Rose Linn Care Center

Resident 8 was admitted to the facility in 3/2026 with diagnoses including depression and dementia. Resident 8GÇÖs 3/2026 Physician Orders indicated the resident was prescribed sertraline (antidepressant) for depression. Resident 8GÇÖs 4/2026 MAR revealed the resident received sertraline daily. Review of Resident 8GÇÖs medical record revealed no indication the resident was informed in advance of the risks and benefits of sertraline. On 4/23/26 at 1:24 PM, Staff 3 (LPN Resident Care Manger) acknowledged Resident 8 was not informed of the risks and benefits for the use of sertraline.

Documentation of informed consent was completed with resident 8 on 4/23/2026 Staff were in-serviced on 4/23/2026 on properly informing residents, or their representative, on their prescribed medications, the alternatives and their preferred options. All residents have the right to be informed on the direction of their care and their options Assessment of residents with medications that require informed consent will be done with our Psychotropic Review monthly for the next 3 quarters and reported to QAPI each quarter

2. Resident 5 was admitted to the facility on 3/13/26 with diagnoses including acute cystitis (sudden bladder infection).-á A 3/30/26 Admission MDS indicated Resident 5 had a BIMS score of 1 which indicated the resident was not cognitively intact.-á A 3/14/26 MAR indicated staff performed daily wound care to Resident 5's left elbow. Wound care orders specified the site did not require a dressing.-á A 4/12/26 MAR indicated staff performed daily wound care to Resident 5's right elbow. The order indicated staff cleaned the wound with cleanser, dried it and applied a new dressing.-á During observations from 4/21/26 through 4/23/26 from 8:00 AM to 12:00 PM, Resident 5 was repeatedly observed wheeling herself/himself in the hallway. During these observations Resident 5's left elbow wound was covered with a dressing dated 4/19/26. The dressing on Resident 5's right elbow was peeled off and the wound was exposed. Resident 5 was observed resting her/his arms on the side rails of the wheelchair. Resident 5 was observed bumping her/his elbow on the hallway rails.-á On 4/23/26 at 12:09 PM, Staff 13 (LPN) stated staff performed daily wound care to Resident 5's right and left elbow. Staff 13 acknowledged Resident 5's left elbow dressing was dated 4/19/26. Staff 13 stated Resident 5 did not require a dressing and removed the dressing. Staff 3 stated she did not perform wound care the previous day and acknowledged the MAR indicated she did perform wound care on that day.-á-á On 4/23/26 at 12:17 PM, Staff 13 and Resident 5 returned back into her/his room and she removed Resident 5's right elbow dressing and applied a new dressing. Staff 3 stated she did not perform wound care the previous day and acknowledged the MAR indicated she did perform wound care on that day.-á On 4/24/26 at 9:08 AM, Staff 3 (LPN, Resident Care Manager) stated she expected staff to follow wound care orders. Staff 3 stated she monitored residents MARs to ensure staff completed wound care. Staff 3 stated she was unaware staff did not complete wound care orders.-á , 1. Resident 40 admitted to the facility in 4/3/2026 with diagnoses including bipolar disorder. A review of Resident 40's Physician Orders dated 4/3/26 included sennoside 8.6 mg and polyethylene glycol 3350 powder, medications indicated for constipation on a PRN basis. The Physician Orders also included a bowel routine for Resident 40 which indicated the resident was to receive Milk of Magnesia for no bowel movement after three days, bisacodyl suppository after four days and fleets enema after five days. A review of Resident 40's Care Plan dated 4/6/26 revealed the resident had bowel incontinence and was dependent on staff for all toileting tasks.-á A review of Resident 40's bowel record indicated the resident had no bowel movement from 4/17/26 to 4/21/26 (five days). A review of Resident 40's 4/2026 MAR revealed no indication the resident received medications for constipation or that her/his bowel routine was followed after three days of no bowel movement.-á On 4/23/26 at 1:58 PM Staff 13 (LPN) stated Resident 40 had bowel movements daily and was unaware if the resident went consecutive days without a bowel movement. Staff 13 stated Resident 40 did not refuse medications and she did not administer medications indicated for constipation to the resident since her/his admission.-á On 4/24/26 at 9:53 AM Staff 3 (LPN Resident Care Manager) confirmed the resident went five days without a bowel movement from 4/17/26 to 4/21/26 and did not receive medications for constipation or her/his bowel routine.-á On 4/24/26 at 11:58 AM Staff 2 (DNS) stated nursing staff were expected to administer Resident 40's medications for constipation on 4/19/26 and to follow her/his bowel routine as ordered on 4/20/26.

Nursing staff are to be inserviced on 5/27/26 regarding the need to follow physician orders and personalized care plans regarding bowel care procedures and wound care. All residents have the potential to be affected by the same deficiencies An audit of all residents will be completed to determine who requires Wound care and bowel care. Verification of Documentation for those who have been identified will be reported to QAPI for the next 3 quarters by the IPCP

Resident 30 was admitted to the facility in 6/2018 with diagnoses including abnormalities of gait and mobility.-á A 1/16/26 Quarterly MDS indicated Resident 30 had a BIMS score of 4 indicating the resident was not cognitively intact. The MDS indicated the resident used a walker and wheelchair. The MDS indicated Resident 30 did not use a brace but she/he performed ROM exercises four days a week.-á A 6/20/25 Referral to Prosthetics and Orthotics indicated Resident 30 required an AFO (ankle foot orthosis) due to ankle weakness and instability and the length of need was lifetime. The referral indicated the current AFO did not fit properly.-á A 10/23/25 Care Conference indicated Resident 30's AFO fit properly when her/his black shoes were worn.-á A 3/6/26 Restorative services referral indicated Resident 30 performed functional transfer maintenance. Resident 30 wore a brace for repeated toilet transfers with bathroom grab bars three times a week.-á A 4/10/26 Care Plan indicated the following restorative services -Transfer program: Staff to perform repetitive toilet transfers with the grab bars and using the right AFO.-á A 4/2026 MAR indicated staff applied Resident 30's brace daily.-á Resident 30's medical record indicated staff performed daily restorative services. During observations from 4/20/26 through 4/23/26 from 8:00 AM to 4:00 PM, Resident 30 was repeatedly observed sitting in her/his wheelchair with her/his right foot inverted to the left side. Resident 30 did not wear the recommended shoes to properly fit the brace. On 4/20/26 at 12:25 PM Resident 30 stated she/he did not wear the brace due to increased pain when using the brace. Resident 30 stated staff adjusted the brace in the past to try and make it more comfortable, but it continued to be painful. Resident 30 indicated she/he was never reassessed for proper fit for the brace.-á On 4/23/26 at 9:07 AM Resident 30 stated staff were not currently offering her/him exercises or use of the brace.-á On 4/23/26 at 1:01 PM and 1:52 PM, Staff 6 (CNA) stated Resident 30 was able to communicate her/his needs. Staff 6 stated Resident 30's mobility decreased and she/he required maximum assistance to stand up. Staff 6 stated he did not offer Resident 30 transfer programs during the day. Staff stated he did not offer Resident 30 to use the brace because ""she/he normally refuses"". Staff 6 stated Resident 30 stopped using the brace several months ago. Staff 6 stated Resident 30 did not wear because it was painful. Staff 6 stated he was unsure if Resident 30 performed ROM or worked with therapy.-á On 4/23/26 at 4:25 PM, Staff 11 (CNA) stated Resident 30 was required to use a brace daily. Staff 11 stated Resident 30 did not use the brace because it was tight and painful. Staff 11 stated staff were aware about the brace not fitting properly. Staff 11 stated Resident 30 continued to report pain and discomfort related to her/his brace.-á On 4/23/26 at 1:59 PM, Staff 18 (PT) stated Resident 30 was not required to use the brace daily. Staff 18 was unsure if Resident 30 was evaluated to stop using the brace.-á-á On 4/24/26 at 8:13 AM, Staff 13 (LPN) stated she did not offer the brace to Resident 30. Staff 13 stated she did not document refusals. Staff 13 stated she was unsure why the resident refused to use the brace.-áStaff 13 stated she was unsure if restorative services were completed daily.-á On 4/24/26 at 8:35 AM, Staff 3 (LPN Resident Care Manager) stated she expected staff to offer the brace daily. Staff 13 stated she was unaware if Resident 30 refused the brace. Staff 3 stated she expected staff to document refusals daily and notify the provider to assess the use of the AFO.-á On 4/24/26 at 9:58 AM, Staff 2 (DNS) stated Resident 30's brace was adjusted but not replaced. Staff 2 stated Resident 30 used the AFO intermittently. Staff stated the AFO was assessed for comfort or proper fitting since adjustment. Staff 2 stated the brace was ordered for stability and proper alignment. Staff 2 stated she expected staff to document refusals and notify the provider to assess for use.-á

MD Order for Therapy to reassess benefit or continued use of AFO. All residents with therapeutic devices will be assessed quarterly for continued benefit and use. This deficiency in practice has the ability to affect all residents All AFOs will be on our RA program and reviewed monthly by the DNS and RCMs

Resident 60 was admitted to the facility in 2/2026 with diagnoses including a stroke and femur fracture. Resident 60GÇÖs 2/10/26 Admission MDS revealed the resident was cognitively impaired. Resident 60GÇÖs 2/3/26 care plan indicated she/he was a high fall risk which required a one person assist with transfers and to ensure her/his call light was within reach. A 3/18/26 and 4/13/26 Fall Assessment revealed Resident 60 had two unwitnessed falls which was a result of the residentGÇÖs attempt to self-transfer to the bathroom independently. Observations between 4/20/26 at 8:30 AM and 4/22/26 at 2:48 PM revealed multiple occasions of Resident 60GÇÖs sitting in her/his wheelchair near the foot of her/his bed and her/his call light draped over the head of her/his bed which was out of reach of the resident.-á On 4/20/26 at 9:08 AM Staff 5 (CNA) stated Resident 60 was able to use her/his call light appropriately if she/he was able to see it. Staff 5 stated Resident 60 was forgetful at times, and the visual of the call light was often a way to remind her/him to call for assistance. On 4/22/26 at 1:35 PM Staff 6 (CNA) stated if the call light was out of the residentGÇÖs reach it would be safe for the resident to ambulate around her/his room to reach it. On 4/22/26 at 1:57 PM Staff4 (Resident Care Manager, LPN) acknowledged Resident 60 was a high fall risk and it was not safe for Resident 60 to ambulate in a wheelchair around her/his bed to reach her/his call light.

Staff will be  inserviced on 5/27 about call light placement and standards of care. This has the ability to affect all residents in this deficiency of practice Residents will be assessed for call light use and care plans updated quarterly

Resident 5 was admitted to the facility on 3/13/26 with diagnoses including acute cystitis (sudden bladder infection).-á A 3/30/26 Admission MDS indicated Resident 5 had a BIMS score of 1 which indicated the resident was not cognitively intact.-á A 3/18/26 MAR indicated staff performed daily care to Resident 5's suprapubic catheter (a tube inserted through the stomach to drain urine from the bladder). Orders specified staff were to clean the site with warm soapy water or other gentle cleanser, pat dry and apply gauze.-á On 4/23/26 at 1:31 PM, Staff 13 was observed performing care to Resident 5's suprapubic catheter. Staff 13 cleaned the site with warm water and did not use soapy water or a cleanser. Staff 13 acknowledged she did not use soapy water or a cleanser and stated she forgot.-á On 4/24/26 at 9:08 AM Staff 3 (LPN Resident Care Manager) stated staff were to follow orders related to the suprapubic catheter.-á -á

IPCP will inservice staff on 5/27 for proper catheter care procedures All residents with a catheter are at risk for this deficiency of practice IPCP officer will monitor catheter care for the next 3 quarters and report to QAPI

A review of personnel records on 4/24/26 indicated the following employees did not received their annual performance evaluations: -Staff 5 (CNA), hire date was 11/2020 and a performance review was completed in 11/2024. -Staff 6 (CNA), hire date was 8/2023 and a performance review was completed in 8/2024. -Staff 7 (CNA), hire date was 11/2011 and a performance review was completed in 11/2024. -Staff 8 (CNA), hire date was 1/2015 and a performance review was completed in 1/2025. On 4/24/26 at 10:43 AM Staff 1 (Interim Administrator) stated performance reviews were to be completed annually and acknowledged annual performance reviews were not completed for Staff 5, Staff 6, Staff 7 and Staff 8.

Human Resources will audit staff records for need of performance reviews Human Resources will establish a tracking mechanism to assure performance reviews are completed prior to anniversary date This deficiency of practice has the ability to affect all staff and resident care Human Resources will report completion rate of performance reviews to QAPI for the next three quarters

Resident 12 was admitted to the facility in 5/2025 with a diagnosis of a stroke. A 6/6/25 Admission MDS revealed Resident 12 had broken natural teeth. A 11/26/25 Care Conference attended by Resident 12 and Witness 1 (Family Member) revealed the resident did not receive dental services since her/his admission but was scheduled to be seen by a dental provider in 12/2025 or 1/2026. On 4/20/26 at 11:57 AM Resident 12 was observed in her/his room in bed with Witness 1 present. Resident 12 was observed with two broken bottom teeth on the left side of her/his jaw. On 4/20/26 at 11:57 AM Resident 12 and Witness 1 stated the resident did not receive dental services since her/his admission.-á On 4/24/26 at 11:24 AM Staff 14 (Social Services Director) confirmed Resident 12 was scheduled to be seen by a dental provider in the facility but was unaware of circumstances that prevented the resident from receiving scheduled dental services in 12/2025 or 1/2026. On 4/24/26 at 12:17 PM Staff 2 (DNS) stated social services notified her if a resident did not receive scheduled dental services. Staff 2 stated she was not notified that Resident 12 was unable to be seen by a dental provider in 12/2025 or 1/2026 and acknowledged the resident did not receive her/his scheduled dental services.-á

IDR was initiated on 5/12/2026

The facilityGÇÖs 7/19/24 Quality Assurance/Performance Improvement Plan (QAPI) for Rose Linn included oversight of Administration, Clinical Care Services, Nutrition Services, Pharmacy Services, Quality of Life and Engagement, Maintenance Services, Housekeeping, and Training And Orientation. The plan included use of a QAPI Committee, Analytics, Core Processes, and Medical Oversight for purposes of Performance Improvement Projects, Systematic Analysis, Communication, QAPI Self-Assessment, as well as Feedback and Data Monitoring.-á On 4/22/26 at 10:24 AM Staff 1 (Interim Administrator) stated there were no current performance improvement projects (PIP) programs in the facility. Staff 1 stated he could find any previous QAPI meeting notes. On 4/24/26 at 11:58 AM Staff 1 (Interim Administrator) acknowledged the evidence of a functional QAPI program.-á

IDR was initiated on 5/12/2026

The facilityGÇÖs 7/19/24 Quality Assurance/Performance improvement (QAPI) program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place.-á -The mission of Rose Linn is to provide the appropriate care for our residents to make their days the best they can be.-á On 4/24/26 at 11:48 AM Staff 1 (Interim Administrator) acknowledged the QAPI program did not recognize or address the following identified concerns:-á - Obtaining consent when psychotropic medications were used.-á - Implementing physician orders regarding wound care, mobility and bowel medications. - Implementing care plans to prevent falls. - Nurse aide performance reviews and required In-Service training.-á - Lack of appropriate infection control practices related to following CDC guidelines. Refer to F552, F684, F689, F730, F790, F880, and F947

IDR was initiated on 5/12/2026

A 2/2024 CDC Implementation of Personal Protective Equipment (PPE) Use In Nursing Homes to Prevent Spread of Multi-drug-resistant Organisms indicated enhanced barrier precautions was required during high-contact activities including device care or wound care.-á-á Resident 5 was admitted to the facility on 3/13/26 with diagnoses including acute cystitis (sudden bladder infection).-á A 3/30/26 Admission MDS indicated Resident 5 had a BIMS score of 1 which indicated the resident was not cognitively intact. A 3/14/26 MAR indicated staff performed daily wound care to Resident 5's left elbow. The order indicated the wound did not require a dressing.-á A 3/18/26 MAR indicated staff performed daily wound care to Resident 5's suprapubic catheter (a tube inserted through the stomach to drain urine from the bladder). The order indicated staff were to clean the site with warm soapy water or other gentle cleanser, pat dry and apply gauze.-á A 4/12/26 MAR indicated staff performed daily wound care to Resident 5's right elbow. The order indicated staff cleaned the wound with a cleanser, dried it and applied a new dressing. On 4/22/26 at 2:14 PM, Staff 19 was observed to empty Resident 30's suprapubic catheter bag without using PPE. Staff 19 stated she was unaware the resident was on enhanced barrier precautions.-á On 4/23/26 at 12:11 PM, Staff 13 stated Resident 5 did not require a dressing. Staff 13 removed Resident 5's left elbow dressing in the hallway. Staff 13 did not use PPE. On 4/23/26 at 12:17 PM, Staff 13 and Resident 5 returned back into her/his room. Staff 13 removed Resident 5's right elbow dressing and applied a new dressing. Staff 13 did not wear PPE. Staff 13 stated PPE was not required because she did not touch the resident's suprapubic catheter.-á On 4/24/26 at 10:07 AM, Staff 2 (DNS) stated staff were not required to use PPE when changing Resident 5's wounds on her/his left and right elbow because staff were not in close contact with the suprapubic catheter. Staff 2 stated staff were not required to use PPE when the catheter bag was emptied because the resident did not have a urine infection.-á -á

Nursing staff will be inserviced on 5/27 on the use of PPE and wound care procedures. All residents have the potential to be affected by the same deficiencies RCMs will conduct weekly audits that wound care procedures are being followed and report to the IPCP. IPCP will report to QAPI for the next 3 quarters

On 4/24/26 at 9:30 AM Staff 12 (Human Resources/Payroll Director) provided minutes for all-staff meetings and sign in sheets for 4/2025-4/2026. The minutes showed Staff 5, 6, 7, 8, 9, 10, and 11 attended various all-staff meetings, but did not indicate what topics were covered and how many hours of training were provided. On 4/24/26 at 9:39 AM Staff 12 stated staff were expected to attend the all-staff meetings to receive the required trainings. If the staff member was not in attendance, they received a packet of the materials covered. Staff 12 could not produce a record of topics covered and how many hours each CNA had attended or received. On 4/24/26 at 10:43 AM Staff 1 (Administrator) acknowledged the 12 hours of annual in-service trainings for CNAs was not completed. -á -á -á

Human Resources will audit for completion for Nursing Staff Training completion. This places all residents at risk for lack of quality care HR Director will maintain a record of each training and report completion of training to QAPI for 3 quarters

Based on interview and record review it was determined the facility failed to ensure residents were provided accurate information and informed in writing of advanced beneficiary information for 2 of 2 sampled residents (#s 114 and 115) reviewed for required beneficiary notification. This placed residents at risk for not being informed of financial liabilities and the right to an appeal. Findings include: Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) indicated notices are "valid when all patient specific information required by the notice is included." 1. Resident 114 was admitted to the facility in 9/2024 with diagnoses including diabetes and schizophrenia (mental health disorder). Resident 114's clinical record indicated the resident had Medicare Part A coverage. Resident 114's Profile indicated her/his financial and care POA (Power of Attorney) was Witness 3 (Family). A 9/25/24 facility email was sent to Witness 3 by Staff 9 (Former Social Services Director) that indicated Resident 114 was provided a Notice of Medicare Non-Coverage (NOMNC) form. The NOMNC form contained no information related to Resident 114's effective date of coverage, a date when coverage was to end or the contact information for the Quality Improvement Organization to request an appeal. A 9/28/24 Discharge Summary indicated Resident 114 was ready to discharge to her/his home with outpatient supervision. A 9/30/24 Social Services Note indicated Witness 3 did not sign and return Resident 114's NOMNC form. On 1/29/25 at 12:54 PM Staff 4 (Social Services Director) acknowledged Resident 114's NOMNC form was not valid due to incomplete information on the form. 2. Resident 115 was admitted to the facility in 11/2024 with diagnoses including dementia and a thoracic vertebrae (spine) fracture. Resident 115's clinical record indicated the resident had Medicare Part A coverage. A 12/17/24 Discharge Summary indicated Resident 115 completed her/his therapy services and was cleared to discharge. Review of Resident 115's clinical record revealed no Notice of Medicare Non-Coverage (NOMNC) form was provided to the resident. On 1/29/25 at 12:54 PM Staff 4 (Social Services Director) confirmed a NOMNC form was needed for Resident 115 and was not provided.

• Residents 114 and 115 are no longer active residents in the facility. Notice of Medicare Non-Coverage (NOMNC) will be mailed to each recipient via certified mail. • Staff in-serviced on 2/3 for Discharge Planning from Medicare Part A services and Notification of Medicare Non-Coverage (NOMNC) notifications • All residents with Skilled Orders have the potential for being affected by the same deficiency of practice. • Skilled Discharges will be audited for 3 quarters and reported to QAPI by Social Services or the appropriate Designee

OAR-411-085-0320: Residents' Rights: Charges and Rate

Refer to F582 ********************************************************

Based on interview and record review it was determined the facility failed to follow the resident's plan of care to prevent a fall for 1 of 1 sampled resident (#1) reviewed for falls. This placed residents at risk for falls with injury. Findings include: Resident 1 admitted to the facility in 2021 with diagnoses including dementia. The 8/16/23 revised Care Plan indicated Resident 1 was at risk for falls related to cognitive impairment and required assistance with mobility. Interventions included the use of a Hoyer (mechanical lift) for transfers. The Care Plan also indicated Resident 1 was resistant to care with interventions including to use a calm tone/approach and to not rush during care. A 9/28/23 facility fall investigation indicated Staff 5 (CNA) transferred Resident 1 using a Sara Lift (sit to stand transfer device) when the resident's foot slipped and the resident lost her/his balance. The resident hit her/his mouth and sustained a cut on the lower lip with bruising. Resident 1 was care planned for a two-person transfer using a hoyer lift. Staff 5 did not follow the Care Plan and used a Sara Lift instead of the Hoyer to transfer the resident. On 6/18/24 at 10:12 AM Staff 5 stated she was familiar with Resident 1. Staff 5 stated on the day of the incident, Resident 1 was to suppose to receive a shower. Staff 5 stated she was scared to use the Hoyer sling on Resident 1 due to her/his aggression when she/he was placed on the sling. Staff 5 further stated stated the facility was out of Hoyer slings at the time and instead of getting three or four staff to assist with transferring Resident 1, she decided to use the sit to stand to transfer the resident. Staff 5 stated Resident 1 did not fall but was guided to the floor. Staff 5 stated Staff 6 (LPN) was present during the entire incident. Staff 5 acknowledged Resident 1 was care planned for two-person assistance with a Hoyer for transfers. On 6/18/24 at 10:27 AM Staff 2 (RNCM) stated she was asked to look at Resident 1 after the fall. Staff 2 stated Resident 1 had a history of being resistant to care if she/he was not approached in a calm manner, and required a two person transfer. Staff 2 stated she asked Staff 5 if she used the sit to stand to transfer Resident 1 and Staff 5 indicated she did. Staff 2 stated she was informed by Staff 5 that Staff 5 transferred Resident 1 by herself. On 6/18/24 at 10:50 AM Staff 3 (CMA) stated she was next door in the medication room when Staff 5 asked for assistance with Resident 1. Staff 3 stated she and Staff 6 went into the room, and Resident 1's feet were off the sit to stand with her/his face leaning on part of the device. Staff 3 stated Staff 3 was present in the room when Staff 5 was told she was not suppose to use the sit to stand to transfer Resident 1, and was not suppose to transfer the resident alone. On 6/18/24 at 11:22 AM Staff 6 stated she was not in the room during Resident 1's fall and did not enter the room until Staff 5 yelled for assistance. Staff 6 stated Staff 5 tried to tell staff she was in the room with her but she was not. Staff 6 stated when she entered the room with Staff 5, the resident's lip was resting against the bar of the sit to stand. Staff 6 further stated Staff 5 was aware she was not supposed to use the sit to stand to transfer Resident 1. On 6/18/24 at 9:30 AM and 12:05 PM Staff 1 (Administrator) stated Staff 5 was terminated as a result of the incident on 9/28/23. Staff 1 acknowledged Staff 5 did not follow the care plan, resulting in Resident 1's fall.

1. Resident #1 was evaluated and treated per MD order post injury. See F689 Response for DNS reporting 2. All residents are potentially at risk for staff not complying with each residents Plan of Care. Care Plan Interventions are supervised by all charge nurses on each shift, each day on an ongoing basis. 3. DNS or designee will determine which residents require transfer assistance as indicated in their Plan of Care. The DNS or designee will conduct weekly observations for compliance with the transfer needs of each resident as indicated in their Plan of Care. Charge Nurses to be in-serviced by 9/20/24 on each residents Care Planned transfer needs including the availability and use of Kardex to instruct CNA/Nursing staff & Agency staff in residents transfer needs. 4. Observations and In-service training will be reported by DNS to the QA/QAPI meeting x 2 quarters to determine need for further action

****************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care Refer to F689 ******************

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 04/01/2024 and 04/07/2024, 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 interview and record review it was determined the facility failed to ensure treatment and services to maintain hearing abilities were provided for 2 of 2 sampled resident (#s 22 and 39) reviewed for hearing. This placed residents at risk for communication barriers and impaired hearing. Findings include: 1. Resident 22 admitted to the facility in 12/2022 with diagnoses including dementia and depression. Social Service Hearing and Vision Summaries revealed the following: -2/28/23: Resident 22 had difficulty hearing a speaker at conversational volume when there was background noise but could hear well once background noise was eliminated. Resident 22 was not seen for an audiology appointment since her/his admission. The resident and Witness 1 (Family Member) requested Resident 22 be seen because the resident had hearing aids in the past. Social Services was to schedule an appointment. -5/15/23 and 8/1/23: Resident 22 "was in the process to receive hearing aids through an audiology appointment per the resident and Witness 1's request." A 7/27/23 Quarterly MDS revealed Resident 22 had severe cognitive impairment. A 9/5/23 Progress Note revealed Staff 3 (RNCM) spoke with Witness 1 and an audiology appointment was scheduled in 5/2023 but was canceled and a new audiology appointment was made. On 9/5/23 at 11:18 AM Witness 1 stated she requested a hearing aid test to be completed for Resident 22 because she/he was hard of hearing and could not participate in conversations when Witness 1 visited. Witness 1 indicated the facility did not initiate an appointment and Resident 22 was "still" without hearing aids. Witness 1 further stated this was "frustrating" and "very important" because it was difficult for Resident 22 to understand and participate in conversations. On 9/6/23 at 12:45 PM Staff 3 stated he was new to his position and scheduled an audiology appointment for Resident 22 but was unaware this was an issue prior to his conversation with Witness 1 on 9/5/23. On 9/7/23 at 1:46 PM Staff 2 (DNS) and Staff 4 (RN) acknowledged Resident 22 did not have an audiology appointment scheduled timely. Staff 2 and Staff 4 stated staff were expected to communicate to Staff 8 (Social Service Director) to follow up and ensure appointments were made timely. Staff 4 stated Staff 8 was new to her position (two weeks). , 2. Resident 39 admitted to the facility in 12/2022 with diagnoses including depression and anxiety. A 7/20/23 Quarterly MDS revealed Resident 39 was moderately cognitively impaired. A Hearing Health Progress note dated 7/27/23 revealed Resident 39 needed an appointment with an ENT (Ear, Nose and Throat) specialist to have her/his ears cleaned. A review of Resident 39's medical record revealed no evidence an ENT appointment was scheduled. On 9/7/23 at 1:53 PM Staff 2 (DNS) and Staff 4 (RN) confirmed an ENT appointment was not made for Resident 39 to get her/his ears cleaned.

- Orders for Res 22 completed 09/13/23 and 39 completed 09/25/2023. - All residents have the potential for being affected by the same deficiency of practice. An audit of 100% of residents HA needs and follow up orders by SSD and/or designee by 10/27/23. - Audit new admits and new orders by SSD and RCM ongoing through the 24 hrs process. - Findings will be reviewed and reported to QAPI s Quarterly for 3 consecutive quarters by DNS and/or designee then as needed

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for medication complications and side effects. Findings include: Resident 6 admitted to the facility in 12/2022 with diagnoses including chronic heart failure and atrial fibrillation (an irregular, often rapid heart rate). A physician order dated 12/19/22 directed staff to administer digoxin (a cardiac stimulant [can cause many adverse side effects, is involved in multiple drug interactions, and can result in toxicity]) one time a day for chronic heart failure. A Pharmacy Recommendation dated 7/1/23 indicated "the facility to consider drawing digoxin level because no digoxin level was on file since admission in 12/2022." On 9/7/23 at 11:45 AM Staff 7 (Pharmacy Consultant) stated she completed monthly pharmacy reviews for Resident 6 and requested a digoxin level in 7/2023 but it was not completed. Staff 7 stated she could not locate a digoxin level and would expect the facility to monitor Resident 6's digoxin level to ensure Resident 6 was stable on her/his current digoxin medication. On 9/8/23 at 9:27 AM Staff 2 (DNS), Staff 4 (RN) and Staff 3 (RNCM) acknowledged the 7/1/23 pharmacy recommendation was not followed up on timely and they could not locate any documentation to verify Resident 6 had a base line digoxin level completed.

- Res 6 laboratory order completed on 09/08/2023. - All residents have the potential for being affected by the same deficiency of practice. An audit of 100% of resident’s orders and follow up by RCMs and/ or designee by 10/27/23 - Audit new admits and new orders during the 24 hrs process for orders follow up by RCMs and/or designee on going. - Findings will be reviewed and reported to QAPI s Quarterly for 3 consecutive quarters by DNS and/or designee then as needed.

Based on interview and record review it was determined the facility failed to ensure the resident's medical record included documentation of the resident's COVID-19 vaccination status for 1 of 5 sampled residents (#39) reviewed for COVID-19 vaccine immunization. This placed residents at risk for the COVID-19 virus. Findings include: Resident 39 admitted to the facility in 12/2022 with diagnoses including depression and anxiety. A 7/20/23 Quarterly MDS revealed Resident 39 was moderately cognitively impaired. A review of Resident 39's medical record revealed no information regarding her/his COVID-19 vaccination status. On 9/7/23 at 1:52 PM and 9/8/23 at 9:03 AM Staff 2 (DNS) and Staff 4 (RN) confirmed there was no documentation regarding Resident 39's COVID-19 vaccination status.

-COVID-19 vaccination Consent obtained for resident 39- vaccine. -All residents have the potential for being affected by the same deficiency of practice. An audit will occur of 100% of residents to determine if COVID-19 vaccination status is documented in the medical record by 10/27/23. -Audit new admits and new orders during 24 hrs process for vaccination records by RCMs or designee. -Findings will be reviewed and reported to QAPI Quarterly for 3 consecutive quarters by DNS and/or designee then as needed.

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

Refer to F685 ***** OAR-411-086-0260: Pharmaceutical Services Refer to F756 ***** OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care Refer to F887 *****

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment accommodated the individual needs and preferences for 1 of 2 sampled residents (#22) reviewed for restorative therapy. This placed residents at risk for skin breakdown. Findings include: Resident 22 was admitted to the facility in 3/2020 with diagnoses including stroke. The 6/2/22 progress note indicated Resident 22 stated she/he needed a new mattress due to the mattress being "sunk in." On 7/26/22 at 10:54 AM Resident 22 stated she/he wanted a new mattress due to the mattress being indented. On 7/26/22 at 10:54 AM Resident 22's mattress was observed to have a large indentation in the middle of the mattress. On 7/28/22 at 11:55 AM Staff 8 (RNCM) stated she was unaware of Resident 22's request for a new mattress as staff did not report it to her. Staff 8 acknowledged the progress note on 6/2/22 indicated the request for a new mattress and no follow up was completed. Staff 8 observed Resident 22's mattress and acknowledged it was visibly sunken in.

1. Resident 22 had an extra gel mattress topper in place, per her choice, on top of a regular good condition, pressure relieving mattress provided by the facility. The topper was re-ordered & replaced by staff on 8/1/22. 2. All resident bed mattresses were audited by 8/16/22 by Environmental Director to ensure all residents have appropriate intact mattresses, none needed replacement. 3. Mattress status for all beds will be audited quarterly by Environmental Director or designee and replaced as needed. When a resident moves in a resident assessment is completed to identify resident needs and preferences by the IDT. Identified needs are then incorporated into the resident’s care plan. The care plan is reviewed and updated quarterly or as needed if the IDT identifies resident needs and preferences have changed. 4. Results of above audit will be brought to QA meeting for 2 quarters to determine need for further action.

Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an advanced directive for 4 of 6 sampled residents (#s 20, 23, 33 and 48) reviewed for advanced directives. This placed residents at risk for not having their health care preferences honored. Findings include: Records reviewed for Residents 20, 23, 33 and 48 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 7/27/22 at 12:45 PM Staff 11 (Admissions Director) stated a POLST (Physician Orders for Life Sustaining Treatment) and advance directive were requested from residents prior to admission. Staff 11 stated if there is a POLST there is not typically an advance directive and if an advance directive were filled out it would be done by the charge nurse the day of admission. On 7/27/22 at 1:13 PM Staff 13 (RN) stated she does not offer the advance directives with new admissions, the Resident Care Managers would do the paperwork with the residents on the day of admission. On 7/27/22 at 1:14 PM Staff 8 (RNCM) stated the advanced directives are in the resident admission packet and she had not filled out an advanced directive with a resident since the pandemic. Staff 8 stated she put "please see POLST" on the top of the advance directive and she had not offered an advanced directive with residents or their representatives in over a year. On 7/27/22 at 1:32 PM Staff 2 (DNS) stated there was not a process for discussing advance directives with residents upon admission to the facility. Staff 2 stated the facility had not provided documentation or verify residents were notified of their right to formulate an advance directive. On 7/27/22 at 2:30 PM Staff 1 (Administrator) provided an undated advanced directive policy and procedure which stated it was the Resident Care Managers responsibility to discuss filling out an advanced directive with a new resident or their representative. Staff 1 stated it was his expectation that residents were presented with an advanced directive and informed upon admission.

1. Residents 20, 23, 48 records were reviewed & resident/resp. party were presented with advanced directive. Resident 33 is discharged from facility. 2. All resident records will be audited to make sure they include documentation that Advance Directive were offered by Medical Records Manager or designee by 09/20/2022. Resident/HCPOA/ Resp. party will be approached with advance directive if appropriate notification is not found in the resident records of current residents. Advanced Directives will be offered on Admission by RCMs/SSD/or designee by 09/20/22. Current Policies will be reviewed to make sure they include the need to provide Advanced Directive at Admission. Admission Coordinator, RCMs, DNS, Medical Records will be ins-serviced on the policy requiring the presentation of Advanced Directive by RCMs/SSD/or designee by 9/20/22. Admission Coordinator will place Advanced Directive in admission packets. RCMs/ SSD or designee will ensure that an appropriate Advanced Directive presentation at admission for new residents has occurred and is documented. 3. Medical Records will audit for completion within 14 days of new admissions. Results of audits to Administrator/QA/QAPI meeting x3 consecutive quarters to determine further action

Based on observation and interview it was determined the facility failed to ensure a clean and sanitary environment for 1 of 2 halls. This placed residents at risk for cross contamination. Findings include: 1. On 7/26/22 at 12:50 PM room 123 was observed to have garbage on the floor. On 8/1/22 at 10:30 AM room 123 floor was observed to be sticky with garbage and crumbs of food on the floor and under the bed including popcorn. Resident 28 stated the room had not been cleaned for a week. On 8/1/22 at 10:34 AM Staff 4 (Housekeeping Supervisor) stated room 123 was "one of our worst rooms." Staff 4 acknowledged the floor was sticky with garbage and crumbs of food under the bed including popcorn. 2. On 7/26/22 at 12:02 PM and 8/1/22 at 10:36 AM room 134 was observed to have a wall next to a resident's bed with several brown smudges on it. On 8/1/22 at 10:36 AM Staff 4 (Housekeeping Supervisor) acknowledged the brown smudges on the wall next to the resident's bed. Staff 4 attempted to remove the smudges with a cleaning wipe, some of the brown smudges were removed and she stated the rest were stains. On 8/1/22 at 10:46 AM Staff 26 (Maintenance Director) acknowledged the brown smudges on the wall and stated the wall was plastic and the smudges could be removed by deep cleaning the wall.

1. Room 123 & 134 Have been thoroughly cleaned. Room 123 is and will be cleaned twice daily based on resident’s current need. Housekeeping Supervisor will periodically audit Rm 123 to make sure 2x/day cleaning is sufficient. Audits will be kept by Housekeeping Director. 2. All rooms were audited by Housekeeping Supervisor by 8/8/2022 to ensure rooms are safe & clean. Housekeeping staff were in-serviced on the need to identify when increased cleaning frequency is needed. 3. Housekeeping Supervisor has set up a tracking system, all housekeeping staff in serviced on this system and was completed 8/8/2022. An audit will be completed by Housekeeping Supervisor/ or designee weekly. 4. Audits results will be brought to QA for 2 quarter to determine need for further action.

Based on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency CNA) adhered to professional standards of practice regarding Staff 17 not following Resident 1's care plan of a two-person assist for transfers. This resulted in Resident 1 sustaining a deep laceration on her/his left knee that required sutures. This placed residents at risk for accidents. Findings include: Resident 1 was admitted in 2015 with diagnoses including dementia. The resident's comprehensive care plan dated 9/17/15 revealed Resident 1 was a two-person assist with all transfers. The Quarterly MDS dated 1/13/22 indicated Resident 1 was severly cognitively impaired. The 4/7/22 progress note revealed Resident 1 sustained a deep laceration with profuse bleeding across her/his left kneecap during a transfer from bed to wheelchair caused by Staff 17 not following the care plan which included a two-person assist with all transfers. As a result, Resident 1 was sent to the hospital emergency department for sutures. The 4/7/22 hospital emergency department discharge summary revealed Resident 1 had a 6 cm (2.3 inches) laceration just below the left kneecap. As a result, the wound was repaired with twelve sutures. On 7/27/22 at 10:54 AM, Staff 2 (DNS) confirmed Resident 1 required a two-person assist for all transfers. Staff 2 stated Staff 17 had completed orientation on Resident 1's unit which included the facility's policy and responsibilities related to resident care plans. Staff 2 stated Staff 17 was oriented to use the Kardex (system of communication) for resident care plans and Staff 17 was familiar with this system as he had worked at this facility three times. Staff 2 stated Staff 17 should have requested assistance for transferring Resident 1 to her/his wheelchair. On 7/28/22 at 6:28 PM, Staff 17 stated the injury sustained by Resident 1 was "his fault" and it was an "unfortunate mistake". Staff 17 stated Resident 1 was a two-person assist for transfers, he did not follow the care plan and he did not ask for another person to assist with the transfer.

1. Incident with resident 1 was investigated and reported by DNS to DHS on 4/8/2022. DNS reported to agency regarding staff member involved in incident. 2. All residents are potentially at risk for staff compliance to Care Plan Interventions and are being supervised by all Charge Nurses/ all shifts on an ongoing basis as required. 3. DNS or designee will conduct weekly audits for compliance to Plan of Care including the transfer assistance needs of residents. Charge Nurses will be in-serviced on care plan and Kardex use so they can monitor and instruct CNA/Nursing staff & Agency staff in resident’s needs by 09/20/22. 4. Audits results and In-service training will be reported by DNS to the QA/QAPI meeting x 1 quarter to determine further action

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (# 28) reviewed for medication. This placed residents at risk for a change in condition. Findings include: Resident 28 admitted to the facility in 2021 with diagnoses including chronic obstructive pulmonary disease (COPD). The 7/11/22 physician orders indicated Resident 28 was to receive daily weights and to notify the physician if the resident gained two pounds in two days or five pounds or more in a week. The 7/2022 TARS and weight records indicated the following weights for Resident 28: -7/16/22: 220 pounds; -7/17/22: 224.6 pounds (4.6 pound weight gain); -7/18/22: 228 pounds (3.4 pound weight gain). There was no indication in the clinical record to indicate the physician was notified of the 4.6 pound weight gain on 7/17/22 or the 3.4 pound weight gain on 7/18/22. On 7/29/22 at 11:11 AM Staff 2 (DNS) acknowledged the physician was not notified of the 4.6 pound weight gain on 7/17/22 or the 3.4 pound weight gain on 7/18/22 and the physician orders were not followed.

1. Resident 28 weight variations as documented were reported to MD and noted. 2. All residents have potential for similar health monitoring needs and where applicable will be followed per order. DNS/designee will in-service all Charge Nurses & RCMs of policy for following and documenting physician orders 3. RCM/designee will audit for order compliance or order changes during Stand up 24 hrs report process review for compliance and report findings to DNS. 4. Audits results and In-service training will be reported by DNS to the QA/QAPI meeting x 1 quarter to determine need for further action

Based on interview and record review it was determined the facility failed to ensure residents received restorative aid (RA) therapy to prevent ADL decline for 2 of 3 sampled residents (#s 22 and 52) reviewed for RA and falls. This placed residents at risk for physical decline and a decrease in well-being. Findings include: 1. Resident 52 admitted to the facility in 2019 with diagnoses including dementia and history of falls. The Resident's 5/2/20 care plan, with revisions on 6/21/22, indicated she/he was on a restorative nursing program to maintain/improve functional status related to strengthening and ambulation skills. The 6/21/22 Assistive Devices Assessment indicated Resident 52 worked with Restorative Nursing with a goal to maintain current strength and ambulation ability. The Restorative program was currently on hold. On 7/29/22 at 1:00 PM Resident 52 stated she/he was not working with RA but it" would be good for someone to work with her/him so she/he can walk." On 7/28/22 at 12:04 PM and 8/1/22 at 10:45 AM Staff 8 (RNCM) stated there was not a current RA program due to staffing and the last time the facility had a restorative program was August of 2021. Staff 8 provided a list of 19 residents who required RA, including resident 52 and acknowledged there was no current program in place to ensure the residents received RA. , 2. Resident 22 was admitted to the facility in 3/2020 with diagnoses including stroke and weakness. The 3/3/20 Care Plan indicated the resident had a history of stroke, left sided weakness and impaired mobility. The 3/3/22 Annual MDS Functional Rehabilitation Potential indicated the resident required assistance to maintain functional status. The 6/2/22 Quarterly MDS indicated Resident 22 was cognitively intact. On 7/26/22 at 10:37 AM Resident 22 stated she/he would like to receive restorative therapy but the RAs were not available to assist her/him due to them being pulled to the floor to work as CNAs. Resident 22 further stated she/he was unable to open her/his left hand independently or move her/his left leg and foot independently. On 7/28/22 at 12:04 PM Staff 8 (RNCM) stated there was not a current RA program due to staffing and the last time the facility had a restorative program was August of 2021. Staff 8 provided a list of 19 residents who required RA, including Resident 22 and acknowledged there was no current program in place to ensure the residents received RA.

1. Resident 52, 22 have been reviewed with MD and residents will be evaluated by PT/OT for potential strengthening and establishing an RA program, 8/16/22 2. All residents with recent RA programs will be audited for potential for RA programs to be reinstated for RA by 09/20/22 All other residents will be evaluated Quarterly and on an as needed basis for potential for RA program needs. 3. The RA program will be re-implemented by 09/20/22. Staffing coordinator will schedule additional CNA for either day or eve shift. 4. RA program implementation will be reviewed on a weekly basis x 4 weeks then monthly by reviewing RA scheduling and documentation by RCMs or designee and brought to DNS. Audits will be reviewed in QA/QAPI Meeting to determine the need for further action for 2 quarters.

Based on interviews and record review it was determined the facility failed to ensure adequate transfer supervision to prevent injury for 1 of 2 residents (#1) reviewed for accidents. This failure resulted in Resident 1 sustaining a deep laceration with profuse bleeding across her/his left kneecap and required sutures at the hospital emergency department. Findings include: Resident 1 was admitted in 2015 with diagnoses including dementia. The resident's comprehensive care plan dated 9/17/15 revealed Resident 1 was a two-person assist with all transfers. The Quarterly MDS dated 1/13/22 indicated Resident 1 was severely cognitively impaired. The 4/7/22 progress note revealed Resident 1 sustained a deep laceration with profuse bleeding across her/his left kneecap during a transfer from bed to wheelchair caused by Staff 17 (Former Agency CNA) not following the care plan which included a two-person assist with all transfers. As a result, Resident 1 was sent to the hospital emergency department for sutures. The 4/7/22 hospital emergency department discharge summary revealed Resident 1 had a 6 cm (2.3 inches) laceration just below the left kneecap. As a result, the wound was repaired with twelve sutures. On 7/27/22 at 10:54 AM, Staff 2 (DNS) confirmed Resident 1 required a two-person assist for all transfers. Staff 2 stated Staff 17 had completed orientation on Resident 1's unit which included the facility's policy and responsibilities related to resident care plans. Staff 2 stated Staff 17 was oriented to use the Kardex (system of communication) for resident care plans and Staff 17 was familiar with this system as he had worked at this facility three times. Staff 2 stated Staff 17 should have requested assistance for transferring Resident 1 to her/his wheelchair. On 7/28/22 at 6:28 PM, Staff 17 stated the injury sustained by Resident 1 was "his fault" and it was an "unfortunate mistake". Staff 17 stated Resident 1 was a two-person assist for transfers, he did not follow the care plan, and did not ask for another person to assist with the transfer.

1. Resident #1 was evaluated and treated per MD order post injury. See F658 Response for DNS reporting 2. All residents are potentially at risk for staff compliance to Care Plan Interventions and are being supervised by all charge nurses on each shift, each day and on an ongoing basis. 3. DNS or designee will conduct weekly observation for compliance with transfer needs of each resident. Charge Nurses to be in-serviced on care plan information, availability and use of Kardex to instruct RLCC CNA/Nursing staff & Agency staff in resident’s needs by 09/20/22. 4. Audits results and In-service training will be reported by DNS to the QA/QAPI meeting x 2 quarters to determine need for further action

Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet resident needs for 2 of 2 resident halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Review of Direct Care Staff Daily Report from 6/1/22 through 7/28/22 revealed the facility failed to meet the state required minimum number of CNA staff for 35 of 58 days. The following interviews were completed by residents regarding staffing: 7/26/22 at 12:34 PM Resident 53 stated she/he has waited up to two hours for assistance from staff. Resident 53 stated she/he needed assistance with brief changes and getting back into bed. 7/26/22 at 12:45 PM Resident 20 stated staff took a long time to answer call lights. Resident 20 stated staff would ask what was needed and not return to assist her/him. 7/26/22 at 1:21 PM Resident 28 stated she/he waited up to an hour for the call light to be answered. 7/27/22 at 10:00 AM Resident 50 stated she/he had to wait "what seemed like an hour" for the call light to be answered. 7/27/22 at 10:40 AM Resident 5 stated the call light could take up to an hour to be answered. The following interviews were completed by staff regarding staffing: On 7/27/22 at 12:26 PM Staff 16 (CNA) stated staffing had been a struggle and at times it was overwhelming to complete her daily assignments. On 7/27/22 at 2:21 PM Staff 9 (CNA) stated residents did not always receive adequate care due to staffing shortages. Staff 9 stated she did not receive her breaks most days and only sat down during lunch time. Staff 9 stated that she was asked to stay late most days to help cover the following shift. Staff 9 also stated Sundays were the most challenging day for staffing needs and CMA's and charge nurses would have to assist with resident care. On 7/28/22 at 11:09 AM Staff 14 (CMA) stated the facility was understaffed most shifts. Staff 9 stated it was not uncommon for staff to do one-person transfers when a two-person transfers was indicated due to staffing shortages and not being able to wait for someone else to assist with the transfers. Staff 9 stated when asked, she would come in early or stay late to help out. Staff 9 stated Sundays were a struggle with the medication pass because the CNA's needed so much assistance with resident care. On 7/28/22 at 12:04 PM Staff 8 (RNCM) stated there was not a current RA program due to staffing and the last time the facility had a restorative program was August of 2021. Staff 8 provided a list of 19 residents who required RA and acknowledged there was no current program in place to ensure the residents received RA. On 7/29/22 at 7:28 AM Staff 24 (LPN) stated the facility was often short staffed. Nursing staff often had to care for up to six residents in addition to completing her nursing duties. On 7/29/22 at 9:19 AM Staff 15 (Staffing Coordinator/CNA) stated he attempted to staff to the daily requirements, but it had been a challenge with regular staff and agency staff calling off. Staff 15 stated he will cover CNA shifts when the requirements cannot be met and there are days the RCM's and the DNS have had to cover the floor to help out. On 7/29/22 at 1:36 PM Staff 2 (DNS) stated staffing had been a struggle with Sundays being the toughest day to cover. Staff 2 stated regular staff and agency staff call off and it was a struggle to find coverage. She stated the staffing coordinator, CMA's, RCM's and sometimes herself would cover as needed. Staff 2 stated the CMA's are not given sections but rather two to three resident's during their shift. Staff 2 stated staffing continued to be an ongoing struggle and they are actively trying to hire staff for several positions. Refer to F688.

1. Resident 53, 20, 28, 50, 5 needs were met without negative outcome. 2. All residents are at risk for delayed responses to calls for assistance if staffing shortage exists. CNAs not on shift will be contacted to cover shift as needed. Staffing Coordinator will increase the number of Agency shifts requests to assure staffing ratio is met when staff calls in. 3. Administrator will continue active hiring process ensuring wage scale for new hires is competitive; establishing new hire incentive bonuses; Increasing advertising; Scheduling on-site CNA Classes to use as recruitment; a General application for waiver for required RN hours will be made to DHS for NOC shift RN to meet requirement of RN hour; and Contacting agency staff to recruit as new hires for the facility prior to 9/20/22. Staffing/scheduling will be monitored by Administrator/or designee. Staffing Coordinator will request additional CNA staffing, including requests for Agency staffing to staff appropriately ahead of schedule. Documentation will continue to be kept by Administrator/designee of all active staffing requests and attempts to hire staff. 4. Administrator/DNS/designee will monitor for appropriate staffing on a weekly basis and report to QA QAPI Meeting on a quarterly basis to determine the need for further action

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours per day for 7 of 58 days reviewed for staffing. This placed residents at risk for lack of care. Findings include: Review of the Direct Care Staff Daily Reports from 6/1/22 through 7/28/22 revealed on 6/3/22, 6/17/22, 6/24/22, 7/1/22, 7/8/22, 7/15/22 and 7/22/22 there was no RN coverage for eight consecutive hours. On 8/1/22 at 9:55 AM Staff 2 (DNS) acknowledged the lack of RN coverage on the indicated dates.

1. RN coverage for 1 out of 7 days of the week demonstrates less that 7day/week & 8hour/day RN coverage. 2. All residents are potentially at risk for assessment delay due to RN staffing. No negative outcomes have occurred. 3. RN requirement will be met by having RCM or DNS cover the shift when an RN is not available by 09/20/22. This will be scheduled in advance as needed. Administrator/designee will continue advertising for facility RN staff, requesting agency staffing on a daily & weekly basis. A general application for waiver for RN Hours will be made to DHS for NOC RN hours to meet requirement. 4. DNS/designee will monitor for RN staffing on a daily & weekly basis and report to QA QAPI Meeting on a quarterly basis to determine need for further action.

Based on interview and record review the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (#28) reviewed for medication. This placed residents at risk for drug to drug interactions and adverse drug events. Findings include: Resident 28 admitted to the facility in 2021 with diagnoses including restless leg syndrome (RLS). The 6/6/22 physician order indicated Resident 28 was to receive ropinorole (antiparkinson agent and dopamine agonist medication used for RLS) 0.5 mg TID for RLS. The 7/7/22 progress note indicated Resident 28 complained of RLS and wanted treatment for relief. A request was sent to the physician to trial medication. A 7/7/22 fax from the physician indicated an order for Mirapex (antiparkinson agent and dopamine agonist medication used for RLS) 0.5 mg PO at bedtime. A 7/18/22 pharmacy recommendation note indicated Resident 28 received ropinorole 0.5 mg TID and Mirapex 0.5 mg QHS. The note indicated to evaluate the use of ropinorole plus Mirapex. The note further indicated the fax to the physician from nursing did not appear the preexisting order for ropinorole was acknowledged by nursing staff. On 7/18/22 the physician signed the recommendation and discontinued Mirapex. The 7/2022 MAR indicated Resident 28 received the following medication: -Mirapex at bedtime from 7/7/22 through 7/17/22; -ropinorole TID for the month of July. On 7/29/22 at 11:17 AM Staff 2 (DNS) acknowledged Resident 28 received both the ropinorole and Mirapex from 7/7/22 through 7/17/22. Staff 2 further acknowledged staff should have reviewed her/his medications prior to starting the Mirapex. Staff 2 acknowledged Resident 28 received medications with the same therapeutic and pharmacologic classifications resulting in duplicate therapy.

1. Resident 28 medication plan was reviewed, and plan is up to date per MD orders. 2. All current residents have been reviewed unnecessary drugs as reported by Pharmacist as of 8/10/2022 with no issues in drug interaction identified. 3. Nursing Staff will be in-serviced by DNS/designee as to appropriate notification to MD when requesting recommendations for resident medication needs, to include review of potential current medications which maybe unnecessary by 09/20/22 . RCMs will review through 24 hour report process for all new orders for accuracy of medication entry, interactions, unnecessary medications and documentation of new orders and report discrepancies to DNS as needed weekly. 4. DNS/designee will monitor RCM reporting on a weekly basis x 4 weeks then monthly to ensure proper training, in-service, and individualized counseling are completed as appropriate to the findings by RCMs; Audit results will be provided to QA/QAPI Meeting on a quarterly basis x2 quarters to determine need for further action.

Based on interview and record review it was determined the facility failed to have an appropriate indication for use of psychotropic medications for 1 of 5 sampled residents (#53) reviewed for medication. This placed residents at risk for receiving unnecessary medication and adverse side effects. Findings include: Resident 53 was admitted on 12/30/21 with diagnoses including anxiety disorder and depression. The 4/7/22 BIMS indicated Resident 15 was cognitively intact. A 5/3/22 physician note indicated Resident 15 had "anxiety/depression disorder- severe, [she/he] has a component of depression ,will increase Lexapro [antidepressant medication] and add Zyprexa [antipsychotic medication] and see if this helps with overall mood." A review of the clinical record indicated no documented behaviors for 3/2022, 4/2022 and 5/2022. The 5/16/22 pharmacy recommendation indicated Resident 53 received an antipsychotic drug Zyprexa without a clear diagnosis in the chart. Centers for Medicare and Medicaid Services (CMS) guidelines require the following conditions to support the use of antipsychotics. Please update diagnosis for the above antipsychotic. (A list of diagnoses was provided and the physician circled the diagnosis of "Behavioral or psychological symptoms of dementia (BPSD) (all antipsychotics carry a FDA Black Box Warning regarding the increased risk of death in elderly patients with dementia." On 7/28/22 at 8:46 AM Staff 23 (Activities Assistant) stated Resident 53 was alert and oriented and enjoyed 1:1 activities in her/his room. On 7/28/22 at 9:01 AM Staff 24 (LPN) stated Resident 53 was alert and oriented and her/his cognition had not changed since admission. On 7/28/22 at 9:11 AM Staff 25 (CMA/CNA) stated Resident 53 was "pretty alert" and able to make her/his needs known and was able to take her/himself to therapy daily. Staff 25 further stated Resident 53 was less anxious and more alert since admission. On 7/28/22 at 11:46 AM Staff 19 (Physical Therapist) was asked if Resident 53 was alert and oriented, Staff 19 stated "yes [she/he] definitely is." Staff 19 stated the resident admitted in December 2021 and had some anxiety and depression but "[Resident 53] is with it." Staff 19 further stated Resident 53 had made improvements in therapy and the plan was for her/him to discharge home. Staff 19 further stated her/his cognition had improved since admission and had no cognitive deficits. On 8/1/22 at 8:59 AM and 12:23 PM Staff 2 (DNS) acknowledged there were no documented behaviors for 3/2022, 4/2022 and 5/2022 for Resident 53. Staff 2 acknowledged there was no supporting documentation by the physician or facility staff to support the diagnosis of dementia and the use of Zyprexa.

1. Resident #53 appropriate indication for psychotropic medication was obtained on 5/17/2022 from MD. SLUMs completed. Resident had a GDR reduction of medication started on 8/15/2022 when seen by MD. Medication to be discontinued on 8/23/2022 if no negative outcome from GDR. 2. All residents have potential to be affected. All Behavior and Psychoactive reviews completed last on 8/10/2022 including pharmacist review with no further indicators found related to medication and diagnosis appropriateness 3. Licensed nurses, including RCMs to be in-serviced by 09/20/2022 on appropriate documentation for medications and required appropriate diagnosis. RCMs will review through 24 hour report process for all new orders on a day-to-day basis to look for accuracy of medication entry and diagnosis. Discrepancies will be reported to DNS as needed and weekly to determine if additional in-servicing is needed. 4. DNS/designee will monitor RCM reporting on a weekly basis to ensure proper training, in-service, and individualized counseling are completed as appropriate to the findings by RCMs; Audit results will be provided to QA Meeting on a quarterly basis x2 quarters to determine need for further action.

Based on interviews, and record review it was determined the facility failed to obtain therapy services for 1 of 2 sampled residents (#2) reviewed for accidents. This placed resident at risk for a decline in functional abilities and accidents. Findings include: Resident 2 was admitted to the facility 7/19/22 with diagnoses including Parkinson's Disease. The resident's care plan dated 7/19/22 revealed Resident 2 was at risk for falls due to impaired balance and mobility and a one person assist for all transfers. A 7/19/22 Nursing Admission Assessment indicated Resident 2 had weakness in her/his legs, a history of falls and a request for physical therapy (PT) was to be completed. A 7/20/22 Nurses Note indicated Resident 2 had a fall in her/his bathroom due to self-transferring from her/his wheelchair to the toilet. A 7/20/22 Fall Assessment-Post Fall indicated as a result of Resident 2's fall, a PT evaluation would be requested. A 7/22/22 Social Service Admission Assessment indicated Resident 2 had a goal to work with therapy to gain strength. On 7/22/22 a Brief Interview for Mental Status (BIMS) was conducted and revealed Resident 2 was cognitively intact. On 7/26/22 at 2:09 PM, Staff 3 (RN) confirmed Resident 2 had a fall in her/his bathroom. On 7/28/22 at 10:36 AM, Staff 19 (PT/acting rehab manager) stated Resident 2 had no order for a PT evaluation. On 7/28/22 at 2:57 PM, Resident 2 stated PT was not been offered to her/him and she/he expressed an interest in PT to gain strength. On 7/28/22 at 3:15 PM, Staff 18 (Social Services) confirmed Resident 2 expressed interest in PT but she did not make a recommendation. On 7/29/22 at 11:08 AM, Staff 21 (LPN, Resident Care Manager) acknowledged the 7/19/22 and 7/20/22 nurse's PT recommendations and confirmed Resident 2 did not have orders for a PT evaluation.

1. Resident 2 has received a PT 8/2/2022 and OT evaluation 8/4/2022. Therapies ongoing as ordered. 2. A resident audit was completed on 8/1/2022 and no other residents were affected. All therapy orders have been followed and new orders have been implemented. 3. RCMs will review through 24-hour report process all new orders and orders for new residents to look for accuracy of implementation of new orders. 4. DNS/designee will monitor RCM reporting on a weekly basis x 4 weeks then monthly to ensure proper training, in-service, and individualized counseling are completed as appropriate to the findings by RCMs; Audit results will be provided to QA Meeting on a quarterly basis x2 quarters to determine need for further action.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 37 of 58 days reviewed for staffing. This placed residents at risk for delayed assistance and unmet care needs. Findings include: Review of the 6/2022 and 7/2022 Direct Care Staff Daily Reports (DCSDR) revealed the following days the minimum CNA staffing ratios were not met: 6/5/22 day shift was short one CNA; 6/10/22 day shift was short one CNA; 6/12/22 day shift was short one CNA; 6/13/22 day shift was short one CNA and night shift was short one CNA; 6/14/22 day shift was short one CNA; 6/15/22 day shift was short one CNA; 6/17/22 evening shift was short one CNA; 6/18/22 day shift was short one CNA; 6/19/22 day shift was short 3 CNAs and evening shift was short 2 CNAs; 6/21/22 day shift was short 1 CNA; 6/24/22 day shift was short 1 CNA; 6/26/22 day shift was short 1 CNA and evening shift was short 2 CNAs; 6/30/22 day shift was short 1 CNA; 7/1/22 day shift was short 1 CNA; 7/3/22 day shift was short 1 CNA; 7/5/22 day shift was short 2 CNAs; 7/6/22 day shift was short 1 CNA; 7/7/22 day shift was short 1 CNA; 7/8/22 day shift was short 2 CNAs; 7/9/22 day shift was short 1 CNA; 7/10/22 day shift was short 1 CNA; 7/11/22 day shift was short 2 CNAs; 7/13/22 day shift was short 2 CNAs; 7/14/22 day shift was short 1 CNA; 7/15/22 day shift was short 1 CNA; 7/16/22 day shift was short 1 CNA; 7/17/22 day shift was short 3 CNAs; 7/18/22 day shift was short 2 CNAs; 7/19/22 day shift was short 1 CNA; 7/20/22 day shift was short 1 CNA; 7/21/22 day shift was short 1 CNA and night shift was short one CNA; 7/22/22 day shift was short 1 CNA; 7/23/22 day shift was short 1 CNA; 7/24/22 day shift was short 2 CNAs; 7/26/22 day shift was short 1 CNA; 7/27/22 night shift was short 1 CNA; 7/28/22 day shift was short 1 CNA. On 7/29/22 at 9:18 AM Staff 22 (Staffing Coodinator) confirmed the minimum CNA staffing ratios were not met on the dates listed. On 7/29/22 at 1:36 PM Staff 2 (DNS) was notified of the findings of this investigation and confirmed the staffing ratios were not met for the dates indentifed.

1. Resident's needs were met without negative outcome. All resources have been contacted when needed. 2. All residents are at risk for delayed responses to calls for assistance if staffing shortage exists. CNAs not on shift will be contacted to cover shift as needed. Staffing Coordinator will increase the number of Agency shifts requests to assure staffing ratio is met when staff calls in. 3. Administrator will continue active hiring process ensuring wage scale for new hires is competitive; establishing new hire incentive bonuses; Increasing advertising; Scheduling on-site CNA Classes if possible to use as recruitment; a General application for waiver for required RN hours will be made to DHS for NOC shift RN to meet requirement of RN hour; and Contacting agency staff to recruit as new hires for the facility prior to 9/20/22. Staffing/scheduling will be monitored by Administrator/or designee. Staffing Coordinator will request additional CNA staffing, including requests for Agency staffing to staff appropriately ahead of schedule. Documentation will continue to be kept by Administrator/designee of all active staffing requests and attempts to hire staff. 4. Administrator/DNS/designee will monitor for appropriate staffing on a weekly basis and report to QA QAPI Meeting on a quarterly basis to determine the need for further action

*********************************** OAR 411-086-0360 Resident Furnishings, Equipment Refer to F558 *********************************** OAR 411-085-0310 Admission of Residents [Advance Directive] Refer to F578 *********************************** OAR 411-087-0100 Physical Environment: Generally Refer to F584 *********************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658 and F684 *********************************** OAR 086-0150 Nursing Services: Restorative Care Refer to F688 *********************************** OAR 411-086-0140 Nursing Services: Problen Resolution & Preventative Care Refer to F689, F757 and F758 *********************************** OAR 411-086-0100 Nursing Service: Staffing Refer to F725 and F727 *********************************** OAR 411-086- 0220 Rehabilitative Services Refer to F825 ***********************************