening to music, audio books, and spending one-on-one time with staff. Although Resident 302 was on Contact Isolation Precautions effective 3/24/25, she/he was to be encouraged to participate in activities.

On 3/25/25 at 2:38 PM, Staff 7 (Activities Director) was observed inviting Resident 302's roommate to a group Bingo game. Resident 302's eyes were open, but she/he was not invited to the game. At 3:55 PM, Resident 302 was observed to be laying in bed with eyes toward the ceiling and the TV off. Audio books and music were not seen in Resident 302's area.

On 3/26/25 the activity schedule included games, Uno, and Yahtzee at 1:00 PM and Activity Cart at 3:15 PM. At 1:10 PM Resident 302 was observed lying in bed with the television off and no music on. At 3:01 PM Resident 302 was observed staring at the ceiling, no television or music on. At 3:15 PM an activity cart was not seen throughout the facility. At 3:26 PM Resident 302 was observed laying in bed, no television or music on.

On 3/27/25 the activity schedule included Chapel Service at 3:30 PM. At 3:36 PM, a religious program was playing on the living room television, and Resident 302 was absent from the service.

On 3/27/25 at 9:08 AM Staff 9 (CNA) confirmed Resident 302 was dependent on staff for care and stated to not know if staff had ever tried to get her/him up for Bingo or other activities.

On 3/27/25 at 10:04 AM Staff 8 (RN) stated he was not sure if Resident 302 participated in any activities. He stated it was usually Staff 7 (Activities Director) who turned music on for Resident 302.

On 3/28/25 at 10:04 AM Staff 10 (CNA) was not sure of Resident 302's likes or activities but stated it could be found on the Activities section of the Kardex.

On 3/27/25 at 11:42 AM Staff 7 (Activities Director) stated she was responsible for inviting residents to group activities. Staff 7 acknowledged she was supposed to invite Resident 302 to group activities and had not been inviting her/him. Staff 7 acknowledged that she was supposed to invite and do other activities with Resident 302 but had not been doing so. Staff 7 stated she had been struggling with doing activities with non-verbal residents as she did not know if they wanted to do anything or not. Staff 7 stated the facility had not procured any music or audio/talking books, but the software applications were accessible on her cell phone. At 3:20 PM, Staff 7 stated she did not know about asking CNAs for help with resident activities, because she did not manage the CNAs.

On 3/28/25 at 8:42 AM Staff 4 (Director of Nursing Services) stated she expected staff to follow Resident 302's care plan. Staff 4 stated this included assisting residents with turning on and off televisions and music for residents. Staff 4 stated activities was a shared task amongst care and activities staff, and a resident's preferred activities could clearly be found on a resident's Kardex and care plan.

Based on observation, interview and record review it was determined the facility failed to ensure pressure injury wounds were comprehensively assessed and care plans were followed for 2 of 4 sampled residents (#s 15 and 16) reviewed for pressure ulcers and positioning. This placed residents at risk for incomplete assessments and worsening of wounds. Findings include:

The facility's Prevention and Treatment of Pressure Ulcers and Other Skin Alterations, last revised 10/15/22, indicated the facility had a system in place to promote skin integrity, prevent pressure ulcer development/other skin alterations, promote healing of existing wounds and prevent further development of additional skin alterations unless the individual's clinical condition demonstrated they were unavoidable.
When assessing the pressure injury and/or non-pressure areas it was important that documentation addressed:
-the type of injury;
-the stage of the injury (a method of classifying wounds based on the depth of tissue damage);
-a description of the pressure injury's characteristics;
-if infection was present;
-the presence of pain, what was done to address it, and the effectiveness of the intervention and
-a description of the dressings and treatment.

1. Resident 16 was admitted to the facility on 2/28/25 with diagnoses including diabetes and acute kidney failure.

Resident 16's 3/7/25 Admission MDS indicated the resident did not have any pressure injuries.

Resident 16's 3/19/25 Skin and Wound Evaluation indicated Resident 16 had a new pressure injury wound to her/his left heel which developed since the resident's admission. The Skin and Wound Evaluation did not include the stage of the pressure injury or any wound characteristics such as a description of the wound bed, if odor was present, a description of the periwound (the area of skin/tissue around the wound), how the wound was acquired or if the resident experienced pain.

A review of Resident 16's health record revealed no additional Skin and Wound Evaluations regarding the resident's left heel pressure ulcer.

Resident 16's skin and tissue integrity care plan, dated 3/19/25, indicated the resident had a new pressure related injury to her/his left heel. A 3/20/25 skin and tissue intervention indicated staff were to off-load (minimize or remove pressure from the heel area) pressure to Resident 16's heel using a pressure relieving boot or pillows.

Multiple observations on 3/25/25, between the hours of 8:00 AM and 4:30 PM revealed Resident 16 in bed without her/his left heel being off-loaded with pillows or a pressure relieving boot.

On 3/26/25 at 9:28 AM, Staff 6 (LPN-Care Manager) examined Resident 16's left heel which was resting directly on the floor. Staff 6 prepared Resident 16 for wound care on her/his left heel pressure injury and stated Resident 16's left heel should not have been resting directly on a hard surface. Staff 6 stated nursing staff should have "caught that before" and ensured the resident had orders to wear her/his pressure relieving boot while out of bed, as well as, when in bed.

On 3/26/25 at 11:48 AM, Staff 8 (RN) stated he found Resident 16's left heel pressure injury on 3/19/25 and contacted hospice. Hospice sent an LPN the same day to look at the wound, but the wound was not staged or comprehensively assessed. Staff 8 stated Resident 16 was not supposed to have her/his heel on the floor and was supposed to have her/his left heel off-loaded using pillows or a pressure relieving boot when in bed. Staff 8 stated "once in a while" the resident refused to have her/his heel off-loaded but any refusals would be documented in the resident's health record. A review of Resident 16's 3/25/25 progress notes revealed no refusals for off-loading her/his left heel.

On 3/27/25 at 9:09 AM and 9:22 AM and 3/28/25 at 11:35 AM, Staff 12 (CNA) and Staff 13 (CNA) stated they did not off-load Resident 16's left heel when she/he was in bed. Staff 22 (CNA) stated Resident 16 did not have a pressure relieving boot until yesterday and the resident allowed staff to off-load her/his left heel as long as her/his legs were not too painful.

On 3/28/25 at 9:37 AM, Staff 4 (DNS) stated she was made aware of concerns regarding Resident 16's left heel pressure injury, yesterday, and there were some "miscommunications" with hospice regarding Resident 16. Staff 4 stated she expected staff offered to off-load Resident 16's left heel while in bed using pillows or a pressure relieving boot and new physician orders were secured to ensure Resident 16 wore her/his pressure relieving boot while out of bed.

, 2. Resident 15 was admitted to the facility in 7/2019 with diagnoses including spinal stenosis, cervical region (a narrowing of the spaces in the spinal canal characterized by back pain and other nerve issues) and spondylosis with radiculopathy, lumbar region (age-related wear and tear of the lower back spinal disks which result in back and leg pain).

A review of Resident 15's 12/14/24 Quarterly MDS revealed she/he had mild cognitive impairment and was dependent on staff for assistance with bed mobility.

Resident 15's 3/24/25 quarterly Braden Scale for Predicting Pressure Sores indicated she/he was at moderate risk for developing pressure sores, her/his ability to change and control body position was very limited and required moderate to maximum assistance for repositioning.

Resident 15's care plan dated 4/25/24 revealed she/he was at risk of skin/tissue integrity related to impaired mobility, incontinence, fragile skin, age, and use of an anticoagulant. Resident 15's care plan indicated her/his heals were to be floated on a pillow or wear prevalon boots while in bed.

Resident 15 signed orders for a Specialty Air Mattress with settings for, low air loss, alternating, 120 lbs. The order reflected Resident 15's care plan and Kardex a note to, Notify nursing if settings need to be adjusted.

A review of Resident 15's weight history revealed she/he weighed 135.9 pounds on 3/21/25.

On 3/24/25 at 11:17 AM Resident 15 was observed in bed with the right side of her/his neck pushed into the air mattress. Resident 15 stated she/he was uncomfortable on the air mattress and told staff she/he wanted a regular mattress instead.

On 3/25/25 at 1:58 PM Resident 15 was observed in bed. Resident 15 was in the middle of the bed,
the air mattress was deflated and her/his heels were not floated on a pillow. Resident 15 stated she/he requested a regular mattress and staff told her/him the air mattress was better for her/him. Resident 15 stated her/his position on the air mattress created a hollow feeling which added to her/his discomfort.

On 3/26/25 at 8:26 AM Resident 15 was observed in the same sunken position with her/his heals not floated or wearing prevalon boots. Resident 15 reported she/he did not sleep well because of the uncomfortable mattress.

On 3/26/25 at 9:37 AM Staff 10 (CNA) stated Resident 15 needed to be repositioned every two hours because the air mattress had a tendency to pull her/him down into it. Staff 10 stated she should report Resident 15's sunken position to the nurse. Staff 10 reviewed Resident 15's air mattress settings and stated the air mattress was supposed to be set at 120 pounds but was set at 50 pounds.

On 3/26/25 at 9:52 AM Staff 28 (LPN) stated Resident 15 weighed 135 pounds and verified the air mattress was to be set at 120 pounds. Staff 28 observed Resident 15's air mattress setting and confirmed it was set at 50 pounds but the physician order was for the air mattress setting to be
at 120 pounds.

On 3/27/25 at 11:52 AM Staff 4 (DNS) stated the air mattress alleviated pressure in places which were prone to skin breakdown. Staff 4 stated she expected staff to follow physician orders. Staff 4 stated she was unaware resident 15 did not care for the air mattress.

3. Resident 15 was admitted to the facility in 7/2019 with diagnoses including spinal stenosis, cervical region (a narrowing of the spaces in the spinal canal characterized by back pain and other nerve issues) and spondylosis with radiculopathy, lumbar region (age-related wear and tear of the lower back spinal disks which result in back and leg pain).

A review of Resident 15's 12/14/24 Quarterly MDS revealed she/he had mild cognitive impairment and was dependent on staff for assistance with bed mobility.

Resident 15's 3/24/25 quarterly Braden Scale for Predicting Pressure Sores indicated she/he was at moderate risk for developing pressure sores, her/his ability to change and control body position was very limited and she/he required moderate to maximum assistance for repositioning.

Resident 15's care plan 4/25/24 revealed she was at risk of skin/tissue integrity related to impaired mobility, incontinence, fragile skin, age, and use of an anticoagulant. Resident 15's care plan indicated her/his heals were to be floated on a pillow or she/he was to wear prevalon boots while in bed.

On 3/25/25 at 1:56 PM and 3/26/25 at 8:25 AM Resident 15 was observed in bed and slumped to her/his right. Resident 15's heels were not floated.

On 3/26/25 at 9:37 AM Staff 10 (CNA) stated Resident 15's heels were to be offloaded when she/he was in bed. Staff 10 entered Resident 15's room and acknowledged her/his heels were not offloaded.

On 3/26/25 at 10:05 AM Staff 6 (LPN Care Manager) acknowledged Resident 15's heels were not floated and stated she expected Resident 15's heels to be floated to prevent skin breakdown.

On 3/27/25 at 11:52 AM Staff 4 (DNS) stated she expected staff to float Resident 15's heels as an intervention to prevent pressure ulcers and to follow the care plan.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 1 of 4 randomly selected CNA staff (#19) reviewed for sufficient and competent staffing. This placed residents at risk for lack of care by competent staff. Findings include:

A review of personnel records on 3/27/25 at 12:41 PM with Staff 20 (Human Resources) indicated the following employee had not received their annual performance evaluation:

-Staff 19 (CNA), hire date 11/6/23: no annual performance review was completed.

On 3/28/25 at 1:44 PM, Staff 20 confirmed an annual performance review for Staff 19 was not completed.

Based on interview and record review it was determined the facility failed to the ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 13 of 38 days reviewed for staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include:

The facility's Posting Licensed and Unlicensed Direct Care Staff policy, dated 11/28/17, indicated the facility posted nurse staffing data on a daily basis at the beginning of each shift which included facility name, current date, total number of actual hours worked by licensed and unlicensed staff and the resident census.

A review of the facility's DCSDRs revealed the following:

From 2/15/25 through 3/24/25, 38 days were reviewed and revealed 13 days when licensed nurse staff hours were inaccurate or the postings had missing/incomplete information on 2/16/25, 2/18/25, 2/19/25, 2/28/25, 3/1/25, 3/2/25, 3/4/25, 3/10/25, 3/16/25, 3/17/25, 3/18/25, 3/21/25 and 3/24/25.

On 3/27/25 at 1:41 PM, Staff 23 (Staffing Coordinator) reviewed the 2/15/25 through 3/24/25 DCSDRs and verified the reports were inaccurate or incomplete on the days identified.

Based on observation, interview and record review it was determined the facility failed to provide necessary behavioral health care and services and develop a comprehensive, person-centered behavioral health care plan for 1 of 1 sampled resident (#16) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include:

The facility's Behavioral Health Services policy, last revised 10/15/22, indicated the facility:
-provided trauma informed care which referred to approaches to care that treat the whole person, taking into account past trauma and the resulting coping mechanisms when attempting to understand behaviors and treat the resident;
-ensured necessary care and services were person-centered and reflected the resident's goals for care;
-monitored residents for signs and symptoms of depression, anxiety disorders, verbal behavioral symptoms directed towards others such as screaming at others.

Resident 16 was admitted to the facility in 2/2025 with diagnoses including schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms).

Resident 16's 2/28/25 Clinical Evaluation Admission indicated the resident had a history of behaviors and was prescribed anti-psychotic medications.

Resident 16's 3/2/25 Psychosocial Evaluation indicated the resident had schizoaffective disorder and Bipolar II (a mental health disorder characterized by depressive and hypomanic episodes) and her/his mental health was unstable. Resident 16 was in a psychiatric hospital for eight months in 2024, discharged home and failed. There were no trauma triggers identified and the resident liked to be left alone when under stress.

Resident 16's 3/3/25 Suicide Risk Evaluation identified the resident as having mild depression and anxiety at a high or panic state. Resident 16 expressed feelings of helplessness, hopelessness, withdrawal and the resident had some constructive coping strategies. Resident 16 had "vague", "fleeting" and "intrusive" thoughts of suicide but no suicide plan. Resident 16 was described as being labile (rapid, often exaggerated changes in mood where strong emotions such as uncontrolled laughter or crying occurred), hyperfocused on people controlling her/him and experienced thought disturbances.

Resident 16's 3/4/25 care plan identified the resident as exhibiting "accusations of being dishonest behaviors." No other behavioral health focuses, goals or interventions were identified.

Resident 16's 3/7/25 Admission MDS indicated the resident had moderate cognitive impairment and received anti-anxiety and routine anti-psychotic medications.

No evidence was found in Resident 16's health record to indicate any anxiety, mood or behavioral symptoms for the resident were monitored and a comprehensive, person-centered care plan was developed to address the resident's anxiety, feelings of helplessness or hopelessness and withdrawal, lack of coping skills, thoughts of suicide, lability or concerns regarding people controlling her/him.

On 3/24/25 through 3/25/25 between the hours of 8:00 AM and 4:00 PM, Resident 16 exhibited multiple episodes of yelling and screaming. The resident reported a frequent sensation of bugs crawling on her/him. Resident 16 was observed speaking with various nursing staff, including the hospice nurse, regarding her/his anxiety and feeling bugs were crawling on her/him. The resident was observed to be upset and anxious and reported needing some medication to help reduced the sensation of bugs crawling on her/him. At times, Resident 16 mumbled and was not able to make herself/himself understood.

On 3/24/25 at 11:02 AM and 3/25/25 at 8:17 AM, Resident 16 stated she/he frequently experienced a sensation of bugs crawling all over her/him, she/he needed something to help reduced this sensation but "nobody" understood what she/he was trying to explain to them.

On 3/26/25 at 10:02 AM and 3/28/25 at 11:48 AM, Staff 10 (CNA) stated Resident 16 was easily frustrated and yelled, at times. Staff 10 stated Resident 16 became upset when people talked to her/him about being in the facility.

On 3/26/25 at 10:35 AM, Staff 5 (Social Service Director) stated Resident 16 was often labile and her/his mood was "mountains and mole hills." Staff 5 stated there was no behavior monitoring in place for Resident 16 and no care plan interventions for the resident's "spiraling stuff."

On 3/27/25 at 9:09 AM, Staff 12 (CNA) stated Resident 16 was "sporadic" at times and had outbursts. Staff 12 stated Resident 16 accused other residents of wearing her/his clothing and the resident usually yelled and screamed when she/he was anxious.

3/27/25 at 9:22 AM, Staff 13 (CNA) stated Resident 16 had outbursts and called people names when she/he was upset.

On 3/28/25 at 9:37 AM, Staff 4 (DNS) stated any resident with mental health diagnoses were expected to be monitored and care planned for behaviors. Staff 4 confirmed Resident 16 had behaviors that were not being monitored and a comprehensive, behavioral care plan was not developed. Staff 4 stated staff should have identified Resident 16's triggers and devised strategies to help her/him feel better, asserting Resident 16 should not have experienced such distress.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 6 sampled residents (#35) reviewed for unnecessary medications. This placed residents at risk for adverse side effect of medications. Findings include:

The facility's 8/1/23 Medication Errors policy outlined the following:
-A significant medication error is one which causes the resident discomfort or jeopardizes their health and safety.
-In the event of a significant medication error, immediate action is taken as necessary to protect the resident's safety and welfare.
-The prescriber is notified promptly of the error.
-A medication error/adverse reaction report is completed.

Resident 35 was admitted to the facility in 3/2024 with diagnoses including vascular dementia (cognitive decline caused by damage to the blood vessels in the brain) and a stroke.

A review of Resident 35's 4/4/24 Admission MDS revealed she/he was cognitively intact and received anticoagulant therapy.

A review of Resident 35's health record revealed a 4/12/24 signed physician order for 20 mg tablet of Rivaroxaban to be administered one time a day for other cerebral infarction due to occlusion or stenosis of small artery.

A review of Resident 35's medication administration record revealed her/his prescribed Rivaroxaban (an anticoagulant) was not administered on 4/14/24, 4/15/24 and 4/16/24.

A facility investigation completed by Staff 29 (Former Administrator) indicated Resident 35's Rivaroxaban was available but Staff 30 (LPN) failed to administer it to her/him on 4/14/24, 4/15/24, and 4/16/24. The investigation also indicated on 4/17/24 Resident 35 presented with "strokelike symptoms" including being unable to hold up her/his head, her/his right pupil was pinpoint and fixed, she/he had weakness on the right side of her/his body, and was unable to respond verbally to questions. As a result, Staff 31 (RN, Former DNS) sent Resident 35 to the hospital emergency department.

On 3/27/25 at 11:43 AM Staff 4 (DNS) stated Resident 35 was not administed her/his medications as ordered and developed stroke-like symptoms for which she/he was sent to the hospital. Staff 4 stated Staff 30 did not notify staff, contact the provider or call the pharmacy. Staff 4 stated Staff 30 did not follow appropirate protocol or follow physician orders.

On 3/27/25 at 5:23 PM Staff 31 acknowledged Staff 30 did not administer Resident 35's medication as ordered and did not notify nursing staff, call the provider, pharmacist, or write a progress note about the missed scheduled doses. Staff 31 stated Staff 30 was terminated due to the incident.

On 3/28/25 at 1:56 PM Staff 30 stated she looked for Resident 35's Rivaroxaban but was unable to locate the medication. Staff 30 stated it was her mistake, she was "overwhelmed" by work and forgot to call the pharmacy as well as the doctor.

Based on observation, interviews and record review it was determined the facility failed to ensure dishwasher temperatures met the minimum requirements for 1 of 1 dishwasher reviewed for the kitchen. This placed residents at risk for communicable diseases, un-sanitized dishware and utensils. Findings include:

The facility's Dishwashing in the Dish Machine Policy dated 1/1/2018 states:
- Test the dish machine for proper water temperatures and sanitizer levels (for low-temp machine), and record readings prior to washing the dishware.
- Do not use the dish machine if sanitizer and water temperatures are not acceptable.

On 3/27/25 at 11:45 AM the facility's dishwashing machine was observed with instructions stating the minimum operating temperature was 120 degrees F.

On 3/27/25 the following observations were made of Staff 27 (Dietary Staff) washing dishes:
- At 11:57 AM trays were washed with the water temperature reading at 90 degrees F,
- At 11:59 AM plates were washed with the water temperature reading at 110 degrees F,
- At 12:03 PM forks were washed with the water temperature reading at 115 degrees F and
- At 1:34 PM plates and cups were washed with the water temperature reading at 118 degrees F.

On 3/27/25 at 1:34 PM Staff 26 (Dietary Manager) was requested to test the dishwasher water temperature using an external thermometer which read 118 degrees F. Staff 26 stated the dishwasher water temperature should be at least 120 degrees F for adequate sanitization. Staff 26 confirmed the dishwater temperature did not meet the minimum requirements.

Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 2 of 2 sampled residents (#s 16 and 304) reviewed for binding arbitration agreement. This placed residents at risk of being uninformed of their legal rights. Findings include:

The facility's undated arbitration agreement included the following:
- The Resident and/or Legal Representative understands that his Arbitration Agreement may be rescinded by giving written notice to the Facility within 10 days of its execution, this Arbitration of its execution. If not rescinded within 10 days of its execution, this Arbitration Agreement shall remain in effect for all claims arising out of the Resident's stay at the Facility.

1. Resident 16 was admitted to the facility in 2/2025 with diagnoses including congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively).

Record review revealed Resident 16's legal representative signed the facility's arbitration agreement on 3/5/25.

On 3/28/25 at 1:54 PM Resident 16's legal representative stated she/he did not know about her/his right to rescind the arbitration agreement within 30 days of signing it.

On 3/28/25 at 1:45 PM Staff 2 (Administrator-In-Training) stated the facility's arbitration agreement had an inaccurate timeframe for the signed agreement to be rescinded and confirmed Resident 16's arbitration agreement was signed with an inaccurate timeframe.

2. Resident 304 was admitted to the facility in 1/2025 with diagnoses including metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly).

Resident 304's 1/27/25 Admissions MDS indicated the resident had severely impaired cognition.

Resident 304's records included the facility's Voluntary Agreement For Arbitration, dated 1/13/25 and signed as "verbal consent."

On 3/28/25 at 1:38 PM Resident 304 stated she/he did not know or understand the Arbitration Agreement and did not remember signing the form or giving verbal consent.

On 3/28/25 at 1:45 PM Staff 2 (Administrator-In-Training) stated the facility's arbitration agreement had an inaccurate timeframe for the signed agreement to be rescinded and confirmed Resident 304's arbitration agreement was signed with an inaccurate timeframe.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 9 and 18) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include:

The facility's Inservice Education/Training policy, last revised on 10/15/22, indicated employee education and in-service training was provided to assist in maintaining the continuing competence and knowledge of the staff.

On 3/27/25 at 2:44 PM, Staff 3 (Clinical Resource) provided a list of annual training hours for CNA staff which revealed the following:
-Staff 9 (CNA): 7.5 annual training hours and
-Staff 18 (CNA): 1.5 annual training hours.

On 3/28/25 at 1:06 PM, Staff 2 (Administrator-In-Training) and Staff 3 confirmed Staff 9 and Staff 18 did not complete the required 12 hours of annual in-service training.

Based on interview and record review it was determined the facility failed to ensure background checks were completed for staff employed two or more years for 2 of 3 sampled staff (#s 15 and 21) reviewed for background checks. This placed residents at risk for abuse. Findings include:

The facility's Preventing Abuse policy, last revised 8/1/23, indicated the facility had a process in place to assist in preventing abuse, neglect, misappropriation of resident property and exploitation. Background checks were completed of new employees and returning employees prior to hire/rehire.

On 3/27/25 at 11:02 AM, during a review of background checks for three randomly selected staff employed two years or more, Staff 20 (Human Resources) stated the following:
-Staff 15 (CNA), hire date 9/28/22, most recent background check was completed 11/2022; a two year background check should have been completed in 11/2024.
-Staff 21 (CNA), hire date 4/28/17, most recent background check was completed on 4/26/21; a two year background check should have been completed on 4/26/23.

On 3/27/25 at 11:02 AM, Staff 20 reported Staff 15's preliminary background check determination was submitted on 3/24/25 when she realized Staff 15 did not have a current background check in place. Staff 20 stated Staff 15 worked from 11/2024 until 3/24/25 without a preliminary or approved background check. Staff 20 verified Staff 15 and Staff 21 were employed for two years or more and did not have background checks completed every two years, as required. Staff 20 stated she expected all staff to have preliminary or approved background checks in place.

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OAR 411-086-0260-Pharmaceutical Services

Refer to F554

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OAR 411-086-0040-Admission of Residents (Advance Directives)

Refer to F578

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OAR 411-087-0100-Physical Environment: Generally

Refer to F584

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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 411-086-0140-Nursing Services: Problem Resolution and Preventive Care

Refer to F686

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OAR 411-086-0310-Employee Orientation and In-Service Training

Refer to F730

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OAR 411-086-0100-Nursing Services: Staffing

Refer to F732

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OAR 411-086-0240-Social Services

Refer to F740

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

Refer to F760

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OAR 411-086-0250-Dietary Services

Refer to F812

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OAR 411-086-0110-Administrator

Refer to F847

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OAR 411-086-0310-Employee Orientation and In-Service Training

Refer to F947

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Based on interview and record review it was determined the facility failed to ensure residents were free from physical restraints for 1 of 3 sampled residents (#7) reviewed for restraints. This placed residents at risk for mistreatment. Findings include:

On 6/8/23, the Past Noncompliance was corrected when the facility implemented a plan of correction, which included:

-Residents on the same unit were interviewed and no other restraints were found to be improperly utilized;
-Educated the staff responsible and placed on corrective discipline;
-Provided in-service training to all nursing staff for abuse and neglect which included the use of restraints; and
-Provided signature sheet verifying nursing staff had completed the training.

Resident 7 was admitted to the facility in 5/2023, with diagnoses including stroke and repeated falls.

Resident 7's care plan dated 5/4/23 revealed she/he was a high fall risk and had a history of falls. Staff were to encourage Resident 7 to transfer to her/his bed, wheelchair or ambulate when she/he was on the unit to prevent further falls.

On 6/7/23 the facility submitted a report to the State Survey Agency (SSA) which stated Resident 7 had been placed in a device which limited her/his ability to stand. Staff 3 (RCM) assisted the resident to the bathroom and found the resident's gait belt was tied to the resident's wheelchair. Staff 11 (CNA) told Staff 3 he had tied the gait belt to the wheelchair to keep Resident 7 from falling while Staff 11 assisted other residents.

The facility investigation revealed Staff 11 was suspended, the resident was placed on alert, a skin check was completed and staff education was initiated.

The investigation included a handwritten statement from Staff 11 dated 6/7/23 which stated in part, Resident 7 was a "super high fall risk. In order to keep a close watch on [the resident] and also be able to care for my other residents, I wheeled [the resident] along with me to rooms. I had a gait belt around [the resident's] waist and tied the extra length of the belt to part of [the resident's] wheelchair. If [the resident's] alarm chimed, I would have enough time to conclude whatever I am doing and still get to [the resident]."

On 9/19/24 at 12:55 PM, Staff 3 confirmed on 6/7/23, Resident 7 was observed by her to have a gait belt tied to her/his wheelchair. She stated she completed a full skin check with no negative findings and Resident 7 did not report any pain or discomfort as a result of the restraint.

On 9/19/24 at 1:20 PM, Staff 11 confirmed he had written the statement on 6/7/23 and had tied Resident 7's gait belt to her/his wheelchair to keep her/him from falling.

On 9/19/24 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were advised of the investigative findings and provided no additional information.

Based on interview and record review it was determined the facility failed to provide pain management to 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at increased risk of unmanaged pain. Findings include:

The facility's pain management policy, revised 10/2022 recognized a resident's right to be free of pain and promoted pain relief utilizing a pain management plan during the resident's stay at the facility. Facility procedures included an initial pain assessment upon admission for all residents.

Resident 3 admitted to the facility in 10/2023, with diagnoses including spinal fractures and chronic pain syndrome.

Resident 3's physician orders dated 10/23/23 included a prescription for morphine tablets (15 mg), to be administered every 12 hours for pain.

Resident 3's care plan dated 10/24/23 revealed she/he was at risk for acute pain related to her/his diagnoses following a spinal cord injury. Interventions were to administer medications as ordered, anticipate need for pain relief and respond immediately to any complaint of pain.

Resident 3's initial pain assessment was completed on 10/24/23 at 5:46 PM by Staff 12 (RN). The assessment revealed Resident 3 reported a pain level of 10 and she/he was in severe pain.

Resident 3's 10/2023 MAR revealed she/he was not administered morphine on 10/24/23 evening shift due to the medication being unavailable.

Pharmacy delivery records revealed the morphine was delivered to the facility on 10/25/23 at 2:30 AM.

The MAR revealed the resident received the first dose of morphine on 10/25/23 at 8:00 AM.

A nursing note written on 10/25/23 at 9:20 AM by Staff 4 (RCM) revealed she gave Resident 3 her/his morning medications which included the morphine, the resident was upset and said she/he had asked for the medication earlier but had not received it.

On 9/19/24 at 11:23 AM, Staff 5 (LPN) stated she completed resident assessments for new admissions to the facility. If a resident complained of pain during her/his assessment, the facility was expected to provide pain medication to the resident as ordered. If the resident's pain medication was not available, it was the responsibility of the admitting nurse to contact the pharmacy and get a code for the Cubix (a medication system that dispenses common medications for emergent care needs). Staff 5 stated pain medications typically found in the Cubix included morphine.

Resident 3's clinical record did not reveal any efforts were made by nursing staff on 10/24/23 to dispense pain medications from the Cubix.

On 9/19/24 at 11:40 AM, Staff 4 confirmed the morphine was not administered to Resident 3 on 10/24/23 and there were no progress notes to explain the delay of the medication's delivery to the facility.

Resident 3 was not interviewed due to discharging from the facility.

Staff 12 was not interviewed due to medical leave.

On 9/19/24 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated it was an expectation that residents receive pain medication timely.

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OAR 411-085-0310-Resident's Rights: Generally (physical restraints)

Refer to F604

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OAR 411-086-0110-Resident Care

Refer to F697

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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 03/04/2024 and 03/10/2024, 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.