Secora Rehabilitation of Cascadia

The facility's 8/21/2025 Activity Program Policy indicated the following: *Residents who prefer not to participate in group programs and/or are independently involved in recreational pursuits will be identified through the assessment process. *Individual interventions will be developed based on each Residents assessed needs and the family will be notified for any special requests.-á *The individual program will be provided according to a consistent schedule identifying specific days of the week and the time frame in which the program will occur.-á *Each Resident's individual program will include interventions that meet the Resident's assessed social, emotional, physical, spiritual and cognitive functioning needs.-á -á Resident 3 was admitted in 12/2025 with diagnoses including stroke and dysphagia (difficulty swallowing).-á -á Resident 3's 12/19/25 Activity Care Plan revealed the following: -The resident enjoyed group activities, entertainment, card games, Bingo, arts and crafts, gardening and plants, pet visits, social clubs, outdoor activities and shopping trips. -á -á Resident 3's 6/16/26 Quarterly MDS assessment indicated the resident's short-term memory was intact, while long-term memory was impaired. The MDS also indicated listening to music, pet visits, participating in group activities, going outside for fresh air on nice days and engaging in activities involving her/his favorite interests were very important to the resident.-á -á A review of Resident 3's Activity Task Records from 6/9/26 to 7/8/26 revealed the resident did not participate in any self-directed or independent activities and did receive any activity visits. During the review period, the only documented activity participation was conversation and reminiscing on 6/16/26 and 6/24/26.-á -á The facility's 7/2026 Activity Calendar revealed the following scheduled activities: -á 7/5/26: -Coffee & News -This day in History -Flower Care -á 7/6/26: -Coffee & News -Gardening -Movie Matinee -á 7/7/27: -Coffee & News -Garden Club -Bingo -á 7/8/26: -Coffee & News -Summer Decorating -Bingo -á 7/9/27 -Coffee & News -One on One Visits -Chapel Service -á On 7/6/26 at 10:02 AM, Resident 3 was observed in her/his room in bed. The resident was nonverbal but able to answer yes/no questions by shaking her/his head. The television was on; the resident was not observed participating in an activity. No items related to the resident's identified interests, including music or activity materials, were observed available for the resident's use.-á -á Observations of Resident 3 from 7/6/26 through 7/9/26 from 8:30 AM to 4:00 PM revealed the resident to be in her/his room in bed. The television was on, no music, pet visit, activity supplies, reading materials, or other items related to the resident's identified interests and preferences were observed in the resident's room or readily available for the resident's use.-á -á On 7/9/2026 at 2:04 PM Staff 8 (CNA) stated she was not familiar with the activities listed on Resident 3's care plan. Staff 8 stated the resident did not participate in facility activities and remained in bed in her/his room watching television with her/his headphones on.-á -á On 7/9/26 at 2:12 PM Staff 10 (CNA) stated Resident 3 remained in her/his room in bed watching television. Staff 10 stated he was not familiar with Resident 3's care-planned activities and reported the resident had not participated in facility activities recently.-á -á On 7/9/26 at 2:33 PM Staff 6 (Activity Director) stated Resident 3's preferred activities included group activities, arts and crafts, and shopping trips. Staff 6 stated activities offered to Resident 3 included television and music. Staff 6 confirmed Resident 3 had not been offered additional activities and reported the only documented activity participation dates were 6/16/26 and 6/24/26 for conversation and reminiscing.-á -á On 7/9/26 at 3:25 PM Staff 2 (DNS) stated it was her expectation the facility adhered to residents identified preferences and ensure residents were provided opportunities for activities based on their individual needs. Staff 2 stated residents' activity preferences should be accurately reflected on their care plans and implemented by staff. -á

A 9/2025 Skin Integrity & Wound Prevention policy indicated the following: *Staff to complete weekly skin inspections. *Staff to notify the provider about new areas of concern that include treatment of new wounds. *Staff to obtain and initiate treatment orders that included a person-centered goal.-á Resident 14 was admitted to the facility on 6/2024 with diagnoses including a blister of abdominal wall.-á A 4/3/26 Quarterly MDS revealed Resident 14 had a BIMS score of 15 indicating Resident 14 was cognitively intact.-á A 8/2025 Care Plan indicated Resident 14 required the following: *Weekly skin checks and required staff to take pictures of new or old wounds identified.-á *Staff to monitor, document location, size and treatment of skin injury in the care plan when new wounds were identified.-á *Daily skin inspections during cares. 1. A 7/2026 MAR/TAR indicated staff applied InterDry (fabric strip) dressing to Resident 14's abdomen daily.-á A 7/3/26 Skin Inspection Evaluation indicated Resident 14 refused a skin inspection. -á On 7/7/26 at 2:00 PM, Resident 14 stated she/he had a new wound near her/his belly button. Resident 14 pointed to the new wound. The edges of the wound were irregular. The center of the area was pink and moist. The area was draining a clear substance, and the edges of the wound had a white substance. Resident 14 did not have InterDry applied.-á On 7/9/26 at 9:22 AM, Staff 22 (CNA) stated Resident 14 had open wounds to her/his abdomen and nursing staff were aware.-á On 7/9/26 at 9:05 PM, Staff 19 (LPN) stated Resident 14 had recurrent blisters near her/his abdomen and staff were expected to apply InterDry daily for preventative breakdown of the skin. Staff 19 stated staff were expected to notify the provider when new wounds were identified. Staff 19 stated wound care orders were initiated at 2:00 AM during the night shift. On 7/9/26 at 9:57 PM, Staff 23 (RN) stated Resident 14 had an open wound near her/his belly button. Staff 23 stated the wound was from friction or moisture. Staff 23 stated he was aware Resident 14 had an open wound but did not notify the provider because he thought the wound was old. Staff 23 stated he did not apply InterDry during his shift.-á Resident 14 stated no wound care orders were entered for the wound near Resident 14's belly button. Staff 23 stated the center of the wound was pink several weeks ago. Staff 23 stated he did not complete a skin assessment because Resident 14 refused and did not notify the provider. On 7/10/26 at 8:39 AM, Staff 24 (LPN) stated Resident 14 had recurrent abdominal blisters and staff were able to identify skin concerns during cares like bed baths or brief changes. Staff 24 stated she did not notify the provider about frequent skin assessment refusals or new skin wounds.-á On 7/10/26 at 10:39 AM, Staff 4 (RNCM) stated she expected staff to notify the provider when new wounds were identified and was unaware Resident 14 had new abdominal wounds.-á 2. A 2/23/26 Progress Note indicated Resident 14 had a referral for dermatology related to re-occurring blisters to the abdomen. On 7/8/26 at 12:00 PM, Resident 14 stated she did not see a dermatologist or had a scheduled appointment. Resident 14 stated Staff 23 (RN) was aware about her/his abdomen wound. Resident 14 stated she/he struggled with moisture and had recurrent blisters. On 7/9/26 at 9:22 AM, Staff 22 (CNA) stated Resident 14 had open wounds to her/his abdomen. Staff 22 stated staff were aware. On 7/9/26 at 9:57 PM, Staff 23 (RN) stated he was unaware Resident 14 had recurrent abdomen blisters. Staff 23 stated Resident 14 did not have any outside dermatology appointments scheduled or after visit summaries to indicate treatment started.-á On 7/10/26 at 8:39 AM Staff 24 (LPN) stated she was unaware about Resident 14's recurrent abdominal blisters. Staff 24 stated Resident 14 did not have a dermatologist.-á On 7/10/26 at 10:39 AM, Staff 4 stated Resident 14 did not have a scheduled appointment with a dermatologist. Staff 4 stated she was unaware Resident 14 had recurrent abdominal blisters.-á On 7/10/26 at 11:43 AM, Staff 2 stated Resident 14 had recurrent abdominal blisters and did not have an appointment to see a dermatologist. Staff acknowledged the referral was entered on 2/23/26.

A 2017 Evencare G2 glucometer Manufacturer Manual indicated, ""Disinfect common use glucometers with the use of approved disinfectant wipes."" The glucometer was to be wiped with the disinfecting wipe and left wet for two minutes to ensure disinfection.-á Resident 22 was admitted to the facility in 9/2024 with diagnoses including diabetes. On 7/7/26 at 11:54 AM, Staff 25 (Agency RN) was observed using a shared Evencare G2 glucometer to obtain Resident 22's blood sugar. Staff 25 returned to the medication cart and cleaned the glucometer with an alcohol pad wipe. Staff 22 placed the glucometer on top of the medication cart and she was stopped prior to obtaining the next blood sugar. Staff 22 stated she did not receive education prior to starting her shift related to blood sugar disinfecting the glucometer after resident use.-á On 7/7/26 at 12:15 PM Staff 2 (DNS) stated staff were expected to use approved EPA disinfectant wipes to disinfect the glucometers.

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¥-á On 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-á On 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-á On 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.-á A 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-á A 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.-á On 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

This Plan of Correction is the center's credible allegation of compliance .   Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies .   The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law .   This provider respectfully requests that the 2567 Plan of Correction be considered the Letter of Credible Allegation and requests a post survey review on or after   9/8/2025. 1. Corrective actions for residents affected by the deficient practice (Fulfilled Week of July 28 th , 2025) Resident #801 was directly affected . Upon identification of the delay, the facility took immediate action to fulfill the outstanding records request, including the missing portions, and confirmed delivery to the resident’s legal representative. No negative outcomes noted. Staff involved were educated on the facility’s responsibility to fulfill records requests in compliance with federal timeframes. 2. How other residents potentially affected will be identified and what corrective action will be taken (Fulfilled Week of August 18 th , 2025) The facility will conduct an audit of   residents at risk for uninformed healthcare needs and delayed access to medical records   through brief interviews to determine whether any recent requests for medical records—either personal or third-party—have been made and not fulfilled timely. If any deficiencies are identified, records will be provided . All future requests will be processed in accordance with the updated policy outlined below. 3. Systemic changes to prevent recurrence (Fulfilled Week of August 18 th , 2025) The facility's medical records request policy has been revised to clarify the following procedures: Requests with valid legal authorization to direct medical records to third-parties (i.e. individuals or organizations other than the resident)  will be fulfilled within 30 calendar days or in accordance with state law, whichever is shorter. Resident requests to personal and medical records pertaining to him/herself, upon an oral or written request, in the form or format requested by the individual will be provided within 24 hours Staff responsible for handling medical record requests have been   trained on these procedures. 4. Monitoring to ensure the deficient practice does not recur The Administrator or designee will conduct audits of all medical record requests: Weekly for 4 weeks Monthly for 2 months thereafter Audit results will be reviewed in the facility's QAPI committee for ongoing oversight and to determine if further actions or training are required.

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.

This Plan of Correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. This provider respectfully requests that the 2567 Plan of Correction be considered the Letter of Credible Allegation and requests a post survey review on or after 5/17/25. 1. Resident #28 will have a Self-Administration of Medication Evaluation completed to determine if safe to self-administer desired medications. An order for self-administration of medication will be obtained, care plan updated and lock box provided for medications evaluated safe to administer. 2. The CNO/Designee will complete a baseline audit of current residents with BIMS of 9 or higher to determine which residents prefer to self-administer medications. Residents who prefer to self-administer medications will have a Self-Administration of Medication Evaluation completed to determine if they are safe to self-administer medications. If it is determined the resident is safe to self-administer medications, orders to self-administer medications will be obtained, care plan updated and lock box provided. 3. The CNO/Designee will provide further education to nursing staff on the requirements for clinically appropriate self-administration of medications. 4. The CNO/Designee will complete weekly audit on five random residents and new admissions to validate the requirements for clinically appropriates self-administration of medications have been completed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Resident #21 has had their Advanced Directive needs addressed and resident assisted to formulate an Advance Directive to reflect resident wishes. 2. The CEO/Designee will complete a baseline audit of current residents to validate residents have been offered/reviewed the choice to formulate an Advance Directive. 3. Education provided by CEO to the Social Services Director on the process for obtaining Advanced Directives and assisting residents with formulating Advance Directives when needed and requested by resident. 4. On-going audits to verify new admissions have their advanced directive needs addressed. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Floor vents/grates in the facility entryway and the North and South Resident hallways were cleaned to remove accumulation of dust and debris. 2. CEO/Designee conducted baseline audit of facility vents and grates in the floor to verify they do not have accumulation of dust and debris. Identified vents/grates were addressed. 3. Education provided by CEO to the Housekeeping manager that the vents will be cleaned every Friday going forward to prevent any dust buildup and provide the residents with a safe, clean, and comfortable homelike environment. 4. On-going random audit will be conducted to observe floor grates/vents to verify they are clean and free of large accumulations of dust. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Resident #16 will be offered bathing opportunities per their preference and no negative outcomes from missed bathing occurred. 2. The CEO/Designee will complete a baseline audit of current residents at risk to verify they are being offered bathing opportunities per their bathing schedule. 3. Education provided to the shower aide, CNA's and LN's by the CNO/Designee on the process of the shower schedules, refusals, documentation, and the importance of offering showers per shower/bath schedule and plan of care. Education provided to LN's and RCM's on following resident preferences for bathing schedules. 4. The CNO/Designee will complete weekly audits to verify bathing opportunities were offered per the resident schedule and hygiene needs are being met. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Resident #302 has had their activities care plan and preferences assessed to verify their activities needs are being met. 2. CEO/Designee will complete baseline audit of current residents who are non-verbal and/or bedbound to verify their care plans are updated and implemented to meet resident activity needs and preferences. 3. CEO/Designee provided education to Activities manager/Nursing staff related to providing activities to residents but more specifically, our residents who may be non-verbal or bedbound to have activities to their liking. 4. CEO/Designee will complete on-going observation of 5 random residents who are non-verbal and/or bedbound to verify they are being offered/invited to activities that meet their like/preferences per their care plan. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Residents #15 low air loss mattress was updated to provide correct pressure relief per provider order and resident weight. Resident will be encourage to float heels when in bed per care plan intervention. 2. Resident #16 left heel was comprehensively assessed and care plans reviewed and verified interventions and positioning are being followed. Resident #16 assessed to verify no negative outcomes occurred due to missing interventions. 3. CNO/Designee will complete baseline audit of residents with pressure injury wounds to verify it has been comprehensively assessed and careplans reviewed and updated if indicated. CNO/Designee will complete baseline observation of residents at risk for skin breakdown to verify that skin at risk care plans is being followed related to pressure relieving interventions. 4. CNO/Designee provided education to LN's on comprehensively assessing and documenting pressure ulcers. Education provided to nursing staff regarding following care plan interventions r/t pressure injuries prevention/care/positioning. 5. CNO/Designee will complete ongoing audit of residents with newly acquired pressure injury wounds to verify it has been comprehensively assessed and careplans reviewed and updated if indicated. CNO/Designee will complete ongoing observation of 5 Residents at risk for skin breakdown to verify that skin at risk care plans is being followed related to pressure relieving interventions. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1.Staff #19 has received their annual performance review. 2.CNO/Designee will complete a baseline audit on CNAs that have been employed for a year or more to validate annual performance reviews have been completed. 3. CNO/Designee will complete identified overdue/due annual performance reviews. 4. CNO/Designee will provide further education to Nurse Management team related to completing annual reviews. 5. CNO/Designee will complete monthly audit of CNAs who were due for their Annual Performance review to verify they had them completed. Audits will be conducted monthly for 3 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Residents are at risk for inaccurate staffing information by inaccurate postings of DHS sheets. 2. The CEO/Designee will complete a baseline audit for the last 7 days to verify Daily DHS posting matches the staff assigned and labor for that day and that the DHS form is fully completed to include census, staff data and signature of the person attesting to the data each shift. 3. The CEO/Designee will provide further education to Licensed nurses related to accurately completing the DHS form at the start of each shift and to verify it matches staff on assignment sheet. 4. The CEO/Designee will complete ongoing weekly audit to verify Daily DHS posting matches the staff assigned and labor for that day and that the DHS form is fully completed to include census, staff data and signature of the person attesting to the data each shift. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Resident #16's care plan will be updated to include addressing resident's anxiety, feelings of helplessness or hopelessness and withdrawal, lack of coping skills, thoughts of suicide, lability and concerns related to people controlling them. 2. CNO/Designee will complete baseline audit of other residents who are at risk for unmet behavioral and emotional needs to verify their care plan has been updated to reflect specific person-centered behavioral/emotional needs and interventions. 3. CNO/Designee provided further education to SSD and RCM's regarding providing necessary behavioral health care and services and develop a comprehensive, person-centered behavioral/emotional needs care plan. 4. CNO/Designee will complete ongoing audits of other residents who are newly admitted and/or newly present with behaviors to verify their care plan has been updated to reflect specific person-centered behavioral/emotional needs and interventions.

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.

1. Resident #35 will receive Rivaroxaban as ordered. 2. CNO/Designee will complete baseline audit of last 7 days of other residents who are prescribed anticoagulant medication to verify they received the medication as ordered by provider. 3. CNO/Designee provided further education to LN's and CMA's on Medication Administration policies to include specific focus on anticoagulant medications. 4. CNO/Designee will complete ongoing audit of other residents who are prescribed anticoagulant medication to verify they received the medication as ordered by provider. 1:1 remediation will be done for any negative findings. Audits will be conducted bi-weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. The dishwasher will be tested to verify water is at proper temperature prior to washing dishware. 2. CEO/Designee will verify dishwasher is in working order and can meet required temperature for cleaning dishware. 3. CEO/Designee will provide education to Dietary manager on regulatory temps and verifying accurate temp tracking for the dishwasher. 4. Education provided to kitchen staff by Dietary Manager/Designee on required dishwasher temp prior to washing dishware and updating temp log daily. 5. CEO/Designee will audit temperature log to verify dishwasher temperatures reached the proper temperature prior to washing dishes. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Resident #16 and #304 had incorrect verbiage in their Arbitration Agreements stating they had 10 days to rescind the agreement and this has been addressed and corrected in both residents Arbitration Agreements and residents were informed and verified to understand the binding arbitration agreement. This was corrected in Secora's Arbitration Agreement form. 2. CEO/Designee will complete baseline audit of other residents who signed Arbitration Agreements noting 10 days to rescind and were educated on the 30 days to rescind period for their Arbitration Agreements. 3. CEO/Designee provided education to Social Services manager on how many days a resident has to rescind Arbitration Agreement. 4. CEO/Designee will complete ongoing audits weekly of newly admitted residents to verify if they chose to sign the arbitration agreement that it reflects 30 days to rescind period and that they understood the agreement. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Staff #9 and staff #15 have been reviewed to ensure the required ongoing training for 12 hours annually has been initiated and is ongoing. 2. CNO/Designee will complete baseline audit of other CNAs who have been employed for 12 months or more to verify they have completed 12 hours of in-service training. 3. CNO/Designee provided education with CNA's on completing their annual requirement of 12 hours of training via Relias and in-house trainings. CNO/Designee provided training to Human Resources Director on tracking of CNA's training hours annually and to notify CEO or CNO if staff fail to have all required education. 4. CNO/Designee will complete ongoing audit of other CNAs who are employed by the facility to verify they complete the monthly in-service training requirements each month. Audits will be conducted monthly for 3 months. Audit trends will be reported to facility QAPI for review and further recommendations.

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.

1. Staff #15 and #21 completed an updated background check. 2. The CEO/Designee will complete a baseline audit of current staff to verify background checks have been completed within the required timeframe. Identified inconsistencies will be addressed. 3. CEO/Designee provided education to HR director on tracking and keeping background checks up to date. 4. CEO/Designee will complete ongoing audits to verify facility staff have background checks completed within the required timeframe. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI for review and further recommendations.

********************************************* OAR 411-086-0260-Pharmaceutical Services Refer to F554 ********************************************* OAR 411-086-0040-Admission of Residents (Advance Directives) Refer to F578 ********************************************** OAR 411-087-0100-Physical Environment: Generally Refer to F584 ********************************************* OAR 411-086-0110-Nursing Services: Resident Care Refer to F677 ********************************************** OAR 411-086-0230-Activity Services Refer to F679 ********************************************* OAR 411-086-0140-Nursing Services: Problem Resolution and Preventive Care Refer to F686 ********************************************** OAR 411-086-0310-Employee Orientation and In-Service Training Refer to F730 ********************************************* OAR 411-086-0100-Nursing Services: Staffing Refer to F732 ********************************************** OAR 411-086-0240-Social Services Refer to F740 ********************************************** OAR 411-086-0110-Nursing Services: Resident Care Refer to F760 ********************************************* OAR 411-086-0250-Dietary Services Refer to F812 ********************************************** OAR 411-086-0110-Administrator Refer to F847 ********************************************* OAR 411-086-0310-Employee Orientation and In-Service Training Refer to F947 **********************************************

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.

How the nursing home will correct the deficiency as it relates to the resident: The resident left facility AMA How the nursing home will act to protect residents in similar situations: Audit of all new admits from the last 30 days completed to ensure no missed administrations of pain medication. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur: RCM to call pharmacy and receive a pull code for all narcotics when new admissions arrives, if RCM is unavailable Staff development will pull, CNO to ensure pull code was received. How the nursing home plans to monitor its performance to make sure that solutions are sustained: New admissions will be audited by the Chief Nursing Officer weekly for 4 weeks, monthly for 3 months, and periodically thereafter to validate thorough investigations of incidents. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement program to ensure compliance

********************************************* OAR 411-085-0310-Resident's Rights: Generally (physical restraints) Refer to F604 ********************************************* OAR 411-086-0110-Resident Care Refer to F697 **********************************************

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.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/15/2024 and 01/21/2024, 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.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/13/2023 and 11/19/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation and interview it was determined the facility failed to ensure resident needs and preferences related to lighting were accommodated for 3 of 3 sampled residents (#s 4, 10, and 13) reviewed for accommodation of needs. This placed residents at risk for lack of access to lighting and an unhomelike environment. Findings include: Resident 4 was admitted to the facility in 2023 with diagnosis including severe protein-calorie malnutrition. Resident 10 was admitted to the facility in 2018 with diagnosis including cerebrovascular (condition which affects the blood vessels in the brain) disease. Resident 13 was admitted to the facility in 2023 with diagnosis including severe protein-calorie malnutrition. On 11/13/23 multiple plastic bags were observed tied together in a chain which extended and hung from the cords of Residents 4, 10 and 13's overbed lights. On 11/13/23 at 10:55 AM Resident 4 stated her/his overbed light cord was too short and she/he could not independently use the light without the extension the plastic bags provided. On 11/14/23 at 1:00 PM Staff 7 (Maintenance Director) stated he expected staff to report to him when overbed light cords were too short. Staff 7 observed the plastic bags tied to the cords and stated the cords needed the proper extensions on them. On 11/14/23 at 1:39 PM Staff 1 (Administrator) acknowledged the findings and stated trash bags were not the solution to extend overbed light cords.

F-558-Reasonable Accommodations Needs/Preferences How the nursing home will correct the deficiency as it relates to the resident. On 11/14/2023, Resident 4, 10, and 13 overhead bed light cords had bags removed and longer appropriate cords were attached. How the nursing home will act to protect residents in similar situations. On or before 12/25/2023, 100% of facility overhead bed lights were reviewed and any issues were corrected. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. Maintenance staff was educated to ensure overhead bed light cords are long enough for resident use. Nursing Staff was educated to place maintenance request when overhead bed light cords are too short and/or require modification by maintenance staff. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Overhead bed lights will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure resident needs are met. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to provide a menu as requested for 1 of 3 sampled residents (#153) reviewed for choices. This placed residents at risk for decreased food intake, weight loss and lack of choices being honored. Findings include: Resident 153 was admitted to the facility in 2023 with diagnoses including fracture of the spine. Resident 153's 11/9/23 Mini Nutritional Evaluation indicated the resident was at risk for nutritional decline related to impaired mobility and chronic pain. Resident 153's 11/9/23 ADL Self Care Performance Deficit and At Risk for Nutritional Decline Care Plans revealed the following interventions: -Ambulation: Distant supervision with ambulation with the assistance of one person. Devices used: front wheel walker, back brace and verbal cueing. -Locomotion: substantial/maximum assistance for wheelchair mobility with the assistance of one staff. Device used: wheelchair with footrests. -Provide feeding/dining assistance as needed. -The resident received a regular diet with a regular texture and thin liquids. On 11/13/23 at 10:24 AM Resident 153 stated she/he asked the facility's dietary manager for a menu approximately three days ago and made the same request to various other staff but was "still waiting" to receive a menu. Resident 153 further stated without a menu she/he had no idea what she/he was going to be served for each meal and was unaware of any available meal alternatives. On 11/15/23 at 9:01 AM Staff 15 (CNA) stated CNAs were supposed to provide residents with a paper menu upon request and Resident 153 had requested a menu. Staff 15 stated the chef was supposed to place the paper menu for the day, which also listed available meal alternatives, in a plastic wall pocket in both resident hallways. At this time, Staff 15 pointed to the empty wall pocket in Resident 153's hall and stated "the kitchen forgot today." On 11/15/23 at 10:06 AM Staff 16 (LPN) stated a former Activity Assistant delivered weekly menus to residents on the weekends but this person no longer worked at the facility so the weekly menus were not being delivered to residents. Staff 16 further stated CNAs were supposed to help deliver menus to residents, but because the facility used a lot of agency staff, menus were not being delivered. On 11/15/23 at 10:47 AM Staff 11 (Agency CNA), on 11/15/23 at 4:00 PM, Staff 18 (CNA) and on 11/16/23 at 8:15 AM Staff 19 (Agency CNA) stated they had not been instructed to deliver menus to residents or to offer residents meal alternatives. On 11/15/23 at 3:15 PM Staff 17 (Dietary Manager) stated the only menu posted in the facility was located outside of the kitchen, which included the meals for the week along with available alternatives. Staff 17 stated he provided Resident 153 with a menu a few days prior upon the resident's request. Staff 17 further stated he did not inquire if Resident 153 wanted to receive ongoing menus as the facility "typically did not do that" but informed the resident the menu was posted outside of the kitchen because the resident was "mobile." On 11/15/23 at 3:51 PM Resident 153 stated she met with Staff 17 a few days earlier when she/he requested a menu. Resident 153 stated Staff 17 said he would bring her/him a menu but never did. Resident 153 stated she/he was never informed a menu was posted outside of the kitchen, and stated, "even if I was, why the hell would I want to walk all the way over there?" Resident 153 further stated she/he "would probably get in trouble if [she/he] walked all the way over there because [she/he] didn't think [she/he was] allowed to walk on [her/his] own." On 11/16/23 at 11:15 AM Staff 1 (Administrator) acknowledged the findings and stated the resident should have been provided with a menu upon her/his request.

F561-Self-Determination How the nursing home will correct the deficiency as it relates to the resident. Resident #153 was provided a menu on 11/16/2023. Resident #153 no longer resides in the facility. How the nursing home will act to protect residents in similar situations. One or before 12/25/2023, residents are provided a copy of the weekly menu at least once per week. The menu is delivered with a meal at least once per week. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Dietary Manager will be educated on the need to deliver a weekly menu to every resident at least once per week and provide one upon request. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Providing Menus will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure menus are being provided. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation and interview it was determined the facility failed to provide a private space for resident council meetings for 1 of 1 resident council group reviewed. This placed the residents at risk for unaddressed concerns and needs related to resident care and quality of life. Findings include: On 11/15/23 at 11:30 AM the resident council group meeting was held in the facility dining room with state surveyors. The facility dining room did not provide privacy as the dining room was open to the lobby and living room. There were no doors or barriers to provide privacy. During the meeting, staff walked into the dining room to administer medications to one of the residents, one staff sat in the corner on her computer, the hallways were loud with staff and residents walking past the dining room and staff were vacuuming nearby while residents were speaking making it difficult to hear them. On 11/15/23 at 2:14 PM Resident 2 stated there were privacy concerns with resident council meetings. She/he confirmed the resident council meetings were held in the facility dining room. There were no private areas in the facility to hold the resident council meetings. Resident 2 expressed some residents were afraid to speak out in meetings due to the lack of privacy. The resident also stated the facility had not implemented any measures to make the meetings more private. On 11/15/23 at 2:20 PM Resident 14 confirmed the resident council meetings were held in the facility dining room. She/he stated the dining room was open and did not feel very comfortable voicing concerns. The resident expressed this was the residents' home and there was no privacy for the meetings. She/he stated there have been employee arguments, outside noises, vacuuming, guests coming in and out of the facility, residents walked to and from staff offices and staff walked into the meetings to administer medications to residents during the resident council meeting. On 11/16/23 at 9:09 AM Staff 9 (Activities Director) stated she was not aware of any of any privacy concerns. Staff 9 confirmed the resident council meetings were held in an open space and it was the only place the meetings could be held. When asked about any measures to ensure privacy during these meetings, Staff 9 indicated there had not been any other privacy measures implemented. On 11/16/23 at 9:15 AM Staff 1 (Administrator) stated he was unaware of the issues regarding privacy and acknowledged no other privacy measures have been put into place.

F565-Resident/ Family Group and Response How the nursing home will correct the deficiency as it relates to the resident. The facility will ensure that Resident Council meetings are provided a barrier to provide privacy from individuals not involved in the meeting. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Activities Director will be provided education that Resident Council meetings shall be provided privacy using a barrier, ensuring privacy from individuals not involved in the meeting. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Resident Council privacy will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure resident council privacy. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation and interview it was determined the facility failed to post notice of the availability of the previous year's survey results in areas of the facility which were prominent for 1 of 1 facility reviewed for required postings. This placed residents and visitors at risk for not being informed of the facility's survey history. Findings include: Observations on 11/13/23 revealed the state survey history binder was located on the wall outside of the nurses' station across from the therapy department near the North hall. There were no postings throughout the facility which identified the location or availability of the state survey binder. On 11/15/23 at 11:30 AM during the resident council group meeting all seven resident attendees indicated they were unaware of where to access a copy of the previous year's survey results in the facility or postings to direct residents where to locate this information. On 11/16/23 at 9:15 AM Staff 1 (Administrator) stated the survey results were located next to the nurse's station in a public location. He acknowledged there were no postings to notify residents or visitors as to where the state survey results binder was located.

F577- Right to Survey Results How the nursing home will correct the deficiency as it relates to the resident. On 11/16/2023, two signs were posted on each side of the building providing instruction on where to find the Survey Binder. How the nursing home will act to protect residents in similar situations. On 11/16/2023, two signs were posted on each side of the building providing instruction on where to find the Survey Binder. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Nursing Home Administrator shall review and be educated on the elements related to Survey Results sign posting requirements. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Survey Results Binder will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure survey results binder signs exist. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to assist residents with formulating an advance directive for 3 of 3 sampled residents (#s 12, 27 and 304) reviewed for advance directive. This placed residents at risk of not having their healthcare wishes followed. Findings include: 1. Resident 12 was admitted to the facility in 2023 with diagnoses including diabetes. Resident 12's Advance Directive Review dated 4/21/23 indicated the resident wanted assistance formulating an advance directive plan. A review of Resident 12's clinical record revealed no advance directive on file. On 11/14/23 at 1:47 PM Staff 10 (Social Services Director) stated she had not followed up with the resident to assist her/him with formulating an advance directive and the resident had not completed an advance directive. 2. Resident 27 was admitted to the facility in 2020 with diagnoses including depression. Resident 27's Advance Directive Review dated 12/20/22 indicated the resident wanted assistance formulating an advance directive plan. A review of Resident 27's clinical record revealed no advance directive on file. On 11/14/23 at 1:47 PM Staff 10 (Social Services Director) stated she had not followed up with the resident to assist her/him with formulating an advance directive and the resident had not completed an advance directive. 3. Resident 304 was admitted to the facility in 2023 with diagnoses including infection. Resident 304's Advance Directive Review dated 11/23/23 indicated the resident wanted assistance formulating an advance directive plan. A review of Resident 304's clinical record revealed no advance directive on file. On 11/14/23 at 1:47 PM Staff 10 (Social Services Director) stated she had not followed up with the resident to assist her/him with formulating an advance directive and the resident had not completed an advance directive.

F578- Request /Refuse /Discontinue Treatment; Advance Directive How the nursing home will correct the deficiency as it relates to the resident. Previous investigations for Resident #1 were reviewed. Resident #1 no longer resides in the facility. Advanced Directives were offered to all residents whom did not have one on file. How the nursing home will act to protect residents in similar situations. Social Services completed a Baseline audit on all admissions for the last 30 days to ensure all residents that have requested advance directives have been offered advance directive assistance. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/12/23, the Interdisciplinary Team was educated by the Chief Executive Officer and the Chief Nursing Officer and/or designee on the process of SS or designee to offer advance directive assistance within 72 hours (about 3 days) of admission evidence of re-education as indicated, and review of patterns/potential other residents at risk. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Advance Directive requests will be audited by the Chief Nursing Officer and/or designee , weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure advanced directives are being requested. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: December 25th,2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation and interview it was determined the facility failed to ensure a clean and homelike environment for 1 of 1 facility and for 1 of 1 sampled resident (#26) reviewed for homelike environment and clean wheelchairs. This placed residents at risk for adverse health conditions and an unclean environment. Findings include: 1. On 11/15/23 at 9:29 AM to 10:06 AM the floor vents in the north hallway were observed with a thick layer of dust on the vent covers. On 11/15/23 at 1:40 PM the floor vents in the north hallway were observed with a thick layer of dust on the vent covers. On 11/15/23 at 10:07 AM Staff 22 (Housekeeping) acknowledged the floor vents were dirty and housekeeping was not responsible to clean them. Staff 22 stated the facility did not have a housekeeping manager. On 11/15/23 at 10:11 AM Staff 1 (Administrator) acknowledged the facility did not have a housekeeping manager. Staff 1 confirmed the floor vents were dirty with a thick layer of dust and needed to be cleaned. 2. Resident 26 was admitted to the facility in 2022 with a diagnoses including psoriasis (condition in which skin cells build up and form scales and itchy dry patches). On 11/13/23 at 12:24 PM Resident 26 stated she/he had psoriasis which caused her/him to shed a lot of skin flakes. Resident 26 expressed concern for the cleanliness of her/his wheelchair due to the skin flakes. Resident 26 stated her/his wheelchair was scheduled to be washed on her/his scheduled shower days, which were Tuesdays and Fridays. Resident 26's wheelchair was observed with an abundance of white flaky particles which coated many parts of her/his wheelchair. A sign was observed on her/his closet door with large lettering of "Shower days Tuesdays and Fridays Eve." On 11/15/23 at 9:27 AM Resident 26's wheelchair was observed with an abundance of white flaky particles which covered many parts of her/his wheelchair. On 11/15/23 at 9:32 AM Staff 21 (CNA) stated all resident wheelchairs or assistive devices were expected to be washed or wiped down on the resident's shower days. On 11/15/23 at 9:34 AM Staff 2 (DNS) stated Resident 26 was expected to get her/his wheelchair wiped down as cleaned on scheduled shower days on Tuesdays and Fridays. Staff 2 observed Resident 26's wheelchair and confirmed it did not appear clean. , 3. Observations of the facility's general environment and residents' rooms from 11/13/23 through 11/17/23 identified the following issues: - Room 7A had a light cover missing above the resident's bed on the wall. - Damaged flooring on the south hall near the courtyard entryway. - Missing endcap on the wall guard outside Room 14. - Room 16 had a torn privacy curtain. - Room 18C had a broken overbed light and the cord was missing. - The wall guard on the north hall near room 32 had a gap that was sharp to the touch. - A light cover in the hall near the dining room was cracked. On 11/17/23 at 9:33 AM Staff 1 (Administrator) stated the identified issues did not meet the facility standards or expectations.

F584-Safe/Clean/ Comfortable/ Homelike Envirooment How the nursing home will correct the deficiency as it relates to the resident. On or before 12/25/2023, facility will correct the issues identified during the Annual Survey related to F584. How the nursing home will act to protect residents in similar situations. On or before 12/25/2023, the facility will conduct a facility wide audit, identify any items in contrast with F584, and begin the process of resolving any issues. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Director of Maintenance and Director of Housekeeping will both be provided education on F584 and the need to ensure the facility provides a clean and homelike environment. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Maintenance Requests will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure maintenance requests are placed and completed. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to implement its abuse policy and procedure to screen new hires for 5 of 5 staff (#s 4, 5, 6, 7, and 8) reviewed for background checks. This placed residents at risk for abuse. Findings include: The facility's Abuse Policy revised 7/23/19 indicated seven key components which included the screening of potential employees for history of abuse. On 11/14/23 a random sample of five newly hired staff members was reviewed for background and reference checks with Staff 3 (Human Resources). There was no evidence criminal history checks were completed for Staff 4 (CNA), Staff 5 (CNA), Staff 6 (LPN), Staff 7 (Maintenance Manager) and Staff 8 (Maintenance Assistant) had reference checks conducted prior to their employment at the facility. On 11/14/23 at 1:42 PM Staff 3 (Human resources) acknowledged the criminal history checks for Staff 5 and Staff 6 were not completed.

F607-Develop/Implement Abuse/Neglect Policies How the nursing home will correct the deficiency as it relates to the resident. On or before 12/25/2023, the facility completed criminal history checks for Staff 5 and Staff 6. The facility also audited 100% of employee records to ensure criminal history checks were completed. On or before 12/25/2023, the facility ensured every employee has at least two reference checks. How the nursing home will act to protect residents in similar situations. On or before 12/25/2023, the facility completed criminal history checks for Staff 5 and Staff 6. The facility also audited 100% of employee records to ensure criminal history checks were completed. On or before 12/25/2023, the facility ensured every employee has at least two reference checks. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Director of Human Resources was provided education on the need to complete criminal history checks and reference checks prior to the start of any employee. How the nursing home plans to monitor its performance to make sure that solutions are sustained. On or before 12/25/2023, the facility completed criminal history checks for Staff 5 and Staff 6. The facility also audited 100% of employee records to ensure criminal history checks were completed. On or before 12/25/2023, the facility ensured every employee has at least two reference checks. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to accurately assess weight gain and vision for 2 of 3 sampled residents (#s 8 and 18) reviewed for nutrition and sensory communication. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: 1. Resident 8 admitted to the facility in 2023 with diagnoses of Multiple Sclerosis (disease of the nerve cells). Resident 8's 5/12/23 Quarterly MDS indicated she/he weighed 119 lb (pounds). Resident 8's 11/1/23 Quarterly MDS indicated she/he experienced no weight gain over the past six months. The MDS indicated she/he weighed 142 lb. Resident 8's weight documentation revealed the following: -5/17/23 at 122 lb. -10/12/23 at 144.5 lb. -11/9/23 at 142 lb. On 11/16/23 at 2:13 PM Staff 20 (MDS Coordinator) confirmed the 5/12/23 MDS and 11/1/23 MDS weights and stated Resident 8 should have been assessed for a weight gain. On 11/16/23 at 2:28 PM Staff 2 (DNS) acknowledged Resident 8's weight were not assessed correctly on the 11/1/23 MDS. , 2. Resident 18 was admitted to the facility in 2019 with diagnoses including stroke. Resident 18's 2/7/22 Ocular (vision) Progress Notes revealed the following: -The resident appeared to have vision problems per caregiver and could not answer questions about self. -The resident had a left eye cataract (cloudy area in the lens of the eye). Resident 18's 10/6/23 Annual MDS revealed the resident's native language was Russian, the resident had no speech, experienced short and long term memory problems, was severely impaired for decision making and had adequate vision. Resident 18's 10/14/23 Clinical Evaluation completed by Staff 2 (DNS) indicated Staff 2 was unable to determine if the resident was visually impaired. Resident 18's 10/16/23 Visual Function CAA indicated the resident had cataracts, glaucoma (eye condition which damages the optic nerve) or macular degeneration (disease affecting the retina of the eye) and experienced impaired visual function related to poor visual acuity. On 11/15/23 at 2:20 PM Staff 20 (MDS Coordinator) stated she was responsible for completing the vision section on MDS assessments. Staff 20 stated she did not complete vision assessments for residents but used the information from the resident's most recent Clinical Evaluation to assist her with determining a resident's visual abilities on the MDS. Staff 20 reviewed Resident 18's most recent Clinical Evaluation and Annual MDS and stated her coding of adequate vision did not match the findings of the Clinical Evaluation. On 11/15/23 at 2:45 PM Staff 2 acknowledged the findings and confirmed the coding of adequate vision for Resident 18 was incorrect.

F641- Accuracy of Assessments How the nursing home will correct the deficiency as it relates to the resident. MDS was corrected for resident 8 and 18 on 11/16/2023 How the nursing home will act to protect residents in similar situations. A baseline audit will be completed for all MDS completed from 11/18 to present to ensure that all MDS were accurate Measures the nursing home will take or systems it will alter to ensure that the problem does not recur On or before December 25th, the Interdisciplinary Team will be educated by the Chief Nursing Offer to ensure that all evaluations match the MDS. How the nursing home plans to monitor its performance to make sure that solutions are sustained. The Chief Nursing Officer or Designee will audit all MDS and evaluations for accuracy weekly for 4 weeks, monthly for 3 months, and periodically thereafter to validate accurate assessments. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: December 25th, 2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to implement a person-centered care plan for 1 of 1 sampled resident (#40) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 40 admitted to the facility in 2023 with diagnoses including intercranial (head) injury. Resident 40's 11/13/23 Physician Order directed staff to use a bedside impact absorbing floor mat next to the resident's bed while she/he was in bed. The 11/13/23 Care Plan for Resident 40 directed staff to provide a bedside impact absorbing floor mat next to Resident 40's bed while she/he was in bed. On 11/13/23 at 11:21 AM Resident 40 was observed in bed with the fall mat folded and placed next to her/his bedside table away from the bedside. On 11/15/23 at 2:20 PM and 11/16/23 at 10:40 AM Resident 40 was observed in bed without a fall mat on the floor at the bedside. On 11/17/23 Staff 14 (CNA) stated she obtained information to care for residents in the resident's care plan. She stated the care plan was expected to be followed for resident care. On 11/17/23 at 9:33 AM Staff 2 (DNS) stated she expected Resident 40's care plan to be followed and a bedside impacting floor mat was care planned to be in place on the floor while Resident 40 was in bed.

F656- Implement comprehensive Care Plan How the nursing home will correct the deficiency as it relates to the resident. The fall mat for resident 40 was placed next to bed as soon as this DNS was notified How the nursing home will act to protect residents in similar situations. The Interdisciplinary Team reviewed current residents' for CarePlan implementation, All Kardex CarePlan tasks were being implemented appropriately. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before December25th 2023, the Interdisciplinary Team will be educated by the Chief Executive Officer. and the Chief Nursing Officer and/or designee that all CarePlan task are to be followed by staff How the nursing home plans to monitor its performance to make sure that solutions are sustained. Careplan task will be audited by the Chief Nursing Officer and/or designee weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure person centered care plans. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: December 25th 2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to ensure comprehensive, person-centered care plans were revised for 2 of 3 sampled residents (#s 13 and 18) reviewed for nutrition, position and mobility. This placed residents at risk for unmet care needs. Findings include: The facility's 10/2022 Care Plan Policy indicated the resident care plan was reviewed after each assessment except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. 1. Resident 13 was admitted to the facility in 2023 with diagnoses including severe protein-calorie malnutrition and epilepsy (seizure disorder). A 6/13/23 Admission MDS and associated CAAs revealed Resident 13 was cognitively impaired and for staff to provide one-to-one feeding and dining assistance as needed. A Care Plan initiated on 6/19/23 revealed the resident was at risk for nutritional decline and required one-to-one supervision with meals. On 11/14/23 at 12:57 PM Resident 13 was observed in bed with her/his lunch tray on the overbed table. No staff were in the room with the resident. On 11/15/23 at 8:45 AM Resident 13 was observed in bed with her/his breakfast tray on the overbed table. No staff were in the room with the resident. On 11/15/23 at 9:31 AM Staff 11 (CNA) stated Resident 13 was independent with her/his meals and did not require staff supervision. On 11/15/23 at 10:01 AM Staff 2 (DNS) acknowledged the resident no longer required one-to-one supervision bud did require distant supervision due to Resident 13's hands trembling. , 2. Resident 18 was admitted to the facility in 2019 with diagnoses including stroke. Resident 18's 10/6/23 Annual MDS revealed the resident experienced short and long term memory problems, was severely impaired for decision making and had a right hand contracture. Resident 18's 10/26/23 Care Plan revealed the following: -The resident used a hand splint related to a right hand contracture. -Resting hand splint on right hand to prevent increased contractures. Encourage the resident to wear the splint for two to three hours or as tolerated BID. -Staff were to put the hand brace on during the day and take it off at HS. On 11/15/23 at 8:57 AM Staff 15 (CNA) stated Resident 18 wore her/his right hand splint for two to three hours each day. On 11/15/23 at 11:16 AM Staff 4 (CNA) stated Resident 18 wore her/his right hand splint during the day and it was to be removed in the evening. Staff 4 further stated she found this information in the resident's care plan. On 11/16/23 at 9:16 AM Staff 2 (DNS) acknowledged Resident 18's care plan was in need of revision and stated the intervention related to staff putting the brace on during the day and removing at night was inaccurate.

F657- CarePlan Timing and Revision How the nursing home will correct the deficiency as it relates to the resident. CarePlan revision was completed for resident 13 and 18 on 11/17/2023 How the nursing home will act to protect residents in similar situations. The Interdisciplinary Team reviewed current residents; the Baseline audit was completed with no further errors identified. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before December 25th, 2023, the Interdisciplinary Team will be educated by the Chief Executive Officer and the Chief Nursing Officer and/or designee that CarePlan's are to be updated when residents have a change in ADL, Activities or O=Change of Condition How the nursing home plans to monitor its performance to make sure that solutions are sustained. Audits by the Chief Nursing Officer and/or designee weekly for 4 weeks, monthly for 3 months, and periodically thereafter to validate care plans. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: December 25th, 2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to ensure discharge planning was developed and implemented for 2 of 5 sampled residents (#s 203 and 303) reviewed for discharge planning. This placed residents at risk for unmet care needs. Findings include: 1. Resident 303 was admitted to the facility in 2023 with diagnoses including stroke. Resident 303's Progress Notes dated 4/14/23 revealed the resident was discharged from the facility. A review of Resident 303's clinical record revealed no indication the facility developed and documented a discharge plan or discussed the discharge plan with the resident and the resident's representative. On 11/15/23 at 12:35 PM and 11/16/23 at 9:50 AM Staff 1 (Administrator) and Staff 10 (Social Services Director) confirmed there was no discharge plan in the resident's clinical record. Staff 1 stated his expectation was for discharge planning to begin within 72 hours of a resident's admission to the facility. Staff 1 stated he would have liked better documentation of Resident 303's discharge plan. , 2. Resident 203 was admitted to the facility in 2023 with diagnoses including acute respiratory failure. Resident 203 was discharged from the facility on 8/3/23. Resident 203's 7/16/23 Care Plan for discharge planning indicated a referral for home health was to be ordered. On 11/15/23 at 4:14 PM Witness 1 (Home Health Agency) confirmed home health orders were received on 8/9/23 (six days after the resident was discharged from the facility). On 11/16/23 at 9:20 AM Staff 10 (RNCM) stated Resident 203 had home health orders and it was her expectation home health orders would be completed and a referral made to the home health agency at the time of discharge. On 11/16/23 at 12:49 PM Staff 10 (Social Services Director) acknowledged Resident 203's home health needs were ordered late. On 11/16/23 at 2:11 PM Staff 2 (DNS) stated she expected home health to be setup in a timely manner so services were provided at the time of discharge.

F660- Discharge Planning How the nursing home will correct the deficiency as it relates to the resident. Residents 203 and 303 are discharged. How the nursing home will act to protect residents in similar situations. Baseline audit will be completed by SS for all current residents to ensure discharge plan is current. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before December 25th, 2023, the Interdisciplinary Team will be educated by the Chief Executive Officer and the Chief Nursing Officer and/or designee that discharge planning is to be started within 72 hours of admission. Discharge process is to be documented in the medical record. DME will be ordered in a timely manner. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Audits will be completed by the Social Services and/or designee with oversight from the Chief Nursing Officer weekly for 4 weeks, monthly for 3 months, and periodically thereafter to validate compliance. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: December 25th, 2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 5 sampled residents (#206) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 206 was admitted to the facility in 2023 with diagnoses including metabolic encephalopathy (chemical imbalance affecting the brain). The resident was discharged from the facility on 8/2/23 on a resident initiated discharge. A review of Resident 206's medical record indicated there was no discharge summary documentation. On 11/16/23 at 2:12 PM Staff 2 (DNS) was not able to provide documentation of a discharge summary for Resident 206. Staff 2 stated it was her expectation for discharge summaries to be completed upon discharge.

F661- Discharge Summary How the nursing home will correct the deficiency as it relates to the resident. SS to complete discharge summary for resident 206 based off notes How the nursing home will act to protect residents in similar situations. The Interdisciplinary Team reviewed current residents from 11/18/2023 to present to ensure all residents that have discharged have signed discharge summaries Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before December 25th,2023, the Interdisciplinary Team will be educated by the Chief Executive Officer and the Chief Nursing Officer and/or designee on ensuring discharge summary is opened and information start to be added throughout the discharge process. Discharge summary is to be completed and signed by resident on discharge How the nursing home plans to monitor its performance to make sure that solutions are sustained. Audits will be completed by the Social Services and/or designee with oversight from the Chief Nursing Officer weekly for 4 weeks, monthly for 3 months, and periodically thereafter to validate compliance. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: December 25th, 2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to provide adequate grooming and toenail care for 2 of 5 sampled residents (#s 18 and 47) reviewed for ADLs. This placed residents at risk for unmet ADL needs. Findings include: 1. Resident 18 was admitted to the facility in 2019 with diagnoses including stroke. Resident 18's 10/6/23 Annual MDS revealed the resident had no speech, experienced short and long term memory problems, was severely impaired for decision making and was dependent upon staff for personal hygiene. Resident 18's 10/26/23 ADL Self Care Performance Deficit Care Plan indicated the resident required extensive assistance with personal hygiene. Observations conducted on 11/13/23 at 11:29 AM and on 11/14/23 at 11:24 AM revealed Resident 18 was in bed with white hairs approximately one inch in length on her/his chin. Resident 18 was unable to answer questions or converse about her/his personal hygiene preferences on either of these occasions. On 11/13/23 at 12:41 PM Witness 2 (Family Member) stated Resident 18 was no longer able to express her/his preferences but he felt the resident would want the hair on her/his chin removed. Witness 2 further stated he thought Resident 18 was cooperative with care, but even if she/he was not, he believed Resident 18 would want staff to "try and shave [the chin hair]." On 11/15/23 at 8:55 AM Staff 15 (CNA) stated one CNA at the facility was primarily responsible for shaving all residents because he was "so good at it." Staff 15 stated CNAs were supposed to report any resident refusals of shaving to the nurse. Staff 15 further stated she had experience shaving Resident 18 and the resident "liked it" and did not refuse shaving. On 11/15/23 at 9:58 AM Staff 16 (LPN) stated CNAs were supposed to provide shaving assistance on resident shower days, and if a resident refused, the nurse should be informed, the refusal should be documented and nurses were to follow up with the resident. Staff 16 stated she was not aware of any reports of Resident 18 refusing to be shaved. On 11/16/23 at 9:07 AM Staff 2 (DNS) stated the expectation was for residents to be shaved on their scheduled shower days and PRN. Staff 2 stated if a resident refused to be shaved, she would expect the nurse to be notified, and for those resident's who did not want to be shaved, a care plan put into place to reflect the resident's preference. Staff 2 stated she did not believe Resident 18 allowed staff to shave her/him but added it was dependent on the specific staff person who approached her/him. Staff 2 confirmed there was no documentation of Resident 18's shaving refusals or a care plan in place reflecting the resident's personal hygiene preferences. , 2. Resident 47 was admitted to the facility in 2023 with diagnoses including COPD (a disease which causes airflow blockage in the lungs). On 11/13/23 at 10:55 AM Resident 47 was observed with extremely long toenails with jagged edges. The resident stated she/he had been waiting for the podiatrist to look at her/his toenails. Resident 47's 11/2023 TAR indicated toenail care was provided on 11/4/23 and 11/11/23. On 11/14/23 at 2:00 PM Staff 2 (DNS) examined the resident's toenails. Staff 2 stated it did not look like nail care was provided.

F677- ADL Care Provided for Dependent Residents How the nursing home will correct the deficiency as it relates to the resident. RCM called Brother of Resident 18 to request electric razor so staff can safety shave resident. Resident 47 was offered podiatry and reviewed during clinical meeting. How the nursing home will act to protect residents in similar situations. Baseline audit was completed to ensure all residents that want to be shaved have been shaved and residents that prefer not to be shaved that CarePlan has been updated. Care Plans reviewed during morning clinical meeting. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before December 25th, 2023, staff will be educated by the Chief Executive Officer and the Chief Nursing Officer and/or designee on the new process , all ADL refusals are to be reported to the nurse and RCM for follow up and to attempt to establish a plan to prevent a recurrence, evidence of re-education as indicated, and review of patterns/potential other residents at risk. How the nursing home plans to monitor its performance to make sure that solutions are sustained. ADL refusals and care will be audited by the Chief Nursing Officer and/or designee weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure ADL documentation is completed appropriately. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: December 25th, 2023 The title of the person responsible to ensure correction: The Chief Nursing Officer is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 3 sampled residents (#18) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's Activity Programs Policy and Procedure dated 11/28/17 outlined the following: -The resident who was confined or choose to remain in his/her room was provided with in-room recreation programs in keeping with life-long interests. Staff assisted the resident with recreation programs that could be pursued independently. -For the resident who had withdrawn from previous activity interests/customary routines and isolated self in room/bed most of the day: a. Provide activities just before or after meal time and where the meal was served (out of the room). b. Provide in-room volunteer visits, music or videos of choice. c. Encourage volunteer-type work. d. Invite to special events with a trusted peer or family/friend. e. Engage in activities that give the resident a sense of value. f. Invite resident to participate on facility committees. g. Invite the resident outdoors. h. Involve in gross motor exercise (e.g., aerobics, light weight training) to increase energy and uplift mood. Resident 18 was admitted to the facility in 2019 with diagnoses including stroke. Resident 18's 10/6/23 Annual MDS revealed the resident's native language was Russian, the resident had no speech, experienced short and long term memory problems, was severely impaired for decision making and was dependent upon staff for all ADL care needs. The MDS also revealed the resident had the following activity preferences: -Listening to music. -Doing things with groups of people. -Participating in favorite activities. -Spending time outdoors. -Participating in religious activities or practices. Resident 18's 10/26/23 Activity Care Plan revealed the following interventions: -Assure the activities the resident attended were compatible with physical and mental capabilities. -Preferred activities: live entertainment, music programs, spiritual services and sensory groups. -When the resident declined to participate in organized activities, turn on television/music in room to provide sensory stimulation. No evidence was found in Resident 18's health record she/he was offered or participated in one-to-one visits, group music activities, outdoor activities or sensory activities from 10/17/23 through 11/13/23. Observations of Resident 18 on 11/13/23 from 10:00 AM to 3:12 PM revealed the resident was in bed with her/his eyes open at times and closed at others. No music was observed to play and the resident's television was off. Resident 18 was unable to answer questions or converse about her/his activity interests or preferences. On 11/13/23 at 12:41 PM Witness 2 (Family Member) stated Resident 18 enjoyed listening to classical music, being outside and around others. On 11/15/23 at 8:48 AM Staff 15 (CNA) stated Resident 18 enjoyed music, watching television, church and group activities. Staff 15 further stated the resident never complained about getting up out of bed and attending activities. On 11/15/23 at 11:10 AM Staff 4 (CNA) stated Resident 18 spent most of her/his time in bed and that the resident was nonverbal. Staff 4 stated the resident did not come out for group activities, go outside or attend religious services. Staff 4 further stated she "tried to turn on the television and open the blinds for something" but she "did not know what the resident want[ed] to watch and [the resident was] not able to tell you if [she/he] liked it or not." On 11/15/23 at 12:31 PM Staff 9 (Activity Director) stated she provided one-to-one visits for those residents who were more impaired, less cognitive or choose not to come out of their room and "[made] sure they [had] things that [were] important to them" such as a radio or television. Staff 9 stated her goal was to provide one-to-one visits at least weekly but she "sometimes [she] could not get to them weekly because all of the computer work." Staff 9 stated Resident 18 was appropriate for both one-to-one visits and sensory activities, during which she would hold the resident's hands, talk with the resident and play music. Staff 9 stated she had not attempted any additional sensory activities with Resident 18 outside of holding hands and playing music and had not been able to complete timely one-to-one visits for Resident 18. Staff 9 was informed of the observations of the resident in bed without the television or music on, and she stated CNAs usually turned on music when the resident was in her/his room and she "needed to work with CNAs more because [the resident] should at least have music on." Staff 9 confirmed the activity preferences from the 10/6/23 Annual MDS were accurate, but stated the resident no longer came out of her/his room for activities because she was told the resident was in pain. Staff 9 stated she had not offered to take the resident outside since the summer, the resident had not participated in spiritual sing alongs, an activity of known enjoyment, since the facility's Activity Assistant left about a month ago and she had not increased the frequency of her one-to-one visits with the resident since her/his out-of-room activity participation had declined over a month ago. On 11/16/23 at 10:52 AM Staff 1 (Administrator) stated residents who were cognitively impaired should receive "a lot of one-to-ones." Staff 1 acknowledged the findings and added the facility purchased an interactive sensory toy cat and a radio on 11/15/23 to "fill the [activity] gap" for Resident 18.

F679- Activities Meet Interest/ Needs each resident How the nursing home will correct the deficiency as it relates to the resident. On or before 12/25/2023, Resident 18 Activity Program was reviewed and amended to ensure that individualized and enriching activities occur moving forward. How the nursing home will act to protect residents in similar situations. On or before 12/25/2023, Director of Activities shall audit 100% of residents to ensure individualized activity plans are in place. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Director of Activities shall be educated on the need to ensure residents have individualized activity plans capable of meeting their needs. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Activities will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure activities are enriching and individualized. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation, interview and record review the facility failed to ensure safety hazards were not accessible for 1 of 2 halls reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 37 was admitted to the facility in 2023 with diagnoses including stroke. Resident 46 was admitted to the facility in 2023 with diagnoses including stroke. On 11/13/23 at 1:42 PM the resident bathroom and shower room to the right of room 27 was observed with an unlocked cabinet which contained four blue disposable razors, an unlabeled personal electric shaver and five bottles of cleaning chemicals. On 11/14/23 at 5:41 AM the resident bathroom and shower room to the right of room 27 was observed with an unlocked cabinet which contained two blue disposable razors, an unlabeled personal electric shaver, shampoo, hair conditioner, a purple deodorant stick and four bottles of cleaning chemicals. On 11/15/23 at 9:31 AM and 10:08 AM the resident bathroom and shower room to the right of room 27 was observed with an unlocked cabinet which contained an unlabeled personal electric shaver, shampoo, hair conditioner, a purple deodorant stick and three bottles of cleaning chemicals. On 11/15/23 at 10:04 AM Resident 46 was observed to walk near the open door to the resident bathroom to the right of room 27. At nearly the same time, Resident 37 was observed to self-propel her/himself into the resident bathroom. Resident 37 was alone and closed the door. On 11/15/23 at 10:22 PM Staff 1 (Administrator) confirmed the resident bathroom, to the right of room 27, cabinet was unlocked and contained cleaning chemicals, razors, and items which he did not expect to be accessible to residents. On 11/15/23 at 11:25 AM Staff 10 (Social Services Director) confirmed Resident 37 and Resident 46 experienced memory impairment.

F689-Free of Accidents Hazards/ Supervision How the nursing home will correct the deficiency as it relates to the resident. On or before 12/25/2023, a facility wide audit occurred in which all potential hazards were removed and/or mitigated, including the items identified during the Annual Survey. How the nursing home will act to protect residents in similar situations. On or before 12/25/2023, staff education was provided to ensure staff were educated on the need to ensure facility is safe and that residents do not have access to any items that may be harmful. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Interdisciplinary Team shall be educated on the need to ensure the facility is safe and that residents do not have access to any items that may be harmful. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Safety issues will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure safety issues are appropriately addressed. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to prevent complications of tube feeding for 1 of 1 sampled resident (#303) reviewed for tube feeding. This placed residents at risk for complications related to tube feeding. Findings include: Resident 303 was admitted to the facility in 2023 with diagnoses including stroke. Resident 303's Progress Notes dated 4/13/23 indicated the resident was bleeding profusely from her/his feeding tube site. Pressure was applied but the resident continued to bleed through the towels [used to apply pressure]. The resident's feeding tube was not completely out [dislodged from the resident's abdomen]. The resident was sent to the hospital. A review of Resident 303's clinical record revealed no indication the resident ever attempted to pull on the feeding tube. There was no explanation for the cause of the partially dislodged feeding tube and no indication a facility investigation was completed. No new interventions were developed to prevent a reoccurrence after the resident returned from from the hospital on 4/14/23. On 11/16/23 at 11:54 AM and 11/16/23 at 12:55 PM Staff 2 (DNS) stated Resident 303 had a history of pulling on the feeding tube during her/his admission to the facility and they discussed a binder (to protect the resident's feeding tube). Staff 2 verified there was no documentation in the resident's clinical record which indicated the resident pulled on the feeding tube or the use of a binder was discussed. Staff 2 stated no investigation was initiated to determine the cause of the resident's partially dislodged feeding tube.

F693-Tube Feeding Mgmt/Restore How the nursing home will correct the deficiency as it relates to the resident. Resident 18 was discharged from facility on day that she was readmitted. Resident no longer residents in facility. How the nursing home will act to protect residents in similar situations. The Interdisciplinary Team reviewed current residents from November 18th till current, Baseline audit completed no concerns noted. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On 11/30/2023, the Interdisciplinary Team was educated by the Chief Executive Officer and the Chief Nursing Officer and/or designee on new process for G-tube dislodgment documentation How the nursing home plans to monitor its performance to make sure that solutions are sustained. G-tube dislodgments will be audited by the Chief Nursing Officer and team, weekly for 4 weeks, monthly for 3 months, and periodically thereafter to G-Tube dislodgements are appropriately investigated and followed up on. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed:December 25th, 2023 The title of the person responsible to ensure correction: The Chief Nursing Officer is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to obtain a physician order and develop a care plan for the use of an oral suction machine for 1 of 1 sampled resident (#18) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include: Resident 18 was admitted to the facility in 2019 with diagnoses including stroke and dysphagia (difficulty swallowing). Resident 18's 10/6/23 Annual MDS revealed the resident had no speech, experienced short and long term memory problems, was severely impaired for decision making and had a feeding tube in place. On 11/13/23 at 10:00 AM and 2:34 PM Resident 18 was observed in bed and an oral suction machine at the resident's bedside. The canister of the oral suction machine contained a yellow liquid and was about a third of the way full. Resident 18 was unable to answer questions or converse about the oral suction machine on either of these occasions. No evidence was found in Resident 18's health record to indicate an order or a care plan for the oral suction machine was in place. On 11/14/23 at 11:18 AM Staff 16 (LPN) stated the facility utilized oral suction machines PRN for residents who were on tube feedings, such as Resident 18, and all residents who needed an oral suction machine should have a physician's order in place. Staff 16 reviewed Resident 18's health record and stated she/he did not have a physician's order for the use of the suction machine. On 11/14/23 at 11:33 AM Staff 2 (DNS) stated the facility used oral suction machines for residents who were on tube feedings as needed, which included Resident 18. Staff 2 stated she expected Resident 18 have a physician order for the use of the oral suction machine and confirmed one was not in place. Staff 2 further stated she thought interventions related to the use of the resident's oral suction machine were listed in the resident's tube feeding care plan and confirmed no such interventions were in place.

F695- Respiratory care and suctioning How the nursing home will correct the deficiency as it relates to the resident. Order was placed on 11/14/2023 order was placed for PRN suctioning by bedside, CarePlan was updated How the nursing home will act to protect residents in similar situations. The Chief Nursing Officer completed the audit of all NPO patients, all orders for suctioning and CarePlan were in place. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before December 25th, 2023, the Interdisciplinary Team will be educated by the Chief Executive Officer and the Chief Nursing Officer and/or designee on updated process that all ADl refusals are to be reported to nurse and RCM to ensure follow-up How the nursing home plans to monitor its performance to make sure that solutions are sustained. Audits will be completed by the Chief Nursing Officer and/or designee weekly for 4 weeks, monthly for 3 months, and periodically thereafter. Any concerns will be addressed promptly. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: December 25th, 2023 The title of the person responsible to ensure correction: The Chief Nursing Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to follow up timely on pharmacist recommendations for 1 of 5 sampled residents (#47) reviewed for unnecessary medications. Findings include: Resident 47 was admitted to the facility in 2023 with diagnoses including COPD (a disease which causes airflow blockage). Resident 47's 9/2023 MAR revealed the resident was administered the following medications: - Multivitamin (supplement) once daily in the AM. - Doxycycline (antibiotic) twice daily for 14 days with a start date of 9/23/23. - Magnesium Chloride (supplement) twice daily. A pharmacist's Note To Attending Physician/Prescriber dated 9/26/23 was sent to Resident 47's physician with a recommendation to consider holding the resident's mineral supplements while the resident was administered doxycycline due to a significant interaction. Resident 47's 9/2023 and 10/2023 TARs revealed no changes were made to Resident 47's multivitamin, doxycycline and magnesium chloride administration. A copy of the 9/26/23 Note To Attending Physician/Prescriber with a handwritten response from the physician was dated 10/17/23 indicated the resident's doxycycline administration ended on 10/7/23. On 11/17/23 at 9:22 AM Staff 2 (DNS) verified the physician did not respond to the 9/26/23 recommendation until 10/17/23. Staff 2 verified the facility could have modified the administration times of the resident's mineral supplements without waiting for the physician to respond.

F756- Drug regimen Review How the nursing home will correct the deficiency as it relates to the resident. Resident 47 was placed on alert to monitor for interactions from antibiotics, Residents antibiotics were completed 10/7.2023 How the nursing home will act to protect residents in similar situations. Chief Nursing officer to read all recommendations to physicians and change medications as my scope of practice allows. If regular physician is sick or unable to attend all recommendations will be faxed to medical director to be signed in a timely manner Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before December 25th, 2023, the Nursing Team will be educated by the Chief Nursing Officer and/or designee on ensuring that physician recommendations are signed within 30 days for all non-urgent matters and in a timely manner for all other recommendations, and review of patterns/potential other residents at risk. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Drug Regimen Review Audits by the Chief Nursing Officer and/or designee will be completed, monthly for 3 months, and periodically thereafter to validate to ensure drug regimen reviews are addressed and completed in a timely manner, according to regulation. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: December 25th,2023 The title of the person responsible to ensure correction: The Chief Nursing Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to complete reference checks for 5 of 5 facility staff (#s 4, 5, 6, 7, and 8) reviewed for background checks. This placed residents at risk for abuse. Findings include: On 11/14/23 a random sample of five newly hired staff members reviewed for background checks revealed no evidence Staff 4 (CNA), Staff 5 (CNA), Staff 6 (LPN), Staff 7 (Maintenance Manager) and Staff 8 (Maintenance Assistant) had reference checks conducted prior to their employment at the facility. On 11/14/23 at 1:42 PM Staff 3 (Director of Human Resources) stated he did not complete reference checks for the five staff members.

M141 – Employees Reference Checks and Verifications How the nursing home will correct the deficiency as it relates to the resident. On or before 12/25/2023, the facility ensured every employee has at least two reference checks. How the nursing home will act to protect residents in similar situations. On or before 12/25/2023, the facility ensured every employee has at least two reference checks. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Director of Human Resources was provided education on the need to complete reference checks prior to the start of any employee. How the nursing home plans to monitor its performance to make sure that solutions are sustained. On or before 12/25/2023, the facility ensured every employee has at least two reference checks. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to ensure criminal history checks were completed for 2 of 5 staff (#s 5 and 6) reviewed for background checks. This placed residents at risk for abuse. Findings include: A review of the facility's new hires from 7/2023 through 11/2023 revealed the following: - Staff 5 (CNA) was hired on 9/5/23. - Staff 6 (LPN ) was hired on 8/17/23. There was no evidence of completed criminal history check forms in Staff 5 and Staff 6's employee records. On 11/14/23 at 1:42 PM Staff 3 (Director of Human Resources) acknowledged the criminal history checks for Staff 5 and Staff 6 were not completed and both staff were actively working in the facility. Staff 3 stated the criminal history checks for Staff 5 and Staff 6 were incomplete as their fingerprints were not submitted.

M143  Employees: Criminal Records Check How the nursing home will correct the deficiency as it relates to the resident. On or before 12/25/2023, the facility completed criminal history checks for Staff 5 and Staff 6. The facility also audited 100% of employee records to ensure criminal history checks were completed. How the nursing home will act to protect residents in similar situations. On or before 12/25/2023, the facility completed criminal history checks for Staff 5 and Staff 6. The facility also audited 100% of employee records to ensure criminal history checks were completed. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Director of Human Resources was provided education on the need to complete criminal history check prior to the start of any employee. How the nursing home plans to monitor its performance to make sure that solutions are sustained. On or before 12/25/2023, the facility completed criminal history checks for Staff 5 and Staff 6. The facility also audited 100% of employee records to ensure criminal history checks were completed. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation, interview and record review the facility failed to provide meaningful activities at least six days a week for 1 of 3 sampled residents (#18) reviewed for activities. This placed residents at risk for decline in psychosocial well-being and diminished quality of life. Findings include: Resident 18 was admitted to the facility in 2019 with diagnoses including stroke. Resident 18's 10/6/23 Annual MDS revealed the resident's native language was Russian, the resident had no speech, experienced short and long term memory problems, was severely impaired for decision making and was dependent upon staff for all ADL care needs. The MDS also revealed the resident had the following activity preferences: -Listening to music. -Doing things with groups of people. -Participating in favorite activities. -Spending time outdoors. -Participating in religious activities or practices. Resident 18's 10/26/23 Activity Care Plan revealed the following interventions: -Assure the activities the resident attended were compatible with physical and mental capabilities. -Preferred activities: live entertainment, music programs, spiritual services and sensory groups. -When the resident declined to participate in organized activities, turn on television/music in room to provide sensory stimulation. No evidence was found in Resident 18's health record of any self-directed/independent activities, group activities or one-to-one visits were completed or provided on the following days: -10/21/23 (Saturday) -10/22/23 (Sunday) -10/28/23 (Saturday) -10/29/23 (Sunday) -11/4/23 (Saturday) -11/5/23 (Sunday) -11/11/23 (Saturday) -11/12/23 (Sunday) On 11/15/23 at 12:31 PM Staff 9 (Activity Director) stated the weekend activity person left about a month ago so she had been coming into the facility on Sundays to make sure a movie was turned on in the facility's common area. Outside of the Sunday group movie, Staff 9 stated she "tried to check in with everybody." Staff 9 stated she had an "activity box" that she kept at the nurses' station which contained paints, puzzles, coloring pages and craft kits. Staff 9 stated the activity box was available on the weekends to those residents who were able to independently participate in activities which Resident 18 was unable to do. On 11/16/23 at 10:52 AM Staff 1 (Administrator) acknowledged the findings and stated the facility was in the process of hiring someone to assist with weekend activities.

M248  Activity Services How the nursing home will correct the deficiency as it relates to the resident. On or before 12/25/2023, Resident 18 Activity Program was reviewed and amended to ensure that individualized and enriching activities occur moving forward. How the nursing home will act to protect residents in similar situations. On or before 12/25/2023, Director of Activities shall audit 100% of residents to ensure individualized activity plans are in place. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Director of Activities shall be educated on the need to ensure residents have individualized activity plans capable of meeting their needs. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Activities will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure individualized and enriching activities occur moving forward. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on observation, interview and record review it was determined the facility failed to post the current week's menu in a location that was accessible and conspicuous to residents for 1 of 1 sampled resident (#153) reviewed for choices. This placed residents at risk for not being aware of food choices. Findings include: Resident 153 was admitted to the facility in 2023 with diagnoses including fracture of the spine. Resident 153's 11/9/23 Mini Nutritional Evaluation indicated the resident was at risk for nutritional decline related to impaired mobility and chronic pain. On 11/13/23 at 10:24 AM and 11/15/23 at 3:51 PM Resident 153 stated she/he asked the facility's dietary manager for a menu approximately three days ago and made the same request of various other staff but was "still waiting" to receive a menu. Resident 153 stated without a menu she/he had no idea what she/he was going to be served for each meal and was unaware of any available meal alternatives. Resident 153 stated she/he was never informed a menu was posted outside of the kitchen, and stated, "even if I was, why the hell would I want to walk all the way over there?" Resident 153 further stated she/he "would probably get in trouble if [she/he] walked all the way over there because [she/he] didn't think [she/he was] allowed to walk on [her/his] own." Resident 153's room was located in the middle of the facility's south hall and the kitchen was located on the other side of the facility at the beginning of the north hall. On 11/15/23 at 3:10 PM the facility's weekly menu for 11/12/23 through 11/18/23 was observed posted on the wall to the left of the kitchen door. The weekly menu was printed on an 8.5 inch by 11 inch piece of paper and the menu was written in small print. An 8.5 inch by 11 inch piece of paper was posted on the kitchen door which listed the Soup of the Day for 11/15 and 11/16 in large print. The menu was not observed posted in the dining room or anywhere else in the facility. On 11/15/23 at 3:15 PM Staff 17 (Dietary Manager) stated the only menu posted for the facility was located outside of the kitchen. Staff 17 stated he provided Resident 153 with a menu a few days prior upon the resident's request. Staff 17 further stated he did not inquire if Resident 153 wanted to receive ongoing menus as the facility "typically did not do that" but informed the resident the menu was posted outside of the kitchen because the resident was "mobile." On 11/16/23 at 11:15 AM Staff 1 (Administrator) acknowledged the findings and stated the resident should have been provided with a menu upon her/his request. Staff 1 further stated he felt the posted menu was visible to residents but he could also "make it bigger."

M320  Dietary Services How the nursing home will correct the deficiency as it relates to the resident. Resident #153 was provided a menu on 11/16/2023. Resident #153 no longer resides in the facility. How the nursing home will act to protect residents in similar situations. One or before 12/25/2023, residents are provided a copy of the weekly menu at least once per week. The menu is delivered with a meal at least once per week. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the Dietary Manager will be educated on the need to deliver a weekly menu to every resident at least once per week and provide one upon request. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Providing Menus will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure menus are being provided weekly. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

Based on interview and record review it was determined the facility failed to allow household pet visits for 1 of 1 sampled resident (#16) reviewed for pain. This placed residents at risk for unmet emotional needs and a decrease in their quality of life. Findings include: Resident 16 was admitted to the facility in 9/2023 with diagnoses including anxiety with panic attacks. Resident 16's 9/21/23 Admission MDS indicated she/he was cognitively intact with a BIMS score of 15. On 11/15/23 at 10:36 AM Resident 16 stated she/he was told by facility staff and other residents her/his cat could visit her/him at the facility if the cat obtained a vet determination it was fee of disease and had proof all vaccines were current. Resident 16 stated she/he spent $300.00 to ensure her/his cat obtained the required vaccines and vet determination of disease free to visit the facility. On 11/15/23 at 11:00 AM Staff 1 (Administrator) provided a copy of the facility's Pets/Pet Therapy Policy and Procedure, dated 11/28/17. The policy included the following: -Facility notifies visitors who bring pets to the facility to follow guidelines intended to minimize risk of harm to others including potential allergic reactions and infections. -Animal should be in good health with up-to-date vaccination records, certified by a vet and the pet was free from disease. The handler was to provide documentation upon request. -If a resident animal was in the facility, the facility was to establish guidelines for regular cleaning such as dog and cat beds. On 11/15/23 at 11:17 AM Staff 1 stated Resident 16 could not have a cat visit the facility because cats are "dirty and infectious". On 11/15/23 at 2:25 PM Staff 1 provided an "updated" Pets/Pet Therapy Policy and Procedure dated 11/28/17. The policy included the following: -Establish guidelines for regular cleaning of dog and cat beds. -Feline pet visits were expressly prohibited. On 11/16/23 at 12:31 PM Staff 10 (Social Services Director) stated Resident 16 really loved and wanted her/his cat to visit her/him. Staff 10 stated she overheard Staff 1 talk to Resident 16 and told the resident "cats were too dangerous to visit because of their diseases." On 11/16/23 at 12:50 PM Witness 4 (Witness) stated multiple cats previously visited the facility multiple times prior to Staff 1 working at the facility. The cats usually came in a carrier and went to the resident's room for a visit. On 11/16/23 at 1:01 PM Resident 16's roommates, Resident 14 and Resident 32, stated they would enjoy Resident 16's cat to visit them in their room. On 11/17/23 at 9:38 AM Staff 1 confirmed Resident 16 admitted to the facility with the facility policy provided on 11/15/23. Staff 1 acknowledged Resident 16's cat obtained vaccinations and determined disease free from a vet. Staff 1 confirmed he would not allow any cat or feline to enter the facility to visit a resident who lived in the facility.

M445 - Pets How the nursing home will correct the deficiency as it relates to the resident. Resident #16 was provided a copy of the update facility policy related to pets. How the nursing home will act to protect residents in similar situations. One or before 12/25/2023, 100% of residents were provided an updated copy of the facility policy related to pets. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur. On or before 12/25/2023, the facility shall transition to a policy, in accordance with OAR 411-086-0340, that all pets must be approved by the facility administrator prior to entering the facility. Approval of pets is at the sole discretion of facility administrator. How the nursing home plans to monitor its performance to make sure that solutions are sustained. Pet Policy adherence will be audited by the Nursing Home Administrator weekly for 4 weeks, monthly for 3 months, and periodically thereafter to ensure pet policy adherence. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: 12/25/2023 The title of the person responsible to ensure correction: The Chief Executive Officer is accountable for compliance.

******************** 411-086-0360 Resident Furnishings, Equipment Refer to F-558 ******************** 411-085-0310 Residents ' Rights: Generally Refer to F-561 and F-565 ******************** 411-085-0030 Required Postings Refer to F-577 ******************** 411-086-0040 Admission of Residents Refer to F-578 ******************** 411-087-0100 Physical Environment: Generally Refer to F-584 ******************** 411-085-0360 Abuse Refer to F-607 ******************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F-641, F-656, F-657 and F-660 ******************** 411-086-0160 Nursing Services: Discharge Summary Refer to F-661 ******************** 411-086-0100 Nursing Services: Resident Care Refer to F-677 ******************** 411-086-0230 Activity Services Refer to F-679 ******************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F-689 ******************** 411-086-0110 Nursing Services: Resident Care Refer to F-693 and F-695 ******************** 411-086-0260 Pharmaceutical Services Refer to F-756 ********************

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 08/21/2023 and 08/27/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing requirements were maintained on 17 of 91 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the Direct Care Staff Daily Reports (DCSDRs) from 3/1/23 through 5/31/23 revealed the following days when state minimum CNA staffing requirements were not met for night shift when the census was greater than 51 residents: 4/21, 4/22, 4/23, 4/24, 4/28, 4/29, 4/30, 5/1, 5/2, 5/3, 5/6, 5/7, 5/8, 5/9, 5/17, 5/18, and 5/22/23. On 8/16/23 at 11:07 AM Staff 1 (Administrator) verified the facility did not have the required number of staff to meet the minimum CNA staffing requirements throughout the entire shift on the above night shifts when the census was over 51.

OAR 411-086-0100(5) 1. Facility has educated Staffing Coordinator on OAR CNA Minimum Staffing Ratio Regulations 2. Staffing Coordinator has been instructed to schedule and staff CNAs based on OAR CNA Minimum Staffing Ratio Regulations 4. NHA or designee will perform daily weekday audits of CNA staffing x 4 weeks then weekly x 4, then monthly x 1 to ensure CNA staffing appropriate. Audit results will be brought to the facility s QAPI meeting for review x 3 months or until a lesser time is warranted. 5. NHA responsible 6. Date of compliance 9/13/2023

Based on interview and record review it was determined the facility failed to provide medication as ordered for 1 of 3 sampled residents (#3) reviewed for medication administration. This placed residents at risk for increased abdominal pain. Findings include: Resident 3 was admitted to the facility in 2022 with diagnoses including Crohn's disease (persistent inflammation of the digestive tract). Physician Orders from 3/6/23 stated Resident 3 was to receive Stelara as an injection every eight weeks for Crohn's disease. Review of the 5/2023 MAR revealed Resident 3 was scheduled to receive Stelara on 5/25/23 but did not receive the medication. An Electronic MAR Note from 5/25/23 at 3:56 PM by Staff 7 (LPN) reported Stelara was not administered due to the medication being on order from the pharmacy. The note also states the pharmacy and management were notified. Review of the 5/2023, 6/2023 and 7/2023 MAR revealed Stelara was not administered until 7/6/23. On 7/14/23 at 10:41 AM Staff 3 (RNCM) confirmed Resident 3 did not receive a Stelara injection when scheduled on 5/25/23 and no follow up on the missed medication was done between the end of May through early July when it was discovered to have been missed.

F684-Quality of care 1. Resident #3 had an assessment done on 7/16/2023 to ensure no adverse effects were noted as a result of the missed medication. 2. All other resident MARs have been reviewed for the past 30 days to ensure ordered medications were administered. Any identified issues have been corrected as appropriate. 3. LN’s have been provided education on medication pass, ordering medications, and what to do if medication is unavailable by 8/14/2023. 4. DNS or designee will perform daily audits of med pass x 4 weeks then weekly x 4, then monthly x 1 to ensure medications are administered as ordered. Audit results will be brought to the facility’s QAPI meeting for review x 3 months or until a lesser time is warranted. 5. DNS responsible 6. Date of compliance 8/14/2023

********************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F-684 *********************

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 06/19/2023 and 06/25/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/29/2023 and 06/04/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/20/2023 and 02/26/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 3 of 3 sampled residents (#s 35, 39 and 141) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 39 was admitted to the facility in 9/2022 with diagnoses including type 2 diabetes mellitus. On 10/3/22 at 10:10 AM Resident 39 was lying in her/his bed with an overbed table within reach. A medication cup which contained two white, round pills was on Resident 39's overbed table and no nursing staff were present in the room. Resident 39's health record did not include evidence the resident was assessed for safe self-administration of medications. No documentation was found to indicate Resident 39 was able to correctly identify her/his medications and the reason for their use. On 10/5/22 at 7:03 AM and 7:30 AM Staff 4 (LPN) and Staff 5 (LPN) stated during medication administration, nurses were required to stay with the resident to ensure the medication was consumed. Staff 4 and Staff 5 stated medications could not be left at residents' bedsides and unattended. On 10/5/22 at 2:16 PM Staff 3 (RNCM) stated there was a required process related to self-administration of medications. Staff 3 stated in order for a resident to self-administer medications, an assessment was completed and if the resident was determined to be appropriate to self-administer medications, a physician order was obtained and a lock box was utilized to safely secure the medications. On 10/5/22 at 2:32 PM Staff 12 (RN) stated on 10/3/22 at "around" 9:00 AM, she administered two Tylenol pills to Resident 39 and stated she thought the resident swallowed the pills. Staff 12 stated she discovered the pills in Resident 39's hands after the state surveyor exited the resident's room on 10/3/22. On 10/6/22 2:04 PM Staff 2 (DNS) was notified of the findings of this investigation. Staff 2 stated nursing staff were not allowed to leave medications at a resident's bedside without an assessment for safe self-administration, a physician order for self-administration and a lock box to secure the medications. , 2. Resident 35 was admitted to the facility in 12/2021 with diagnoses including respiratory failure and stroke. On 10/3/22 at 1:48 PM, 10/4/22 at 2:26 PM and 3:45 PM and 10/5/22 at 8:18 AM Resident 35's room and bedside table were observed. An albuterol inhaler (used to treat wheezing and shortness of breath) was observed to be on Resident 35's bedside table within the resident's reach. During these observations, various staff were observed to enter the resident's room and stood in close proximity to the bedside table and interacted with the resident. On 10/5/22 at 9:03 AM Resident 35 stated she/he utilized the inhaler every day, several times a day and she/he did not have a lock box to store her/his medication. Resident 35's health record did not include evidence the resident was assessed for safe self-administration of medications, there were no physician orders allowing Resident 35 to have medications at bedside and no evidence Resident 35 was able to administer the medications according to the physician orders. On 10/5/22 at 10:02 AM Staff 10 (CNA) stated Resident 35 kept her/his inhaler on the bedside table, without a lockbox, for her/him to use anytime. On 10/5/22 at 8:44 AM and 11:20 AM Staff 4 (LPN) stated all medications, including inhalers, required a physician order if they were left at a resident's bedside. Staff 4 stated even when residents were cleared to have medications at the bedside they needed to be supervised and monitored to ensure they took the medications correctly and all medications needed to be secured in a lock box. Staff 4 stated she was unaware Resident 35 had medications at her/his bedside. On 10/5/22 at 2:16 PM Staff 3 (RNCM) reported in order for residents to have medications at their bedside, a medication self-administration evaluation was required, physician orders clearing the resident were then obtained, a nursing order was written to ensure the MAR reflected that the resident could self-administer medications and the care plan was updated. Staff 3 stated she was aware Resident 35 had unlocked medications at her/his bedside and none of the required assessments or documentation were in place. 3. Resident 141 was admitted to the facility in 8/2022 with diagnoses including juvenile diabetes and end-stage kidney disease. On 10/3/22 at 1:03 PM Resident 141's room and bedside table were observed. An albuterol inhaler and nasal spray was observed to be on Resident 141's bedside table within the resident's reach. Resident 141 stated the medications belonged to her/him and she/he used them when needed. No additional observations were made due to Resident 141 being transferred to the hospital on 10/4/22. Resident 141's health record did not include evidence the resident was assessed for safe self-administration of medications, there were no physician orders allowing Resident 141 to have medications at bedside and no evidence Resident 141 was able to administer the medications according to the physician orders. On 10/5/22 at 8:44 AM and 11:20 AM Staff 4 (LPN) stated all medications, including inhalers, required a physician order if they were left at a resident's bedside. Staff 4 stated even when residents were cleared to have medications at the bedside they needed to be supervised and monitored to ensure they took the medications correctly and all medications needed to be secured in a lock box. On 10/5/22 at 2:16 PM Staff 3 (RNCM) reported in order for residents to have medications at their bedside a medication self-administration evaluation was required, physician orders clearing the resident were then obtained, a nursing order was written to ensure the MAR reflected that the resident could self-administer medications and the care plan was updated. Staff 3 stated she was aware Resident 141 had unlocked medications at her/his bedside and none of the required assessments or documentation were in place.

F-554 Resident Self-Admin Meds-Clinically Appropriate¿ How the nursing home will correct the deficiency as it relates to the resident.¿ On 10/03/2022, the Resident Care Manager, RN, completed the Self-Administration of Medication Evaluations for Residents #s 35, 39, and 141 and determined that this practice was clinically appropriate for Residents #s 35 and 141. Resident # 39 was unable to demonstrate the appropriate use and understanding of self-administrating medications. The Licensed Nurses were educated on the requirement to visualize residents taking their medications. In addition, the licensed nurse obtained physician orders, and a lockbox was placed in each resident's room to ensure the medications were securely stored. How the nursing home will act to protect residents in similar situations.¿ The clinical management team reviewed current residents with a BIMS score of greater than 13 out of 15, indicating cognitively intact, to determine the clinical appropriateness for those residents who expressed the desire to participate in self-administering medications and use at the bedside. In addition, the clinical management team validated clinical appropriateness through observation and demonstration of the residents ability to identify and safely self-administer medications. The clinical management team identified no concerns. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before November 04, 2022, the Chief Nursing Officer and or designee will educate licensed nurses on the required process related to the self-administration of medications, including but not limited to evaluating residents to determine clinical appropriateness, obtaining a physician's order and utilizing a lock box to secure medications safely on admission and per resident request. The licensed nurses will also be educated on a self-administration medication questionnaire querying the resident's desire to participate in the self-administration of medication. How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ New resident admits and/or re-admits will be audited by the Chief Nursing Officer and/or designee weekly for four weeks and monthly for three months, and periodically thereafter as needed to validate residents who are identified and determined to be clinically appropriate and express their desire to participate in self-administering medications, a physicians order was obtained, and a lockbox was utilized to secure medications. The Chief Nursing Officer and or designee will address identified concerns promptly. Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: November 04, 2022 The title of the person responsible for ensuring correction:¿¿ The Chief Nursing Officer is accountable for compliance.¿

Based on interview and record review it was determined the facility failed to obtain, request and review copies of advance directives if available or periodically review resident wishes to execute an advance directive for 2 of 4 sampled residents (#s 39 and 141) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 141 was admitted to the facility in 8/2022 with diagnoses including juvenile diabetes and end-stage kidney disease. No evidence was found in Resident 141's health record to indicate the facility discussed advance directives with the resident or resident representative. On 10/4/22 at 4:18 PM Staff 8 (Social Services) confirmed the facility did not discuss the benefit of advance directives with Resident 141 upon admission. , 2. Resident 39 was admitted to the facility in 9/2022 with diagnoses including osteomyelitis (bone infection) of the spine and depression. No information was found in Resident 39's health record to indicate the facility discussed advance directives with the resident or resident representative. On 10/4/22 at 4:18 PM and 10/7/22 at 8:43 AM Staff 8 (Social Services) stated the advance directive procedure was to have the receptionist review advance directives with the resident with admission paperwork. Staff 8 confirmed she did not discuss the benefit of advance directives with the resident upon admission.

F-578 Request/Refuse/Discontinue Treatment; Formulate Advance Directives How the nursing home will correct the deficiency as it relates to the resident.¿ On October 04, 2022, the Social Worker uploaded the Advance Directive for Resident #s 141 and 39, reflecting the residents' wishes. ¿ How the nursing home will act to protect residents in similar situations.¿ ¿On October 04, 2022, the facility's Social Worker conducted a facility-wide review and audit of residents Advance Directives to validate their current Advance Directives were uploaded. The Social Worker identified no concerns.¿ Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before 11/04/2022, the Chief Nursing Officer will educate the Social Worker and or designee on the requirement to ensure the residents' current advance directives have been uploaded in the residents' EMR to reflect the residents/representatives wishes. How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ The Social Worker and or designee, with oversight from the Chief Nursing Officer, will conduct advance directive audits on new admission, readmissions, quarterly, after a life-altering illness and or return from hospitalization to reflect the residents/representatives wishes weekly for four weeks, monthly for three months, and periodically thereafter to validate resident's current advance directive has been uploaded to reflect their wishes. The Chief Nursing Officer and the designee will address identified concerns promptly. Results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: November 04, 2022 The title of the person responsible for ensuring correction:¿Social Worker and Chief Nursing Officer are accountable for compliance.

Based on observation and interview it was determined the facility failed to ensure the building was kept in good repair for 3 of 29 resident rooms and 1 of 1 main resident lobby area reviewed for environment. This placed residents at risk for living in an unkempt and unhomelike environment. Findings include: During resident screening throughout the day on 10/3/22, it was found that rooms 14 and 27 had broken window blinds. Additionally, room 19 had large scrapes and gouges on the wall next to the bed and the floor had an approximate six inch in diameter spot that appeared to be dirty flooring on the left side of the room. In the residents' lobby area, there were three leather-like arm chairs which had ripped armrests with large areas of leather missing and uncleanable fabric exposed. On 10/7/22 at 12:00 PM Staff 1 (Administrator) and the surveyor completed a facility walk-through. Staff 1 verified the broken window blinds, ripped chairs and dirty flooring. Staff 1 stated it was important to replace the broken blinds and ripped chairs and the floors needed to be stripped and waxed in several resident rooms.

F-584 Safe/Clean/Comfortable/Homelike Environment ¿ How the nursing home will correct the deficiency as it relates to the resident.¿ New blinds were ordered on 10/25/2022 for room #s 14, and 27. The Chief Executive Director will order new Sofas and Chairs for the residents main lobby area on or before 11/04/2022. The Maintenance Director and the Chief Executive Director updated the wax and strip schedule to include room #s 14 and 27 on 10/25/2022. The Maintenance Director will repair the large scrapes and gouges on the wall in room #19 on or before 11/04/2022. How the nursing home will act to protect residents in similar situations.¿ The Chief Executive Officer and the Maintenance Director conducted environmental rounds to ensure resident window coverings were in good repair. The Chief Executive Officer will address any concerns on or before 11/04/2022. In addition, the Maintenance Director examined the floors in resident rooms. The strip and wax floor schedule was updated to reflect residents floors requiring further follow-up. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before November 04, 2022, the Chief Executive Officer will educate the Maintenance Director on the importance of maintaining a safe, clean, comfortable, and homelike environment for residents. In addition, the Chief Executive Officer educated the maintenance director, the clinical interdisciplinary team, and floor staff on the use of the TELS network to communicate work orders with the Maintenance Department to ensure maintenance staff can effectively manage daily maintenance tasks and handle unexpected emergencies. Finally, the Chief Executive Officer will educate the maintenance director on the requirement to conduct morning environmental rounds and ensure resident walls and floors are kept clean and in good repair. Furthermore, the Healthcare Services Group (HCSG) will coordinate with the Maintenance Director and the Chief Executive Director regarding the strip and waxing of resident floors on or before 11/04/2022. How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ Weekly environmental rounds will be conducted by the Interdisciplinary team, including but not limited to resident rooms, common areas, etc. with oversight from the Chief Executive Director for four weeks, monthly for three months, and periodically thereafter to validate that the facility's common areas and resident rooms are kept clean and maintained to promote a home-like environment. The Chief Executive Director will address any identified concerns promptly, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance.¿ Dates when corrective action will be completed: November 04, 2022 The title of the person responsible for ensuring correction: Maintenance Director is accountable for compliance

Based on interview and record review it was determined the facility failed to document evidence of sufficient preparation and orientation to residents to ensure a safe and orderly transfer from the facility for 1 of 1 sampled resident (#43) reviewed for hospitalization. This placed residents at risk for misinformation. Findings include: Resident 43 was admitted to the facility in 7/2022 with diagnoses including second degree burn of right foot and open wound of left foot. Resident 43's 8/22/22 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 43's health record revealed no documentation to indicate the resident was prepared and notified regarding the discharge to the hospital. No evidence was found to indicate Resident 43 was informed about where she/he was going and if the resident understood the reason for the discharge. On 10/10/22 at 9:09 AM Staff 2 (DNS) was notified of the findings of this investigation and acknowledged there was no documentation in Resident 43's health record which indicated the resident was informed and understood the discharge to the hospital.

F-624 Preparation for safe/Orderly Transfer/Discharge¿ How the nursing home will correct the deficiency as it relates to the resident.¿ The discharge progress nursing note was updated on 10/10/2022 by the attending licensed nurse for resident #43 to reflect the clinical justification for the resident discharge to the acute care hospital and included the appropriate documentation during the nurse-to-nurse handoff. How the nursing home will act to protect residents in similar situations.¿ The clinical interdisciplinary team reviewed and audited resident discharge/transfers from the previous 30 days from October 2022 to validate that the facility followed the appropriate steps to sufficiently prepare and provide the proper documentation to facilitate a safe transition of care. The clinical interdisciplinary team identified no concerns. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before November 4th, the Chief Director of Nursing will educate the licensed staff on the requirement of completing the items on the Discharge/Transfer checklist and documentation that reflects licensed nurses followed the appropriate transition of care process.¿ How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ Discharge/Transfers will be audited by the Chief Nursing Officer and/or designee weekly for four weeks, monthly for three months, and periodically thereafter to validate that the resident's discharge documentation aligns with federal and state guidelines. The Chief Nursing Officer will promptly address identified concerns, and the audit results will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: November 04, 2022 The title of the person responsible for ensuring correction:¿Chief Nursing Officer is accountable for compliance

Based on observation, interview and record review it was determined the facility failed to invite and include residents to activities events for 1 of 2 sampled residents (#38) reviewed for activities. This placed residents at risk for social isolation. Findings include: Resident 38 was admitted to the facility in 3/2022 with diagnoses including cerebral infarction (stroke) with right-sided hemiplegia (paralysis). Resident 38's 3/24/22 Admission MDS indicated the resident was sometimes understood, was able to understand others and was totally dependent on staff assistance for locomotion on and off the unit. The MDS indicated Resident 38 was unable to complete the activity preferences interview, there was potential for resident isolation and the Activity Director would investigate areas of interest through trial and error. Resident 38's care plan included an activities focus, last revised 3/28/22, which included the following interventions: - Activity Director will continue to attempt to learn resident needs on a trial and error basis related to [resident] being non verbal; - Encourage and invite and assist as needed to activities of choice/interest as tolerated; - Provide activity calendar in room. Resident 38's 9/19/22 Activities Assessment indicated the resident's favorite activities included the following: - rest in bed; - up for meals; - observe exercise groups; - observe/passively participate in music groups. Resident 38's undated Kardex (a tool used by CNAs to direct resident care and preferences) indicated the following: - Activity Director will continue to attempt to learn resident needs on a trial and error basis [related to resident] being non verbal; - Engage [resident] in simple, structured activities that avoid overly demanding tasks. The facility's 10/2022 Activities Calendar included the following events which were assessed as Resident 38's favorite activities: - 10/4/22 at 10:30 AM: group exercises; - 10/5/22 at 2:00 PM: songs with Sydney; - 10/6/22 at 10:30 AM: group exercises. Observations of Resident 38 were conducted from 10/3/22 through 10/7/22 between the hours of 7:56 AM and 4:15 PM. During these observations, Resident 38 was in her/his wheelchair in the hallway for meals or in her/his bed. Resident 38's TV was on at times without the volume. Resident 38 was not in attendance at the 10/4/22, 10/5/22 or 10/6/22 activity events and was not observed in other activities. On 10/3/22 at 9:50 AM Resident 38 was interviewed. Resident 38 was awake, did not appropriately answer questions and was unable to provide detailed information regarding her/his care and activity preferences. On 10/5/22 at 9:17 AM Staff 14 (CNA) stated she used the Kardex to obtain information regarding Resident 38's care needs and preferences. Staff 14 stated she was responsible for Resident 38's ADLs and getting the resident ready for activity events when needed. When asked what Resident 38's activity preferences were, Staff 14 stated the resident worked with physical therapy, liked to watch western shows in bed, preferred to lay down and she thought the resident attended activities in the past. On 10/5/22 at 1:58 PM Staff 15 (Activity Director) invited various residents on the South hall to a live singer/piano event. No observations were made to indicate Resident 38 was invited to the event. At 2:00 PM there were six residents in attendance at the singer/piano event. Resident 38 was not in attendance. On 10/5/22 at 2:09 PM Staff 15 stated Resident 38's activity preferences included to sit in bed, watch TV and attend groups. Staff 15 stated she remembered a time when Resident 38 attended a music event, she/he tapped her/his foot to the music and the resident appeared to enjoy the music. Staff 15 stated she was unsure if other staff invited the resident to the live singer/piano event and stated she did not invite Resident 38 to the event. On 10/10/22 at 9:55 AM Staff 2 (DNS) was notified of the findings of this investigation. Staff 2 agreed Resident 38 was care planned to be invited to activities and she expected the resident to be included in the activity events.

F-679 Activities Meet Interest/Needs Each Resident¿ How the nursing home will correct the deficiency as it relates to the resident.¿ The Activities Director reviewed resident #38 care plan on 10/10/2022 and invited the resident to activities according to their interests. After the confirmed invitation, the resident was present for the movie activity on 10/10/2022. How the nursing home will act to protect residents in similar situations.¿ On or before November 4, 2022, the clinical interdisciplinary team will review current residents' comprehensive MDS section, F0300, coded as 0, indicating staff should not conduct the resident's interview daily and activity preferences for residents who are rarely/never understood. In addition, the MDS section F0700 that triggered that staff assessment of daily and activity preferences should not be conducted was reviewed to identify any other residents that may require alternate means of assessing their daily preferences, i.e., observations of resident behaviors to understand their likes or dislikes. The Activities Director will address any identified concerns. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before November 4, 2022, the Chief Executive Officer and/or designee will educate the Activities Director and Certified Nursing Assistants on the importance of encouraging residents to participate in activities according to their physical, mental, and psychosocial interests and their well-being. In addition, the Activities Director will place a Daily Activity Schedule in the Nursing Staff Communication binder for each resident requiring additional assistance to participate in activities per their individualized care plan needs. How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ The Activities Director will conduct weekly audits for four weeks, monthly for three months, and periodically thereafter to validate that the residents' activities align with their interests with oversight from the Chief Executive Officer. The Chief Executive Officer will promptly address identified concerns, and the audit results will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance Dates when corrective action will be completed: November 04, 2022¿ The title of the person responsible for ensuring correction: Activities Director is accountable for compliance

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 5 sampled residents (#141) reviewed for unnecessary medications. This placed residents at risk for adverse health consequences. Findings include: Resident 141 was admitted to the facility in 8/2022 with diagnoses including juvenile diabetes and end stage renal disease. An 8/26/22 physician order indicated Resident 141 was prescribed insulin Lispro-aabc Solution 100 unit/ML; subcutaneously before meals per sliding scale. The order specified to notify the medical provider if the resident's blood sugar was 400 or greater. A 9/23/22 physician order indicated Resident 141 was prescribed insulin Lispro Solution 100 unit/ML; subcutaneously before meals and at bedtime per sliding scale. The order specified to notify the medical provider if the resident's blood sugars were 350 or greater. A review of Resident 141's health record indicated the following times when the resident's medical provider was not notified of blood sugars as per physician orders: -9/1/22 at 11:30 AM blood sugar of 449; -9/24/22 at 7:00 AM blood sugar of 400; -9/24/22 at 12:00 PM blood sugar of 437 and -9/30/22 at 12:00 PM blood sugar of 494. On 10/6/22 at 11:36 AM Staff 4 (LPN) reported she completed Resident 141's blood sugars on the identified dates which lacked physician notification. Staff 4 and the surveyor reviewed Resident 141's health record and were unable to locate any evidence Resident 141's medical provider was notified of the resident's high blood sugars as per physician orders. On 10/6/22 at 12:22 PM Staff 3 (RNCM) confirmed there was no evidence Resident 141's medical provider was notified of the resident's high blood sugars as per physician orders.

F-684 Quality of Care ¿ ¿ How the nursing home will correct the deficiency as it relates to the resident.¿ On October 04, 2022, the attending nurse updated resident #141 nursing note to reflect that the medical provider was notified of the residents abnormal blood sugar assessed on 09/2/2022 and 09/24/2022. How the nursing home will act to protect residents in similar situations.¿ On October 4, 2022, the clinical management team reviewed and conducted an audit of abnormal blood sugar readings that may require follow-up and or notification to the residents provider. The Clinical management team identified no concerns. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ ¿On or before November 4th, 2022, the Chief Nursing Officer and Staff Development Coordinator will educate licensed nurses on the requirement to follow physician orders, including but not limited to notifying the residents provider as indicated. How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ The Blood Sugar exception vital report will be reviewed and audited by the clinical interdisciplinary team with oversight from the Chief Nursing Officer weekly for four weeks, monthly for three months, and periodically thereafter to validate that the licensed nurse followed the physicians orders, including proper documentation that reflects in the residents medical record. The Chief Nursing Officer will address any identified concerns and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance.¿ Dates when corrective action will be completed: November 04, 2022 The title of the person responsible for ensuring correction: Chief Nursing Officer is accountable for compliance

Based on observation, interview and record review it was determined the facility failed to ensure physician orders for splint devices were implemented for 1 of 2 sampled residents (#15) reviewed for mobility. This placed residents at risk for worsening contractures. Findings include: Resident 15 was admitted to the facility in 11/2017 with diagnoses including cerebral infarction (stroke). Resident 15's 8/15/22 Quarterly MDS indicated the resident had upper extremity impairment to one side and used a splint. Resident 15's 10/2022 physician orders included the following: - Apply hand splint to left hand [every day], wear for four hours during the day. Monitor BID for alteration in skin. Resident 15's 10/2022 TAR revealed the following documentation for the splint physician order: - 10/3/22 days: checkmark with staff initials; - 10/3/22 evenings: "NN" with staff initials; - 10/4/22 days: "NN" with staff initials; - 10/4/22 evenings: "NA" with a checkmark and staff initials; - 10/5/22 days: "+" with a checkmark and staff initials. The TAR indicated NN = "other - see nurse notes" and NA = "medication not available" Review of Resident 15's progress notes revealed no documentation related to the resident's splint. Resident 15's 10/2022 tasks included the following: - Wear [left] hand splint for two - three hours daily. Check under splint for irritation. Resident 15's Care Plan and Kardex (a tool used by CNAs to direct resident care and preferences) directed the following: - RA to encourage resident to wear brace/splint to left forearm/hand to prevent further contractures. Nurse to check skin under brace with donning and doffing; - Wash left hand, pat dry , stretch before applying brace; - Encourage [resident] to wear brace for two to three hours as tolerated. Observations were conducted 10/3/22 at 9:45 AM and 12:20 PM, 10/4/22 at 10:58 AM and 2:08 PM and 10/5/22 at 8:12 AM. During these observations, Resident 15 had a left hand contracture and her/his fingers were curled into a fist, a blue splint device was on Resident 15's nightstand and the resident did not have a splint donned on her/his left hand. On 10/5/22 at 11:26 AM a blue foam roll was observed in Resident 15's hand with her/his fingers curled around it. On 10/3/22 at 9:45 AM and 10/4/22 at 10:58 AM Resident 15 was interviewed. Resident 15 was unable to provide detailed information regarding her/his splint. Interviews were conducted on 10/5/22 at 9:17 AM, 11:40 AM, 11:52 AM, 11:59 AM and 12:15 PM with Staff 5 (LPN), Staff 13 (CNA/RA), Staff 14 (CNA) and Staff 16 (CNA). Staff 14 and Staff 16 stated they referred to the Kardex to learn information regarding Resident 15's care needs and stated the resident had a left contracture. Staff 16 stated her responsibilities included to strongly encourage Resident 15 to wear the splint. Staff 13 stated he provided RA services to residents, he was responsible to don Resident 15's splint and he had not worked with the resident yet. Staff 5 stated her responsibility included checking Resident 15's left hand skin and the CNAs and RA were responsible to don the splint. At 12:15 PM, Staff 14 stated she was assigned to Resident 15, observed the blue foam roll in her/his hand and was unaware who applied the roll or when it was applied. On 10/5/22 at 12:32 PM Staff 3 (RNCM) stated Resident 15 had a left hand contracture and interventions included to don the splint for two to three hours. Staff 3 stated nurses were responsible to don/doff the splint. Staff 3 reviewed Resident 15's physician orders, TAR, Care Plan and Kardex for the splint and acknowledged the discrepancies between the splint order, TAR, Care Plan and Kardex. On 10/5/22 at 12:51 PM Staff 2 (DNS) was notified of the findings of this investigation. Staff 2 acknowledged the physician order for the splint differed from the Care Plan and Kardex and confirmed the CNAs, the RA and the nurses were confused related to whose responsibility it was to don/doff Resident 15's splint. Staff 2 stated a checkmark with staff initials on the TAR indicated the task was completed and if staff documented NN, there should have been a corresponding progress note. Staff 2 stated she expected Resident 15's splint to be donned according to the physician orders.

F-688 Increase/Prevent Decrease in ROM/Mobility¿ How the nursing home will correct the deficiency as it relates to the resident.¿ On 10/06/2022, the MDS resource nurse implemented Resident #15's physician's order for their splint device. In addition, the MDS resource nurse updated Resident #15's, Care Plan and Kardex to ensure scheduling and documentation per plan of care. How the nursing home will act to protect residents in similar situations.¿ The clinical interdisciplinary team reviewed current residents requiring assistive devices, to ensure the proper use and implementation of the residents Restorative Nursing program and documentation per plan of care. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before November 4, 2022, the Chief Nursing Officer will educate the clinical interdisciplinary team on the requirement to review daily task reports as part of the daily clinical meeting to validate that donning and doffing of splint tasks were performed and documented by the Restorative Aide and or designee. In addition, the Chief Nursing Officer will educate the restorative nursing aide and or designee on Restorative Nursing Task documentation. How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ The Chief Nursing Officer and or designee will conduct Restorative Nursing Task audits for four weeks, monthly for three months, and periodically thereafter to validate Restorative Nursing tasks reflect the physician's order and the documentation on the care plan and Kardex. The Chief Nursing Officer and the designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: November 04, 2022 The title of the person responsible for ensuring correction:¿¿Chief Nursing Officer is accountable for compliance

Based on observation, interview and record review it was determined the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 sampled resident (#91) reviewed for respiratory care. This placed residents at risk for discomfort. Findings include: Resident 91 was admitted to the facility in 9/2022 with diagnoses including cancer. Resident 91's 9/30/22 Admission MDS indicated the resident used supplemental oxygen. On 10/3/22 at 9:56 AM Resident 91 was lying in bed in her/his room and receiving oxygen which was produced and delivered from an oxygen concentrator. The concentrator was powered on and set at two LPM (liters per minute) of oxygen. A humidifier bottle was attached to the concentrator, dated 9/21/22 and contained no fluid. A nasal cannula and tubing was attached to the oxygen concentrator and placed in Resident 91's nose. Observations from 10/3/22 at 12:12 PM through 10/6/22 at 12:03 PM revealed no humidifier bottle attached to the oxygen concentrator. On 10/05/22 at 11:16 AM Resident 91 was not in her/his room and the nasal cannula was on the resident's bed. The nasal cannula was coated with thick, brown dried debris. Resident 91's health record included a 9/21/22 physician order for the following: - Change oxygen tubing, humidification bottle and clean filter every week, every night shift every Sunday for maintenance. Resident 91's 9/2022 and 10/2022 TARs revealed a check mark and staff initials on Sunday 9/25/22 and Sunday 10/2/22. On 10/6/22 at 12:03 PM Staff 5 (LPN) stated Resident 91 used oxygen to maintain her/his oxygen saturation and for comfort. Staff 5 stated there was a task to change the tubing, nasal cannula and humidifier bottle and it was scheduled to be completed every Sunday night. Staff 5 stated she was the day shift nurse for Resident 91 and her duties included to ensure the humidifier bottle was filled with distilled water, ensure the tubing was free of condensation and ensure the nasal cannula was clean. Staff 5 visualized the oxygen concentrator, tubing and nasal cannula and confirmed the nasal cannula was dirty and confirmed there was no humidifier bottle. On 10/6/22 at 12:45 PM Staff 3 (RNCM) stated Resident 91 used oxygen for respiratory maintenance. Staff 3 stated there was an order for the nurses to clean the filter and change the tubing and humidifier bottle every Sunday. Staff 3 verified staff initials and a checkmark on the TAR indicated the respiratory equipment task was completed. Staff 3 was notified regarding the empty humidifier bottle dated 9/21/22 and the dirty nasal cannula. Staff 3 stated she expected the task to be completed as ordered. On 10/7/22 at 8:40 AM and 8:48 AM Staff 17 (RN) stated he worked on 9/25/22 and 10/2/22. Staff 17 confirmed his initials on Resident 91's 9/2022 and 10/2022 TAR corresponding to the physician order to change oxygen tubing, humidification bottle and clean filter every week, every night shift, every Sunday for maintenance. Staff 17 stated he attempted to complete the task and Resident 91 requested Staff 17 come back at a later time. Staff 17 stated his shifts became very busy and he was unable to return to Resident 91's room. Staff 17 confirmed he did not complete the task on 9/25/22 and 10/2/22.

F-695 Respiratory/Tracheostomy Care and Suctioning ¿ How the nursing home will correct the deficiency as it relates to the resident.¿ Resident # 91 oxygen tubing and humidifier bottle were replaced on 10/06/2022 by the licensed nurse. In addition, the licensed nurse cleaned resident #91 oxygen concentrator filter. How the nursing home will act to protect residents in similar situations.¿ The Chief Nursing Officer reviewed and audited current residents requiring oxygen on 10/25/2022. The Chief Nursing Officer identified no concerns. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before November 4, 2022, the Chief Nursing Officer will educate licensed nurses on the requirement of changing residents' oxygen tubing and humidifier bottles once weekly and as needed per the physicians order. In addition, to ensure residents' oxygen equipment is appropriately maintained, the Chief Executive Officer will educate the Maintenance Director to ensure the facilitys oxygen concentrator filters are cleaned per the manufacturers recommendation. ¿ How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ Oxygen equipment will be audited by the Staff Development Coordinator and or designee with oversight from the Chief Nursing Director for four weeks, monthly for three months, and periodically thereafter to validate residents oxygen tubing and humidifier bottles were replaced once weekly, and filters are cleaned per manufacturer. The Chief Nursing Officer and/or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: November 04, 2022 The title of the person responsible for ensuring correction:¿Chief Nursing Officer is accountable for compliance

Based on interview and record review it was determined the facility failed to use the services of an RN for eight consecutive hours per day for 16 of 30 days reviewed for staffing. This placed residents for unmet medical-based care needs. Findings include: A review of the Direct Care Staff Daily Reports dated 9/1/22 through 9/30/22 revealed there were 16 days (9/1, 9/2, 9/3, 9/7, 9/8, 9/9, 9/10, 9/15, 9/16, 9/17, 9/21, 9/22, 9/23, 9/24, 9/29, 9/30) with no RN coverage. On 10/7/22 at 11:15 AM Staff 2 (DNS) stated she was under the impression if she was present in the facility she was counted as an RN on the daily staffing report and was not aware she had to dedicate time for direct patient care. Staff 2 confirmed there was no RN coverage on the identified dates.

F-727 RN 8Hrs/7days/Wk, Full Time DON¿ How the nursing home will correct the deficiency as it relates to the resident.¿ In October 2022, the facilitys Staffing Coordinator assumed the responsibility of recruitment and staffing licensed nurses to focus recruiting efforts on hiring Registered Nurses (RN). How the nursing home will act to protect residents in similar situations.¿ On October 27, 2022, the Chief Executive Officer, Chief Nursing Officer, Staffing Coordinator, and Human Resource Director reviewed and audited the current licensed nurse schedule to identify available RN shifts. The Chief Nursing Officer and the Staffing Coordinator will address identified concerns. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On October 27, 2022, the Regional Human Resources Specialist educated the Chief Executive Officer, Chief Nursing Officer, Staffing Coordinator, and Human Resource Director on the automated UKG scheduling software to assist the Staffing Coordinator make accurate and timely predictions and forecasting of RN staffing and map schedules according to federal and state law. In addition, the Staffing Coordinator will validate sufficient RN coverage, and internal staff will cover available shifts; if internal RN staff cannot, the Staffing Coordinator will post RN coverage to an RN staffing agency. How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ The Staffing Coordinator, with oversight by the Chief Nursing Officer and/or designee, will audit the licensed nurse staffing schedule for four weeks, monthly for three months, and periodically thereafter to validate sufficient RN coverage per federal guidelines and state law. The Chief Nursing Officer and/or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: November 04, 2002 The title of the person responsible for ensuring correction:¿¿Chief Nursing Offer and Staffing Coordinator

Based on observation, interview and record review it was determined the facility failed to implement appropriate adaptive dining equipment for 1 of 3 sampled residents (#38) reviewed for nutrition. This placed residents at risk for decreased food intake and an undignified dining experience: Findings include: Resident 38 was admitted to the facility in 3/2022 with diagnoses including cerebral infarction (stroke) with right-sided hemiplegia (paralysis). Resident 38's care plan for ADL self care performance deficit with eating, last revised 3/18/22, included the intervention to use a scoop plate (an adaptive meal plate with a high, curved rim which enables food to be rolled back onto the spoon to minimize spillage) for all meals for maximum independence. Resident 38's health record included an 8/23/22 physician order for the following: - Scoop plate for resident meals to promote self-feeding abilities. Observations of Resident 38 were conducted from 10/3/22 through 10/7/22 between the hours of 7:56 AM and 4:15 PM. During these observations, Resident 38 was in her/his wheelchair in the hallway for the breakfast and lunch meals. For each of the meals observed, Resident 38's food was served on a ceramic plate. On 10/3/22 from 12:53 PM until 1:07 PM, Resident 38 unsuccessfully attempted to gather the food onto her/his spoon from the ceramic plate. As a result, up to 50% of the resident's food was on her/his lap or scraped off the plate onto the table. At 1:07 PM Staff 13 (CNA/RA) cleared Resident 38's meal tray. On 10/5/22 at 9:17 AM Staff 14 (CNA) stated Resident 38 liked to eat, she/he tried to eat independently and staff often helped her/him with meals when needed. Staff 14 stated she was not aware if Resident 38 used adaptive dining equipment such as a scoop plate. On 10/6/22 at 1:58 PM Staff 5 (LPN) stated she was familiar with Resident 38. Staff 5 stated the resident often required cueing during meals and tried to feed herself/himself. Staff 5 stated she did not believe Resident 38 used a scoop plate for meals. On 10/6/22 at 2:19 PM Staff 7 (Kitchen Manager) stated the printed diet slips included information regarding the use of adaptive equipment such as a scoop plate. Staff 7 obtained Resident 38's diet slip and acknowledged the diet slip indicated the resident required a scoop plate. Staff 7 stated he expected dietary staff to follow the diet slip. On 10/7/22 at 8:06 AM Resident 38 ate breakfast in the hallway and used a ceramic plate. Staff 3 (RNCM) observed Resident 38's ceramic plate, stated she was unsure if Resident 38 used a scoop plate for meals and needed to look at the resident's care plan. At 8:11 AM, Staff 3 stated she looked at Resident 38's care plan and stated staff should have provided a scoop plate for meals.

F-810 Assistive Devices Eating Equipment/Utensils¿ How the nursing home will correct the deficiency as it relates to the resident?¿ On 10/11/2022, the Dietary Manager provided Resident #38 with an adaptive scoop plate. How the nursing home will act to protect residents in similar situations.¿ The Dietary Manager reviewed and conducted a Nutrition Management audit on 10/11/2022 to identify if other current residents requiring adaptive feeding equipment for meals were provided per physician order. In addition, facility managers conducted rounds during mealtimes to validate residents requiring adaptive feeding equipment. The Dietary Manager and the facility managers identified no concerns. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before November 4th, 2022, the Dietary Manager will educate the kitchen and direct care staff on providing residents with dietary adaptive feeding equipment at meals. In addition, the Dietary Manager will ensure adaptive feeding equipment remains at adequate par levels. How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ The Dietary Manager will conduct audits with oversight by the Chief Executive Officer weekly for four weeks, monthly for three months, and periodically thereafter to ensure residents who require adaptive equipment for meals are followed. The Chief Executive Officer and/or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. Dates when corrective action will be completed: November 04, 2022¿ The title of the person responsible for ensuring correction:¿Dietary Manager is accountable for compliance

Based on observation and interview it was determined the facility failed to prevent potential contamination of the ice machine in 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for potential infections related to foodborne pathogens. Findings include: The Federal Food Sanitation Rules code 5-402.11 Backflow Prevention directed facilities to ensure "a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed." On 10/3/22 at 9:30 AM the ice machine was observed to drain directly into the plumbing without an air gap. This allowed for backflow into the ice machine from the sewer. Staff 7 (Kitchen Manager) reported, "It's been like that since I started working here in September 2022." On 10/6/22 at 2:47 PM Staff 1 (Administrator) confirmed the ice machine did not have an air gap. He stated, "I didn't know that was an issue."

F-812 Food Procurement, Store/Prepare/Serve¿ ¿ How the nursing home will correct the deficiency as it relates to the resident.¿ On October 24, 2022, a licensed plumber with River City Environmental Services inspected the airgap pipe to the ice machine. River City Environmental Services purchased the materials to complete the modification per Federal Food Sanitation Rules code 5-402.11. How the nursing home will act to protect residents in similar situations.¿ The licensed plumber with River City Environmental Services identified no other concerns or pipes that drain into the sewage system in the kitchen. Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before October 31, 2022, River City Environmental Services will complete the modification to the airgap pipe to the ice machine and educate the Maintenance Director on conducting routine pipe inspections as needed. How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ The Maintenance Director will conduct audits with oversight by the Chief Executive Officer weekly for four weeks, monthly for three months, and periodically thereafter to ensure airgap the pipe to the ice machine is properly maintained according to Federal guidelines. The Chief Executive Officer and/or designee will promptly address identified concerns, and the results of the audits will be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance. ¿ Dates when corrective action will be completed: November 04, 2022 The title of the person responsible for ensuring correction: Maintenance Director is accountable for compliance

Based on observation and interview it was determined the facility failed to ensure waste was properly contained in dumpsters and garbage storage areas were maintained in a sanitary condition for 1 of 1 facility garbage area reviewed for sanitary disposal of garbage. This placed residents at risk for exposure to pathogens related to the harborage and feeding of pests. Findings include: On 10/6/22 at 2:01 PM old furniture, a broken door, broken service carts, empty food boxes, large empty vegetable cans (with remnants of vegetables inside), and empty half-gallon milk jugs (with remnants of milk inside) were observed to be discarded outside of the kitchen door on the pavement and grassy area adjacent to the kitchen door on the north side of the building. Staff 7 (Kitchen Manager) stated the kitchen staff placed larger food garbage items such as cans and boxes outside of the door prior to taking them to the dumpster around the corner from the kitchen door. He stated the boxes and other recyclables were also placed outside the kitchen door before they were broken down and added to the recycle bin. Staff 7 acknowledged the area should be kept clear of debris. On 10/6/22 at 2:43 PM Staff 1(Administrator) stated, "Obviously we can do better" and confirmed the need to clear the area of discarded items. He stated the facility was in the process of "purging" old equipment and furniture. On 10/6/22 at 4:12 PM seven large empty tomato soup cans (with remnants of soup inside) and one large empty fruit can (with remnants of fruit and juice inside) were observed to be stacked on the window unit air conditioner adjacent to the exterior kitchen door on the north side of the building. Staff 9 (Maintenance Director) reported he planned to take the large items that were discarded outside of the kitchen door on the north side of the building to the dump once there was enough to fill a truck. On 10/10/22 at 10:31 AM Staff 1 (Administrator) stated, "We have some work to do as far as training to make sure they know about the potential problem with regard to the garbage and making sure that it's not just out there for pests to find it."

F-814 Dispose of Garbage and Refuse Properly ¿ How the nursing home will correct the deficiency as it relates to the resident.¿ On October 11, 2022, the Maintenance Director removed the garbage and debris from the facility premises. How the nursing home will act to protect residents in similar situations.¿ The Maintenance Director conducted environmental rounds on 10/12/2022 and identified no other garbage and or debris on the facility premises. ¿ Measures the nursing home will take or systems it will alter to ensure that the problem does not recur.¿ On or before November 4, 2022, the Maintenance Director will educate dietary staff on the proper procedure for disposing of garbage/debris in the dumpsters. In addition, the Chief Executive Director purchased garbage containers on 10/22/2022, received them on 10/28/2022, and placed them outside the kitchen exit door to ensure staff disposes of garbage and debris appropriately.¿ How the nursing home plans to monitor its performance to make sure that solutions are sustained.¿ The Maintenance Director will conduct environmental rounds with oversight from the Chief Executive Officer weekly for four weeks, monthly for three months, and periodically thereafter to ensure that garbage/debris is disposed of appropriately. The Chief Executive Director will address any identified concerns promptly, and results from audits will be brought to Quality Assurance and Performance Improvement Program to validate compliance. Dates when corrective action will be completed: November 04, 2022 The title of the person responsible for ensuring correction: Maintenance Director is accountable for compliance

******************** OAR 411-086-0260 Pharmaceutical Services Refer to F554 ******************** OAR 411-086-0040 Admission of Residents [Advance Directive] Refer to F578 ******************** OAR 411-087-0100 Physical Environment: Generally Refer to F584 ******************** OAR 411-088-0020 Basis for Involuntary Transfer Refer to F622 ******************** OAR 411-088-0030 Considerations Required Prior to Involuntary Transfer Refer to F624 ******************** OAR 411-086-0230 Activity Services Refer to F679 ******************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ******************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F688 ******************** OAR 411-085-0110 Nursing Services: Resident Care Refer to F695 ******************** OAR 411-086-0100 Nursing Services: Staffing Refer to F727 ******************** OAR 411-086-0250 Dietary Services Refer to F810, F812, F814 ********************