Avalon Care Center - Scappoose

Resident was admitted on 9/2024 with diagnosis of diabetes. A PhysicianGÇÖs Order dated 1/24/26 directed Resident 2 to receive diabetic nail care every week on Saturdays. Resident 2's 1/19/26 Care Plan indicated licensed nurses were responsible for providing nail care to Resident 2. On 4/2/26 at 2:11 PM, observation revealed Resident 2GÇÖs left thumb nail was approximately 3/4 inches thick, significantly elevated off nail bed and discolored. Resident 2GÇÖs left index finger had minimal nail bed remaining. Resident 2 denied pain to her/his left fingers at time of observation. In an interview on 4/2/26 at 11:35 AM, Staff 10 (CNA) stated they do not provide nail care to Resident 2GÇÖs nails due to Resident 2GÇÖs diabetic status. Staff 10 reported occasionally cleaning but indicated Resident 2GÇÖs nail care was the responsibility of the nursing staff. On 4/2/26 at 1:41 PM, Staff 6 (RN) stated they had not performed nail care for Resident 2 and confirmed Resident 2GÇÖs left hand nails appeared not to have been maintained for at least a month. Staff 6 reported Resident 2GÇÖs nail care needs had been discussed among other nursing staff and that a note had been submitted to the provider for further evaluation; however, no follow-up has occurred. On 4/3/26 at 6:17 AM, Staff 7 (RN) stated they documented completion of Resident 2GÇÖs nail care in the DAR for Resident 2GÇÖs right hand only. Staff 7 reported they had not performed care on Resident 2GÇÖs left hand due to lack of skill, knowledge, and comfort level. Staff 7 stated the DAR instructions were vague and acknowledged Resident 2 requires specialized nail care services. On 4/2/26 at 5:15 PM, Staff 2 (DNS) acknowledged concern regarding the condition or Resident 2GÇÖs left thumb nail and stated Resident 2 had a history of ongoing fungal infection. Staff 2 stated they believed Resident 2's health insurance provider was responsible for managing Resident 2's nail care, Staff 2 was unable to provide documentation to support that nail care services had been completed.-á

1. Corrective Action for Resident Affected The resident identified during survey was immediately assessed by a licensed nurse. Fingernail care was completed in accordance with provider orders. The resident’s diabetic status and associated risks were reviewed. The care plan was updated to reflect individualized fingernail care needs, including frequency, staff responsible, and clinical considerations. 2. Identification of Other Residents at Risk A review was conducted of residents with diabetes requiring fingernail care. For identified residents, provider orders were verified, fingernail condition and completion status were assessed, and any concerns were immediately addressed. Care plans were reviewed and updated as needed. 3. Systemic Changes Implemented Licensed nurses to be educated on proper diabetic fingernail care practices, clinical considerations, identification of abnormalities, and documentation requirements. Education to be done by DNS or designee. During weekly skin assessments nurses to verify fingernail condition and completion of ordered care. Nurse management to oversee compliance through routine review. 4. Monitoring for Ongoing Compliance Audits for four (4) weeks and then monthly for two (2) months of 6 diabetic resident’s nails to include verification of care completion per order, observation of nail condition, review of documentation, and confirmation that any abnormalities are addressed. Audit results will be reported to the Administrator, Director of Nursing, and brought to the QAPI committee for tracking, trending, and to ensure the process remains in compliance.

Resident 11 was admitted to the facility in 4/2025 with diagnoses including Alzheimer's disease. The 12/8/25 Quarterly MDS indicated Resident 11 had a BIMS score of zero and was not cognitively intact.-á The 4/15/24 Care Plan indicated, notifying maintenance when the padded mobility bars were damaged or removed.-á -á On 12/15/25 through 12/16/2025 from 8:00 AM to 4:00 PM, the padding around the bed rails in Resident 11's room was unkept, the metal was rusty, and parts of the mobility bars were left uncovered, and the metal was exposed. -á On 12/17/25 at 1:19 PM, Staff 15 (CNA) stated she told maintenance, the nurses and the administrator when equipment was damaged and made sure equipment was safe before she used it. Staff 15 stated she didn't report any damaged equipment in Resident's 11 room. Staff 15 entered Resident 11's room and acknowledged the padding on the mobility bars were damaged.-á -á On 12/17/25 at 4:09 PM, Staff 12 (CNA) stated she didn't have concerns with the equipment in Resident 11's room. Staff 12 stated she reported broken and damaged equipment to maintenance and the nurses. Staff 12 entered Resident 11's and stated she guessed the padding on the bed rails needed replacement. Staff 12 acknowledged the padding was ripped. -á On 12/17/25 at 4:23 PM, Staff 3 (LPN- Unit Manager) stated she communicated with staff on the floor when damaged equipment was observed. Staff 3 stated she notified maintenance immediately. Staff 3 stated the paddings around the mobility bars were used for all residents to help prevent injury. Staff 3 stated she was unaware the padding in Resident 11's room was damaged. Staff 3 stated all staff had access and were expected to utilize the communication system to report damaged and broken equipment.-á -á On 12/19/25 at 3:48 PM, Staff 16 (Maintenance Director) stated he wasn't notified about damaged padding around the mobility bars in Resident 11's room. Staff 16 stated all staff had access to a communication system when damaged equipment was reported and should be entered in the system to alert him. Staff 16 stated he monitored the communication system daily.-á -á-á

Immediate: On 12/19/26 resident 11 had the foam protector on their bed enabler replaced. Education completed with Maintenance Director on ensuring protectors are replaced promptly when breaks occur. Identification of Others: A walkthrough was completed of resident rooms to identify other foam protectors that need replacement by maintenance director and administrator. Systemic changes: Education with nursing and housekeeping staff on identifying and reporting bed enabler bar issues. Monitoring: Audits of enabler bars to ensure that they do not have any flaking padding to be done weekly for 4 weeks, then monthly for 2 months. Results of audits to be shared with administrator and brought to QAPI for 3 months for tracking and trending to ensure process returns to compliance.

2. Resident 18 was admitted to the facility in 12/2024 with diagnoses including ischemic stroke (obstruction of blood flow to a part of the brain) and hemiplegia (decrease or loss of function of one side of the body). A review of Resident18GÇÖs medical records revealed the resident was hospitalized on 3/12/25, 4/14/25, 9/13/25, 10/15/25, and 10/29/25. Resident 18 was not provided a physical copy of the bed hold policy on those dates. On 12/17/25 at 3:51 PM Staff 14 (Social Services Director) stated a bed hold policy was to be provided to residents when they discharged to the hospital and were expected to return to the facility. Staff 14 confirmed the bed hold policy was not provided to Resident 18 on 3/12/25, 4/14/25, 9/13/25, 10/15/25, and 10/29/25. On 12/17/25 at 4:14 PM Staff 7 (RN) stated the paperwork provided to residents upon hospitalization was a face sheet, current orders, progress notes and a transfer notice. Staff 9 stated a bed hold policy form was not part of the paperwork provided to residents upon hospitalization. On 12/18/25 at 1:32 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 18 should have received a bed hold policy every time she/he was hospitalized and expected to return to the facility. , 1.Resident 8 was readmitted to the facility in 9/2025 with diagnoses including mechanical complications of an indwelling ureteral stent (a tube from the kidney to the bladder to maintain drainage). Resident 8's medical record indicated she/he was transferred to the hospital on 5/18/25, 6/15/25, 7/23/25 and 9/18/25. No evidence was found in Resident 8's clinical record indicating written notice of the facility's bed hold policy was provided to her/his representative when she/he was transferred to the hospital on 6/15/25, 7/23/25 and 9/18/25. On 12/18/25 at 10:43 AM, Staff 9 (RN) stated the nurses, or social services staff completed the bed hold policy. Staff 9 stated she didn't complete the bed hold policy when Resident 8 was hospitalized.-á On 12/19/25 at 10:51 AM, Staff 14 (Social Services Director) stated all residents were provided a bed hold policy when they admitted. Staff 14 stated she provided a bed hold policy once to the Resident 8's family representative. She acknowledged Resident 8's family representative wasn't provided a bed hold policy on 6/15/25, 7/23/25 and 9/18/25 when the resident was hospitalized. On 12/19/25 at 3:49 PM, Staff 2 (DNS) stated he expected staff to complete and provide the bed hold policy to the resident or representative prior to residents leaving to the hospital. Staff 2 acknowledged Resident 8's family representative was not provided a bed hold policy prior to his/her hospitalization on 6/15/25, 7/23/25 and 9/18/25.-á-á -á -á -á -á -á

Immediate correction: Resident 18 has discharged from the facility. Resident 8 had a bed hold form completed. Education done with SSD on bed hold notices. Identification of others: A review of residents who discharged over the last 30 days with an intent to return was completed and bed hold notices sent to any that were missing them. Systemic Changes: During IDT morning meetings reviews of discharges both emergent and planned to be done by IDT team with a check of bed hold notices being provided if appropriate to be done. Education with nurses on bed hold notices to be completed. Monitoring: Weekly for 4 weeks then monthly for 2 months audits of the process and proper bed hold notices being sent to be done by SSD or designee. Results of audits to be shared with the administrator and brought to QAPI for 3 months for tracking, trending, and to ensure the process returns to compliance.

The facility's 11/2017 Resident Assessment policy and procedure specified the following: -The facility would address residents' needs and strengths regardless of whether or not the issue was included in the MDS or CAAs. -The facility would use resident observation and communication as the primary source when completing assessments and also review records, communicate with staff and other sources as needed to complete residents' assessments. Resident 19 was admitted to the facility in 5/2025 with diagnoses including metabolic encephalopathy (a change in brain function due to an underlying condition) and hearing loss. A review of Resident 19's 6/5/25 admission MDS and 12/6/25 Quarterly MDS revealed she/he had severe cognitive impairment and she/he did not have hearing aids. The CAA for communication indicated she/he was hard of hearing without hearing aids and staff were to elevate their voices when speaking to her/him. On 12/18/25 at 5:17 PM Staff 4 (MDS Coordinator) stated she was responsible for completing the facility's MDS assessments and acknowledged information about Resident 19's need to use hearing aids was not captured in the 6/5/25 Admission MDS or the 12/6/25 Quarterly MDS assessment. Staff 4 stated it was necessary for MDS assessments to be accurate to ensure care plan interventions would be developed in a timely manner.

1. Corrective Action for the Affected Resident The resident’s hearing status and hearing-aid needs were reassessed. The MDS was corrected/modified to accurately reflect hearing-aid use, level of staff assistance required, and barriers to hearing function if present. The comprehensive care plan was reviewed to ensure it matches the resident’s needs and the corrected MDS. Education was provided to the Unit Manager and MDS Coordinator regarding accurate coding of hearing-aid use and alignment with the care plan. 2. Identification of Other Residents at Risk An audit was completed of residents in the last 3 months with MDS’s due for hearing accuracy. Their MDS assessments were reviewed to verify that their hearing ability is accurate along with their assistive device along with the level of assistance were accurately coded and consistent with the care plan. Any discrepancies were corrected immediately and reported to the Director of Nursing. 3. Systemic Changes MDS staff and licensed nurses involved in assessment and care planning were educated regarding, correct coding of hearing status and hearing-aid use and ensuring that MDS data matches both the care plan and the actual care being provided. Communication expectations were reinforced between charge nurses and the MDS Coordinator when assistive-device needs change. 4. Monitoring Audits of new and corrected MDS assessments for hearing-aid needs will be completed weekly for 4 weeks and then monthly for 2 months. Audits will verify accurate coding of hearing-aid use and assistance, consistency between the MDS, orders, and care plan, and that documentation supports the coding. Results will be shared with the Administrator and reviewed in QAPI for 3 months. Any variance will result in immediate correction and staff re-education as needed.

The facilityGÇÖs 11/2017 Comprehensive Care Plans policy and procedure indicated a care plan will be comprehensive and person-centered. It will drive the type of care and services that a resident receives and will describe the residentGÇÖs medical and nursing needs as well as how the facility will assist in meeting those needs. Resident was admitted to the facility in 7/2019 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs and torso). A Care Plan revised 9/6/25 stated Resident 1 was at risk of constipation as result of bowel incontinence and was to have one bowel movement every three days. No information was included regarding Resident 1GÇÖs normal bowel movement consistency. On 12/18/25 at 4:58 PM Staff 9 (RN) stated Resident 1 was at risk for constipation due to quadriplegia and she/he was monitored daily to ensure she/he had two bowel movements each day. Staff 9 stated Resident 1GÇÖs normal bowel movements were of loose consistency. Staff 9 stated if the expected frequency or consistency did not occur, a bowel assessment was to be performed on Resident 1 and she/he was to receive a suppository to prevent constipation and fecal impaction. On 12/19/25 at 12:20 PM Staff 2 (DNS) confirmed Resident 1GÇÖs care plan did not accurately reflect Resident 1GÇÖs bowel care needs including frequency of bowel movements, bowel movement consistency and what Resident 1GÇÖs normal bowel movements were. Staff 2 stated having Resident 1GÇÖs care plan reflect her/his bowel care needs was important to prevent complications from constipation and fecal impaction.

1. Corrective Action for the Affected Resident The resident’s comprehensive care plan was reviewed and updated to accurately reflect the physician-ordered bowel regimen, including the daily suppository, monitoring parameters, and documentation expectations. The resident was assessed, and no negative outcomes were identified as a result of the care-plan omission. Education was provided to the Unit Manager regarding clarification of bowel-related orders, ensuring bowel regimens are implemented per the facility bowel protocol, and timely and accurate reflection of bowel programs in the resident care plan. Nursing staff responsible for the resident’s care were notified of the updated care plan and expectations. 2. Identification of Other Residents at Risk A facility-wide audit was completed of residents receiving bowel regimens such as laxatives, stool softeners, suppositories, enemas, or other bowel programs. Residents whose bowel regimen was not reflected in the care plan had the care plan updated immediately. Results were reported to the Director of Nursing. 3. Systemic Changes Implemented to Prevent Recurrence Licensed nursing staff and nurse management staff educated on identifying and accurately reflecting each resident’s bowel care regimen in the comprehensive care plan. 4. Monitoring & Quality Assurance An audit of new admissions and residents with new or revised bowel care orders will be conducted to ensure the bowel regimen is reflected in the comprehensive care plan. These audits will be completed weekly for 4 weeks, then monthly for 2 months by the DON or designee. The results of these audits will be shared with the Administrator and reviewed during the facility QAPI Committee meetings for 3 months to ensure sustained compliance and effectiveness of the corrective actions. Any areas of non-compliance identified during the monitoring period will be immediately corrected, and staff re-education will be provided as indicated.

Resident 19 was admitted to the facility in 5/2025 with diagnoses including metabolic encephalopathy (a change in brain function due to an underlying condition) and hearing loss. A review of Resident 19's 6/5/25 admission MDS revealed she/he had severe cognitive impairment, functional limitation in range of motion of both sides of her/his upper body, was dependent on staff for completion of ADLs and she/he did not have hearing aids. The CAA for communication indicated she/he was hard of hearing without hearing aids and staff were to elevate their voices when speaking to her/him. A review of Resident 19's care plan revealed she/he had a communication deficit related to being hard of hearing without hearing aids. No evidence was found in the care plan for staff to provide Resident 19 with assistance to use her/his hearing aids. Random observations from 12/15/25 through 12/16/25 from the hours of 11:00 AM through 2:00 PM, Resident 19 was observed without hearing aids. On 12/16/25 at 3:29 PM Resident 19 was observed wearing hearing aids. Resident 19 stated they were her/his hearing aids but she/he did not know who helped her/him put them in or take them out. Resident 19 stated she/he did not know who was supposed to put her/his hearing aids in the charger when she/he was ready for bed. On 12/17/25 at 10:47 AM Staff 10 (CNA) stated he normally worked with Resident 19 during the day shift and was unaware she/he had hearing aids because it was not listed in her/his Kardex (a quick reference summary of resident needs). He stated when Resident 19 stated she/he could not hear him he spoke louder. On 12/17/25 at 12:49 PM Staff 11 (CNA) stated Resident 19 was hard of hearing and her/his family told him she/he had hearing aids. Staff 11 stated Resident 19GÇÖs hearing aids were not listed in her/his Kardex and he thought it was GÇ£oddGÇ¥ because she/he lived in the facility for several months. On 12/17/25 at 2:02 PM Staff 12 (CNA) stated she worked with Resident 19 in the evening three days each week. Staff 12 stated when Resident 19 was in bed, she occasionally found hearing aids sitting on the windowsill next to her/his bed. Staff 12 stated she believed they were Resident 19GÇÖs and she put them in the charger on her/his nightstand. Staff 12 stated Resident 19GÇÖs hearing aids were not listed in her Kardex and her/his family GÇ£never said anything about the hearing aidsGÇ¥ when they visited her/him. On 12/18/25 at 1:28 PM Resident 19 was observed in her/his room and not wearing hearing aids. Resident 19 was unable to hear questions asked of her/him by the Surveyor in a normal speaking voice. Resident 19 stated she/he had hearing aids and wanted to wear them when she/he was out of bed. -á-á -á On 12/18/25 at 5:00 PM Staff 3 (LPN, Unit Manager) acknowledged Resident 19 was ""very hard of hearing"" and required hearing aids which the resident had in her/his room for hearing and communication. Staff 3 stated staff members did not provide adequate assistance with Resident 19's hearing aids because it was not reflected in the care plan.

1. Corrective Action for the Affected Resident The resident’s comprehensive care plan was reviewed and updated to include Assistance required for hearing-aid placement and removal, cleaning and battery maintenance, storage location and labeling, daily hearing-aid checks for function and fit, and documentation expectations when the device is not in place and why. Education was provided to the Unit Manager and MDS regarding ensuring assistive device needs (including hearing aids) are clarified with providers and therapy, implementing device-related interventions per facility protocol, and ensuring care needs are clearly reflected in the care plan and communicated to staff. Nursing staff responsible for the resident were notified of the updated care plan and expectations. 2. Identification of Other Residents at Risk An audit was completed of residents with hearing aids or other assistive hearing devices. Care plans were reviewed to ensure the level of assistance needed for device care and placement was included. Any missing or incomplete care-plan interventions were updated immediately. Results of the audit were reported to the Director of Nursing. 3. Systemic Changes Clinical staff will receive education, recognizing sensory assistive-device needs (hearing aids, glasses), accurately reflecting those needs in the comprehensive care plan, daily use, storage, labeling, maintenance, and loss-prevention practices for hearing aids, and documentation expectations when devices are refused, lost, or not functioning. Education completed by the DON or designee 4. Monitoring Audits of new admissions and residents with hearing aids or assistive-hearing devices will be completed weekly for 4 weeks and then monthly for 2 months. Audits will verify that hearing-aid assistance needs are identified, care plans reflect the assistance required, and staff are assisting as planned. Audit results will be shared with the Administrator and reviewed in QAPI for 3 months. Any variance will result in immediate correction and staff re-education as needed.

Resident 11 was admitted to the facility in 2024 with diagnoses including Alzheimer's disease. -á The 4/15/24 Care Plan indicated Resident 11 required one person substantial to dependent assistance completing personal hygiene and directed staff to offer and encourage nail care twice per week on shower days.-á -á The 12/8/25 Quarterly MDS, revealed Resident 11 had a BIMS score of zero which indicated the resident was not cognitively intact and required maximum assistance to complete personal hygiene.-á -á The 12/2025 Documentation Survey Report indicated Staff 15 (CNA) completed a shower for Resident 11 on 12/16/25 and didn't provide nail care.-á -á On 12/15/25 through 12/17/25 from 8:00 AM to 4:00 PM, Resident 11 had untrimmed nails. The left hand had uneven trimmed fingernails. Two nails had a brown substance under the nailbed. The right hand had untrimmed fingernails, and four nails had a yellow and brown substance under the nailbed. -á -á On 12/15/25 at 3:35 PM and 12/15/25 at 2:22 PM, Resident 11 stated she/he was unsure when staff performed nail care and would allow staff to complete nail care when they offered. -á On 12/17/25 at 1:35 PM, Staff 15 stated Resident 11 was pleasant and cooperative. Staff 15 stated she had great rapport with the resident and was able to complete personal hygiene tasks. Staff 15 stated she didn't provide nail care on 12/16/25 and stated she didn't double check her/his nails post shower. Staff 15 stated she was unsure if nail care was supposed to be provided on shower days. Staff 15 entered Resident's 11 room and acknowledged the resident's nails were dirty, cracked and needed to be trimmed. -á On 12/17/25 at 4:13 PM, Staff 12 (CNA) stated CNAs were able to perform nail care since Resident 11 was not diabetic. Staff 12 stated she performed nail care when resident's nails were long and typically completed nail care post shower. Staff 12 entered Resident 11's room and acknowledged the resident's nails were covered in ""gunk"" under the nailbed and required trimming. Staff 12 stated she didn't perform nail care for Resident 11.-á -á On 12/17/25 at 4:23 PM, Staff 3 (LPN- Unit Manager) stated CNAs were able to perform nail care on non-diabetic residents. Staff 3 stated Resident 11 was combative and refused nail care. Staff 3 acknowledged Resident 11's nails were unkept and expected staff to perform nail care after showers. Staff 3 stated Resident 11 was dependent on staff for personal hygiene and expected CNAs to implement and follow the care plan.-á -á On 12/18/25 at 10:51 AM, Staff 9 (RN) stated she was unaware Resident 11 refused nail care and expected staff to perform nail care after Resident 11 showered.-á -á

1. Corrective Action for the Affected Resident Nail care was provided to the affected resident. The care plan was updated to show the level of assistance needed for nail care and frequency. The resident was assessed and no negative outcomes were identified. The Unit Manager was educated on regarding ensuring nail-care needs are added to the care plan and monitored. 2. Identification of Other Residents at Risk An audit of dependent resident’s care plans to ensure they have their nail care needs listed. Any resident without nail-care needs listed in the care plan was updated immediately, and nail care was provided if needed. 3. Systemic Changes CNAs and licensed nurses were educated to provide nail care for residents who are dependent on staff, ensure nail-care needs are reflected in the care plan. 4. Monitoring 3 residents on each hall will have nail-care audits completed weekly for 4 weeks, then monthly for 2 months. Audits will confirm that nail care is provided and listed in the care plan when assistance is needed. Results will be shared with the Administrator and QAPI for 3 months.

The 11/2017 Quality of life: Activities Policy indicated the following: -The facility activities will be meaningful to the residents.-á -Activities will enhance the physical, cognitive and emotional health of the residents. -Activities are scheduled daily, and residents are given an opportunity to contribute to the planning, preparation and conducting of the program as able and as appropriate. -The activity program consists of individual, small and large activities which are designed to meet the assessed needs and interest of each resident. Resident 13 was admitted in 9/2025 with diagnoses including chronic pain and muscle weakness.-á The 9/29/25 Care Plan indicated the following: -Resident 13 wishes to attend spiritual activities.-á -Staff to post calendar in room and remind and offer her/him to participate in activities.-á The 10/5/25 Admission MDS indicated Resident 13 was cognitively intact. The MDS indicated the resident liked listening to music, being around animals, read the newspapers/magazines and participating in religious services were important activities to the resident.-á The 11/2025 Documentation Survey Report indicated Resident 13 didn't participate in any in or out of the room activities. On 12/15/25 through 12/18/25 from 8:00 AM to 4:00 PM, Resident 13 was observed in her/his room in bed. No music, books, magazines or newspapers were visible in the resident's room. No activity calendar was posted in her/his room. On 12/15/25 at 1:33 PM, Resident 13 was lying flat in bed and stated she/he was in pain and didn't tolerate sitting in the wheelchair to participate in group activities. Resident 13 stated staff didn't offer an alternative activity to do in her/his room.-á On 12/17/25 at 8:51 AM, Resident 13 was lying flat in bed and stated using the Hoyer (mechanical) lift and frequent incontinence episodes were barriers to getting out of bed and participating in group activities. Resident 13 stated an activities calendar was not offered. Resident 13 stated group activities were offered daily including the weekends. On 12/18/25 at 10:10 AM, Staff 10 (CNA) stated Resident 13 tolerated being out of bed for one hour but preferred to stay in bed due to pain in her/his legs. Staff 10 stated Resident 13 participated in group activities when she/he was out of bed but was unsure in room activities were offered. Staff 10 stated Resident 13 was discouraged because she enjoyed activities in her/his room but was not offered things to do in her/his room.-á On 12/18/25 at 10:35 AM, Staff 17 (CNA) stated Resident 13 preferred staying in bed when group activities were offered. Staff 17 stated one on one visits were not an option due to lack of staffing, but group activities were offered daily. Staff 17 stated Resident 13 refused coloring pages and books when offered. -á On 12/18/25 at 10:58 AM, Staff 9 (RN) stated Resident 13 participated in group activities. Staff 9 stated Resident 13 didn't get out of bed due to chronic pain. Staff 9 stated in room activities included card games and were facilitated by the CNAs or the Staff 18 (Activity Director). -á On 12/18/25 at 11:10 AM, Staff 18 stated she offered residents who preferred to stay in bed word searches, coloring pages and card games. Staff 18 stated she provided activity calendars for all residents. Staff 18 stated Resident 13 preferred staying in bed and didn't participate in group activities. Staff 18 stated a sound machine and activities calendar was in Resident 13's room. Staff entered Resident 13's room and acknowledged the resident didn't have an activities calendar or sound machine in her/his room.-á On 12/19/25 at 10:55 AM, Staff 3 (LPN Unit Manager) stated residents who preferred to stay in bed were offered one on one visits. Staff 3 stated Resident 13 participated in group activities, napped and watched tv. Staff 3 was aware Resident 13 refused participating in group activities. Staff 3 stated Resident 13 complained staying out of bed for long periods of time due to chronic pain. Staff 3 acknowledged Resident 13 wasn't offered in room activities.-á -á -á -á -á -á -á -á -á -á -á -á -á -á

Immediate Correction: Resident 13 was provided with an activities calendar and had one hung up in her room and information on how to access her streaming music was provided. Education with the Activities Director was completed on ensuring calendars are posted for each resident and that residents are offered activities based on their preferences. Identification of Others: A review of residents to ensure calendars were posted in all rooms was completed by Activities Director or designee. A review of residents participation in the last month was completed with residents who are not participating in in room or group activities was reviewed to ensure that careplan for their activities preferences were being followed and any corrections needed made immediately. Systemic Changes: Education with activities staff on ensuring that resident preferences are followed, that activity calendars are hung in rooms, and to monitor when residents are not participating in activities to determine if resident’s careplan needs to be adjusted. Monitoring: Weekly for 4 weeks then monthly for 2 months an audit of activity calendars in resident’s rooms and residents participation in activities will be completed by Activities Director or Designee to ensure that those not participating in 1:1 and group activities are having their careplans followed. Results of audits to be shared with administrator and brought to QAPI for 3 months for tracking, trending, and to ensure the process returns to compliance.

The 8/2018 Quality of Care Skin Integrity Policy indicated the following: A weekly evaluation of the PU/PI (Pressure Ulcer/Pressure Injury) will include: -Evaluation of the PU/PI, if no dressing is present. -Evaluation of the status of the dressing, is present. -Status of the area surrounding the PU/PI (without removing existing dressing). -If pain is present, is it being controlled.-á PU/PI documentation will include: -The type of injury (pressure versus non-pressure) -The stage -A description of the PU/PI's characteristics -Progress toward healing and identification of potential complications -If infection is present.-á Resident 13 admitted to the facility in 9/2025 with diagnoses including quadriplegia (paralysis or significant weakness in both arms and legs). A 2024 Care Plan indicated the following: -Monitor/document wound size, depth, margins: peri wound skin, sinuses, undermining, exudate, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated.-á A 11/2025 Skin & Wound Evaluation indicated Resident 1 developed a facility acquired stage three pressure ulcer (wound extends through skin into fat). Revealed the following. -11/20/25 the wound measured 1.6 in length and 0.9 in width. New wound. Staff did not include a description of the wound. -11/29/25 the wound measured 0.2 in Length and 0.2 in width. Wound was improving. Staff did not include a description of the wound. -12/9/25 the wound measured 1.45 in length and 1.23 in width. Wound was improving. Staff did not include a description of the wound. -12/17/25 the wound measured 2.95 in length and 3.11 in width. The wound was healed and resolved. Staff did not include a description of the wound. The medical record indicated Resident 1's wound care order started on 11/21/25 and ended on 12/18/25. The wound care order indicated the following: -Cleanse buttocks, apply collagen and hydrogel, pack with alginate and cover with a foam dressing. Change every 2 days and as needed. One time a day every 2 day(s). On 12/18/25 at 11:38 AM and 2:01 PM, Staff 9 (RN) performed PPE (Personal Protective Equipment) prior to exposing Resident 1's coccyx (bone located at the end of the spine). There was no dressing over the area which was closed and was blanchable. Staff 9 stated the residents wound was healed and wound care orders were discontinued.-á On 12/18/25 at 2:11 PM, Staff 9 stated staff used a wound care app which monitored progression and measurements of wounds. Staff 9 stated no training was offered for the wound app and she was trained by other staff who utilized the wound app. Staff 9 stated she was unsure what the wound app measured when she documented the wound. Staff 9 stated the measurements she took were not accurate and additional instructions were not provided on how to utilize the wound app. On 12/19/25 at 2:14 PM, Staff 3 (LPN- Unit Manager) stated staff used a wound app to monitor progression and the size of wounds. When staff used the wound app they used a paper measuring tape to compare wound measurements for accuracy. Staff 3 stated her and Staff 2 (DNS) monitored the wound app daily. Staff 3 stated the wound app measured growth and progression of wounds when a sticker was placed near the wound. Staff 3 stated staff were able to manually enter measurements if the wound app measured the wounds incorrectly. Staff 3 stated no policy or education was provided relating to the wound app. Staff 3 stated a healed wound wouldn't have measurements. Staff 3 stated the wound to Resident 1's buttocks was not measured or documented accurately. Staff 3 acknowledged proper measurements and documentation were an important part of wound care to ensure appropriate healing of a wound.-á On 12/19/25 at 3:00 PM, Staff 2 stated staff used a wound care app that was used for pictures and measurements. The wound care app included a sticker and communicated with a cell phone. The sticker was placed near the wound and Staff 2 expected staff to place the sticker accurately to ensure accurate measurement of the wound. Staff 2 stated no formal education was provided on how to use the wound app but Staff 9 trained other staff on the floor on how to use the wound care app. Staff 2 stated he was unsure what the wound care app measured taken by Staff 9 once Resident 1's wound was healed. Staff 2 acknowledged measurements were not accurate and expected staff verified measurements and used a paper measuring tape for accuracy. -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á

1. Corrective Action for the Affected Resident Resident #1’s wound and surrounding skin were reassessed. The wound status was confirmed as healed. Documentation was updated to reflect the healed status and to correct inaccurate entries where healed tissue had been measured in error. Wound treatment orders were discontinued as appropriate. No adverse resident outcomes were identified as a result of documentation errors. Staff involved in the resident’s wound documentation were educated regarding complete and accurate wound documentation consistent with facility policy. 2. Identification of Other Residents at Risk An audit of residents with pressure injuries completed. Documentation was reviewed to ensure wound descriptions included wound type, stage, wound bed characteristics, peri-wound condition, signs of infection, healing progress, size measurement and pain status. Any missing or inaccurate documentation was corrected immediately and staff were re-educated as needed. Results were reported to the DON. 3. Systemic Changes Implemented Education with Licensed nurses regarding the facility Skin Integrity Policy including requirements that weekly wound evaluations include wound type, stage, wound characteristics, signs of infection, pain assessment, size measurements, and progress toward healing. Staff were instructed that healed wounds are not to be measured, and the healed status must be documented. 4. Monitoring and Quality Assurance The DON or designee will audit residents with wounds weekly for 4 weeks, then monthly for 2 months. Audits will verify that wound documentation includes required policy elements, measurements are manually obtained and accurate, healed wounds are not measured, and documentation reflects the resident’s clinical condition. Audit results will be shared with the Administrator and reviewed at QAPI for 3 months. Any deviation from policy will result in immediate correction and staff re-education.

2. Resident 1 was admitted to the facility in 7/2019 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs and torso). A 12/4/23 physician order included hand splints to be placed on both hands at night and remain on the residentGÇÖs hands for four hours for skin care. The order was discontinued on 9/19/25 with no information was located to indicate why the splints were discontinued. A 9/6/25 Care Plan included instructions for splints to be worn on both hands for four hours at night to prevent contractures. -á On 12/18/25 at 12:35 PM Resident 1 stated she/he was unaware he was supposed to wear hand splints at night, and staff did not assist her/him with placing or removing the bilateral hand splints. On 12/18/25 at 1:10 PM Staff13 (CNA) stated she followed care instructions from a computer to determine Resident 1GÇÖs care needs and documented when care was provided. Staff 13 reviewed Resident 1GÇÖs task records for each shift and stated no instructions were found regarding Resident 1 wearing bilateral hand splints at night and no place to document if the resident wore her/his bilateral hand splints.-á On 12/18/25 at 1:42 PM Staff 3 (LPN - Unit Manager) stated instructions for Resident 1 wearing bilateral hand splints were missing from her/his orders. Staff 3 stated the orders for the bilateral hand splints were discontinued on 9/18/25 and she was unable to locate documentation on why the order was discontinued. Staff 3 stated Resident 1GÇÖs bilateral hand splint orders should have continued after 9/17/25 to prevent contractures and skin issues. On 12/18/25 at 1:59 PM Staff 2 (DNS) confirmed Resident 1GÇÖs care instruction regarding the use of wearing bilateral hand splints were missing from the order. Staff 2 stated no records indicated Resident 1 had been assisted with bilateral hand splints since 9/17/25. -á , The facilityGÇÖs 11/2017 Quality of Life ADLs/Maintain Abilities Policy indicated the facility provided necessary care and services to prevent avoidable decline in ADLs, ensured residents received treatment to maintain or improve ADL abilities, including mobility, and staff avoided using clinical diagnoses as the sole justification for decline. 1. Resident 3 was admitted to the facility in 3/2023 with diagnoses including AlzheimerGÇÖs disease, generalized weakness, and pain. Random observations from 12/15/25 through 12/19/25 from 8:50 AM to 2:47 PM revealed Resident 3 was seated in a recliner with her/his left foot and ankle resting on a footrest, and the left foot and ankle were rotated towards the midline of the body. Resident 3 was not grimacing or groaning while in the recliner. On 12/17/25 at 11:21 AM and 12/18/25 at 4:56 PM Staff 5 (CNA) stated Resident 3GÇÖs left foot and ankle were rotated inward, and she adjusted the position of Resident 3GÇÖs left ankle and foot when she noticed it turned inward in the recliner. Staff 5 stated she reported the issue to the DNS in 9/2025 or 10/2025, but the issue was not addressed. On 12/17/25 at 11:59 AM and 12/18/25 at 4:43 PM Staff 6 (CNA) stated Resident 3GÇÖs left ankle and foot rotated inward when seated in the recliner. Staff 6 stated Resident 3 sat in her/his recliner often. Staff 6 stated he was concerned regarding Resident 3GÇÖs foot positioning, and he reported the issue to a nurse a few months ago but did not recall which nurse he informed. On 12/17/25 at 1:01 PM Staff 7 (LPN) stated Resident 3 sat in her/his recliner often and noticed Resident 3GÇÖs left foot rotated toward the midline whenever she/he was sitting in the recliner. Staff 7 stated she was unaware if an assessment was completed regarding Resident 3GÇÖs left foot. On 12/18/25 at 11:50 AM and 12/19/25 at 9:06 AM and 11:45 AM, Staff 8 (Director of Rehabilitation) stated he worked with Resident 3 from 7/2025 to 9/2025 on gait training, transfers, and balance, and discharged her/him from physical therapy on 9/12/25. Staff 8 stated there was no foot or ankle rotation present with Resident 3 when she/he discharged from therapy. Staff 8 confirmed Resident 3GÇÖs inward ankle rotation placed the ankle in an unstable position and her/his ankle bone close to the skin, increasing the risk for decreased ROM and skin impairment. Staff 8 stated Resident 3GÇÖs ankle had been unstable, and the inward rotation of the left ankle had developed gradually over time.

1. Corrective Action for Affected Residents Resident #3 was assessed by therapy for left ankle inversion/rotation. A ROM/positioning plan was initiated including proper ankle/foot positioning supports or orthotic per therapy recommendation, monitoring for pain or skin risk, and ROM or positioning program as tolerated. The care plan was updated to reflect identified needs and interventions. Resident #1 was reassessed by therapy regarding risk for upper-extremity contracture and continued need for hand splints. Hand-splint orders were reviewed with the provider, and appropriate splint use orders were reinstated or revised based on current clinical need. The care plan and task documentation were updated so staff are prompted to apply splints per order and document use. 2. Identification of Other Residents at Risk An audit of residents for contractures was completed to verify therapy recommendations were in place and implemented, assistive devices/splints/orthotics were ordered when appropriate, care plans accurately reflected ROM and positioning needs, and staff documentation tasks existed to support implementation. Any missing or outdated orders or care plans were immediately updated, and residents were referred to therapy as needed. Audit findings were reported to the Director of Nursing (DON). 3. Systemic Changes Implemented Education was provided to licensed nurses, CNAs, and therapy identification of ROM decline or abnormal positioning; prompt referral to therapy when positioning or ROM concerns arise; ensuring ROM and positioning needs are care-planned; ensuring orders are not discontinued without justification and provider involvement; and that staff do not rely on diagnosis alone to justify decline. CNA assignment sheets/EMR tasks now include splinting/ROM/positioning tasks when ordered so completion and tolerance can be documented. 4. Monitoring and Quality Assurance Director of Nursing (DON) or designee will audit residents with ROM deficits or splint/positioning orders weekly for 4 weeks, then monthly for 2 months. Audits will verify orders match resident ROM/contracture needs; care plans reflect active interventions; splints/positioning supports are in use as ordered; and documentation exists to show monitoring and tolerance. Any missing or inaccurate documentation or interventions will be corrected immediately with staff re-education. Audit results will be shared with the Administrator and reviewed in QAPI for 3 months. Monitoring will continue until sustained compliance is achieved.

Resident 401 was admitted to the facility in 3/2025 with diagnoses including dementia and a femur fracture. A 3/30/25 Admission MDS indicated Resident 401 had significant cognitive impairments. A 6/19/25 Grievance Form revealed concerns of Staff 4 (CNA) forcing Witness 1 (Power of Attorney) to leave Resident 401's room when care was provided. When Witness 1 requested to remain present, Staff 4 was reported to have stormed out of the room. A request was made by Witness 1 for Staff 4 to no longer provide care to Resident 401. A 6/24/25 Grievance Summary Report completed by Staff 2 (DNS) revealed the resolution was for Staff 4 to no longer provide care to Resident 401. Review of the 6/2025 and 7/2025 Documentation Survey Reports revealed Staff 4 provided ADL care which included brief changes, oral hygiene and/or showers to Resident 401 on 6/25, 6/27, 7/2, 7/3, 7/4, 7/5, 7/16 and 7/22. Review of vital tracking records during 6/2025 and 7/2025 revealed Staff 4 assessed Resident 4GÇÖs vitals on 6/25 and 7/22. -áA 7/23/25 Interdisciplinary Team Care Plan Conference Quarterly Review included comments from Witness 1 ensuring Staff 4 did not provide care to Resident 401. On 8/26/25 at 12:18 PM ADL care and vital records from 6/2025 and 7/2025 were reviewed with Staff 4. Staff 4 acknowledged her initials were were recorded as having provided care to Resident 401 on 6/25, 6/27, 7/2, 7/3, 7/4, 7/5, 7/16 and 7/22.-á On 8/26/25 at 2:23 PM Witness 1 stated she/he visited Resident 401 on 7/16/25 and observed Staff 4 providing one on one care to Resident 401. Witness 1 stated she/he reported her/his concerns regarding Staff 4 not providing care to Resident 401 on 7/16/25 and again during a care conference on 7/23/25. On 8/26/25 at 2:40 PM Staff 2 was informed Staff 4 continued to provide care to Resident 401 after the grievance was addressed. Staff 2 did not provide any additional information. Staff 2 confirmed records showed Staff 4 continued to provide care to Resident 401 following the resolution of the grievance.-á

Immediate Correction: Staff number 4 was placed on administrative leave pending outcome of investigation and resigned from the company on 8/27/25.  Education on the grievance process done with IDT team, by Administrator. Identification of Others: A review of the last 30 days of grievances was completed by the Administrator to validate that resolutions are being followed. Systemic changes A new process for tracking staff assignments was put into place by the DNS and Scheduler. The length of time needed for point of care charting to automatically log a user out was adjusted to 15 minutes. Nursing staff were re-educated to ensure proper log out when moving away from a device and only charting on care delivered by them, not others. Open grievances will be reviewed at morning IDT meetings by administrator or designee until resolved. Ongoing Monitoring: Audits of point of care charting stations and tablets to ensure CNAs are properly logging out to be done by administrator or designee weekly for 4 weeks then monthly for two months. Audits of new staff assignment tracking process to be done weekly for 4 weeks, then monthly for two months by DNS or designee. Follow up with residents/representatives having filed a grievance to be completed by administrator one week after resolution to ensure resolutions are fully implemented and effective. Results of audits to be shared with the administrator and brought to QAPI monthly for 3 months for tracking, trending, and to ensure the process remains in compliance.

Based on observation, interview and record review it was determined the facility failed to implement a comprehensive person-centered care plan for 1 of 1 sampled resident (#24) reviewed for communication-sensory services. This placed residents at risk for decreased ability to communicate their wants and needs. Findings include: Resident 24 was admitted to the facility in 6/2024 with diagnoses including aphasia (a language disorder that affects a person's ability to communicate) following non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane) and dysarthria (weakness in the muscles used for speech, causing slowed, slurred speech) following non-traumatic subarachnoid hemorrhage. A review of Resident 24's 6/27/24 Admission MDS revealed she/he had adequate hearing but did not speak during the assessment. On 8/13/24 at 9:31 AM Resident 24 was observed sitting up in bed. Her/his eyes were closed and she/he was awake. She/he did not speak when asked how she/he felt, but she/he gestured to a pool of saliva on her/his shirt. A review of Resident 24's 6/20/24 care plan revealed she/he was at risk of impaired communication related to low tone of voice, post subarachnoid hemorrhage and "some cognitive impairment." Resident 24's care plan revised on 6/28/24 indicated she/he was able to read written communication and had a picture board for communication kept at the nurses' station. On 8/13/24 at 10:41 AM Resident 24 was observed in her/his room with a caregiver. Resident 24 did not communicate verbally with the caregiver and there was no evidence of a communication board in her/his room. On 8/14/24 at 9:15 AM Staff 7 (CNA) reported Resident 24 nodded to indicate she/he understood but and used "weird facial expressions" to indicate she/he did not understand. Staff 7 stated staff did not have a communication board for Resident 24 and she thought, "it would be a great idea." She also stated, "I don't know if a board is in the works." On 8/14/24 at 12:49 PM Staff 6 (Activities / Recreation Director) reported she was not aware of a communication board on Resident 24's care plan but she thought it would be a good tool for many departments to use when communicating with her/him. On 8/14/24 at 1:21 PM Staff 6 reported she found the communication board at the nurses station "under a big pile of stuff" and stated "I didn't even know it was there. It's not specific for her. I don't know if she has ever used it." On 8/14/24 at 1:30 PM Staff 1 (Administrator) acknowledged staff members were not using the communication board as instructed on Resident 24's care plan. He stated, "I expect that if it is on the care plan, the caregivers and nurses should be following it. There should be a copy of it for her in her room rather than just at the nurses station."

F656 Develop/implement Comprehensive Care Plan CFR(s): 483.21 (b)(1)(3) 1. Resident #24 remains a resident in the facility. Communication board was placed in resident room and care plan was updated. Resident verbalized understanding and satisfaction. 2. DNS/designee audited resident communication care plans to ensure interventions are current and appropriate. 3. The facility will assess residents communication needs and preferences upon admission, during care conferences, and with change of condition, and develop and maintain a comprehensive care plan. Nursing staff received education regarding the identification of residents needing a communication board. Nursing staff were also educated on Resident Kardex, the location of communication devices, and usage with residents. 4. Unit manager/designee will audit new admissions and 5 random resident communication care plans weekly x 4 weeks, and then monthly for 2 months to ensure the communication care plans are appropriate. Audit findings will be brought to the administrator and reviewed at QAPI for further recommendations if indicated. 5. Date of Compliance 09/24/24

Based on interview and record review it was determined the facility failed to provide care in accordance with care planned interventions while pushing a resident in a wheelchair for 1 of 1 sampled resident (#1) reviewed for accidents. This failure resulted in an avoidable fracture to Resident 1's left ankle. Findings include: Resident 1 was admitted to the facility in 2015 with diagnoses including dementia. The 6/2023 Annual MDS revealed Resident 1 had a BIMS of 11 (moderate cognitive impairment). Resident 1's mobility care plan dated 12/9/22 instructed staff to promote Resident 1's independence with locomotion as tolerated without leg rests and revealed Resident 1 needed assistance with leg rests in place for wheelchair mobility when being pushed by staff. A 12/6/23 FRI report revealed on 12/3/23 Resident 1 mobilized her/himself independently while in her/his wheelchair from the dining room toward her/his room. Resident 1 became tired and Staff 11 (CNA) pushed Resident 1 towards her/his room. Staff 11 felt resistance while pushing Resident 1 and immediately stopped while Resident 1 yelled "Ow!" Staff 12 (LPN) was nearby and told Staff 11 to put Resident 1 into bed so he could look at Resident 1's ankle. Resident 1's ankle had a normal range of motion. Staff 12 administered medication for pain management and applied ice to the resident's ankle. Resident 1's physician was notified and staff were instructed to obtain an X-ray if the resident experienced increased pain or swelling. The FRI revealed Resident 1 had moderate pain and swelling to her/his left ankle, and 12/5/23 X-ray notes revealed she/he sustained an "...oblique [slanting] fracture involving the distal fibula [a prominent bone on outside of the ankle] with minimal callus [a temporary development that occurs at the site of a bone fracture and helps the bone move from the inflammatory phase to the repair phase] and mild displacement. The joint alignment is maintained. There is associated soft tissue swelling..." The resident was taken to the emergency department for an evaluation. A 12/4/23 5:57 PM progress note by Staff 12 revealed Resident 1 was on alert charting, rested in bed, and her/his behavior was at baseline. Resident 1 stated her/his left ankle hurt when it was moved. The resident's left ankle was noted to be slightly swollen and tender, and she/he complained of pain twice during the shift. Staff 12 administered pain medication. A 12/5/23 3:10 AM progress note by Staff 13 (LPN) revealed Resident 1's left ankle was swollen and painful to touch. The resident requested an ice pack for comfort which was effective. A 12/5/23 10:15 PM progress note by Staff 14 (LPN) revealed a new physician's order was received for a left ankle X-ray to rule out a fracture. A 12/6/23 1:54 AM progress note by Staff 15 (LPN) revealed X-ray results of Resident 1's left ankle found an oblique fracture with mild displacement and soft tissue swelling. Resident 1's physician was notified and orders were provided to offer ice packs and to send Resident 1 to the emergency department in the morning since the resident was stable and effective pain management was in place. Resident 1's 12/6/23 hospital after visit summary and X-ray results revealed she/he had a left foot ankle fracture. The facility obtained a follow up statement from Staff 11 on 12/6/23 at 9:00 AM. Staff 11 stated Resident 1 wheeled her/himself partway down a hall. Staff 11 assisted Resident 1 as she/he sounded out of breath and wanted to go to bed. As they approached the nurses station Resident 1 dropped her/his foot. Staff 11 felt resistance and stopped pushing the wheelchair. Resident 1 cried out and her/his ankle was assessed by another staff. Staff 11 was instructed to assist the resident back to her/his room. Staff 11 stated she then pushed Resident 1 very slowly and reminded her/him to hold her/his legs up. Staff 11 stated she knew how to access care plans and thought she reviewed Resident 1's care plan. An untitled facility document dated 12/8/23 by Staff 16 (former DNS) revealed Staff 11 pushed Resident 1 in her/his wheelchair without leg rests which resulted in Resident 1's fractured left ankle. An interview with the resident found she/he felt safe and comfortable with Staff 11 continuing to provide care. On 8/12/24 at 1:00 PM Resident 1 was observed self propelling slowly in her/his wheelchair with no leg rests. During an interview on 8/12/24 at 2:46 PM Staff 12 stated he assessed the resident at the time of the incident and put ice on her/his foot because she/he complained of pain but there was no swelling or bruising at the time. He indicated the resident was able to identify pain appropriately. Staff 12 stated Resident 1 self propelled in her/his wheelchair independently but when she/he got tired staff placed leg rests on her/his wheelchair before pushing her/him. On 8/13/24 at 10:47 AM Witness 1 (resident representative) stated she was informed of the 12/3/23 incident right away and believed it was a "pure accident." She added, Resident 1 would take the leg rests off her/his wheelchair or she/he would ask the staff to remove them. Witness 1 stated Resident 1 was pretty independent and liked to move her/his wheelchair on her/his own but when she/he got tired or was not feeling well she/he asked for help and staff would place the leg rests on the wheelchair before pushing her/him. On 8/14/24 at 3:58 PM Staff 11 confirmed she pushed Resident 1 down the hallway to her/his room without the leg rests on her/his wheelchair, which resulted in Resident 1 sustaining a fractured ankle. Staff 11 stated the resident's foot was not swollen and had no bruising immediately after the accident. On 8/15/24 at 7:18 PM Staff 15 confirmed the incident happened when she was not on shift but she did observe Resident 1's foot on 12/5/24. Staff 15 stated Resident 1 was placed on alert charting, was monitored every shift and received pain medication. Staff 15 stated she observed Resident 1's foot was swollen and the resident said it was slightly painful when she/he moved it. Staff 15 said the day shift nurse ordered the X-ray but she received the X-ray report. Since Resident 1 was stable at the time and it was the middle of the night, a physician's order was received for ice packs if Resident 1 needed it and the on-call doctor gave the okay to go to the hospital in the morning which allowed the resident to sleep. Staff 15 stated if Resident 1 was in a lot of pain she/he would have been sent to the emergency room sooner. Staff 15 added, she believed Resident 1 was care planned to have the footrests on the wheelchair when being pushed by staff before the incident happened and this hasn't happened again to her knowledge. During an interview on 8/16/24 at 9:40 AM Staff 1 (Administrator), Staff 2 (DON), and Staff 3 (Regional Nurse Consultant) were informed of the findings of this investigation. They all confirmed the incident occurred. On 12/8/23, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was a failure to follow Resident 1's care plan to ensure leg rests were on her/his wheelchair before pushing her/him. The Plan of Correction included: 1. Staff education, for all staff, on placing leg rests onto resident wheelchairs, and how to look resident care plans and resident profiles. 2. A notice was created for Resident 1's wheelchair to remind staff to put the leg rests on her/his wheelchair before pushing her/him and what to do if Resident 1 declined the use of the leg rests. 3. Licensed nursing staff monitored use of leg rests on resident wheelchairs for residents who required assistance with mobilizing in wheelchairs.

Based on observation, interview, and record review it was determined the facility failed to ensure proper food temperatures were maintained for meals served to residents on 3 of 3 halls reviewed for dining. This placed residents at risk for increased risk for impaired nutrition. Findings include: Observation on 8/12/24 at 11:45 AM during tray pass Resident 1 complained of cold food. Observation on 8/12/24 at 11:47 AM during tray pass Resident 4 complained of cold food. Resident Council Meeting documentation from 5/2024 recorded residents complaints that breakfast was often cold. On 8/14/24 at 3:37 PM Staff (5) Dietary Manager confirmed the residents had complained about cold food. Twelve residents were interviewed during a Resident Council meeting on 8/15/24 at 10:21 AM. The residents complained about cold food on all halls. On 8/15/24 at 2:51 PM the concern related to cold food was shared with Staff 1 (Administrator). No additional information was provided.

F804 Nutritive Value/Appear, Palatable/Prefer Temp CFR(s): 483.60(d)(1)(2) 1. Resident #1 and #4 reside in the facility and have a grievance filed related to concerns with cold food. Residents educated to inform staff at mealtimes if the food temp is undesirable to allow for immediate correction in the kitchen. The Dietary Manager and Activities Director have met with the Resident Counsel to address the complaints about cold meals. 2. Facility residents have the potential to be affected by this practice. 3. The Dietary Manager/designee will order a plate warmer and insulated bases/covers to assist with maintainng proper food temperatures after plating. The dietary department will also order a tray cart cover for trays delivered to resident rooms to help maintain palatable food temperature. Nursing and Dietary staff were educated on process related to returning and replacing trays if a resident voices concern related to food palatability/temperature. 4. The Dietary manager will conduct an audit of 10 random residents' weekly on food temperature x 1 month and then monthly x 2 months, along with monthly follow up in resident counsel. Audit findings will be brought to the administrator and reviewed at QAPI for further recommendations if indicated. 5. Date of Compliance 09/24/24

Based on observation, interview, and record review it was determined the facility failed to monitor temperatures and cleanliness of 1 of 1 unit refrigerator. This placed the residents at risk for food-borne illness. Findings include: The facility guideline for Dietary Service Resident Community Refrigerator stated: -Housekeeping staff/designee will monitor the refrigerator daily for cleanliness. Concerns will be delegated to the designated department. - Each refrigerator will have an approved thermometer inside the refrigerator. Designated staff will record the temperature at least daily. On 8/14/24 at 12:48 PM the unit refrigerator used for resident snacks and personal foods was observed to have yellow liquid spilled on a lower shelf. There was no thermometer in the refrigerator. On 8/14/24 at 12:49 PM Staff 5 (Dietary Manager) stated the cleaning and monitoring of unit refridgerators was the responsibility of the kitchen staff. She confirmed the refridgerator needed to be cleaned and no thermometer was present. She was not able to locate a temperature log for the refrigerator.

F812 Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) 1. No residents were affected by this practice. The refrigerator was immediately cleaned, and the temperature log and thermometer were replaced to ensure proper resident refrigerator temperature tracking. 2. Current residents with food stored in identified refrigerator have the potential to be affected by this practice. 3. Dietary staff/designee will monitor the refrigerator daily for cleanliness. The Dietary Manager will in-service Dietary staff on the importance of maintaining the cleanliness of the refrigerator, maintaining the temperature log daily, and verifying presence of a working thermometer. Nursing staff will be given an in-service to report to dietary if any cleanliness concerns are identified. 4. Dietary manager/ designee will audit refrigerator and refrigerator log weekly x 4 weeks and then monthly x 2 months to ensure cleanliness, and thermometer in place and temperature logs completed. Audit findings will be brought to the administrator and reviewed at QAPI for further recommendations if indicated. 5. Date of Compliance 09/24/24

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 47 of 134 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident care and services. Findings include: A review of the Direct Care Staff Daily Reports from 1/1/24 through 3/31/24 and 7/1/24 through 8/12/24 revealed the following 47 days without an RN working for eight consecutive hours in the facility between the start of day shift and the end of evening shift: -1/1/24 no RN worked on any shift; -1/2/24 no RN worked on any shift; -1/3/24 no RN worked on any shift; -1/4/24 no RN worked on any shift; -1/7/24 no RN worked on any shift; -1/8/24 no RN worked on any shift; -1/10/24 no RN worked on any shift; -1/15/24 no RN worked on any shift; -1/16/24 no RN worked on any shift; -1/21/24 no RN worked on any shift; -1/22/24 no RN worked on any shift; -1/28/24 no RN worked on any shift; -1/29/24 no RN worked on any shift; -1/30/24 no RN worked on any shift; -2/4/24 no RN worked on any shift; -2/5/24 no RN worked on any shift; -2/11/24 no RN worked on any shift; -2/12/24 no RN worked on any shift; -2/13/24 no RN worked on any shift; -2/18/24 no RN worked on any shift; -2/19/24 no RN worked on any shift; -2/25/24 no RN worked on any shift; -2/26/24 no RN worked on any shift; -2/27/24 no RN worked on any shift; -3/10/24 no RN worked on any shift; -3/17/24 no RN worked on any shift; -3/25/24 no RN worked on any shift; -3/26/24 no RN worked on any shift; -3/27/24 no RN worked on any shift; -3/28/24 no RN worked on any shift; -3/31/24 no RN worked on any shift; -7/7/24 no RN worked on any shift; -7/15/24 no RN worked on any shift; -7/18/24 no RN worked on any shift; -7/19/24 no RN worked on any shift; -7/21/24 no RN worked on any shift; -7/22/24 no RN worked on any shift; -7/25/24 no RN worked on any shift; -7/26/24 no RN worked on any shift; -7/27/24 no RN worked on any shift; -7/28/24 no RN worked on any shift; -8/2/24 no RN worked on any shift; -8/4/24 no RN worked on any shift; -8/5/24 no RN worked on any shift; -8/9/24 no RN worked on any shift; -8/11/24 no RN worked on any shift; and -8/12/24 no RN worked on any shift. On 8/15/24 at 9:25 AM Staff 10 (Staffing Coordinator) acknowledged the days with insufficient RN staffing and stated, "It is absolutely our goal to have the RN shifts covered." On 8/16/24 at 10:01 AM Staff 1 (Administrator) reported he was aware of multiple days not having the required RN coverage. He stated it was his goal to have all RN shifts covered.

M182 OAR 411-086-0100(4) Nursing Services: Minimum Licensed Nurse Staff 1. No residents were affected by this practice. 2. All residents have the potential to be affected by this practice. 3. Avalon Care Center is currently in the process of sourcing adequate RN staff. Due to the rural area, recruitment has posed challenging, but center is dedicated to ongoing recruitment efforts. A sign on bonus has been implemented and wages have been increased to encourage increased applicant flow. Recruiters are actively sourcing for RN applicants. If an assigned RN is unable to cover shift or in-house replacement cannot be found to cover required RN hours, the shift will then be sent out to the 3 agencies that the facility is contracted with for coverage. 4. Administrator/ DNS/ Staffing Coordinator will have weekly meetings with corporate recruiter to discuss any open RN positions, and continued recruitment efforts to support coverage. Audit findings will be brought to the administrator and reviewed at QAPI for further recommendations if indicated. 5. 09/24/2024

*********************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 *********************** 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 *********************** 411-086-0250 Dietary Services Refer to F804, F812 ***********************

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 10/09/2023 and 10/15/2023, 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 05/15/2023 and 05/21/2023, 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 08/01/2022 and 08/07/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/13/2021 and 09/19/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to meet the minimum required CNA to resident staffing ratio for nine out of 14 night shifts reviewed. This placed residents at risk for unmet needs. Findings include: Effective 8/24/21, temporary OAR 411-086-0100 allows for a minimum of one CNA per 18 residents on the night shift. The Direct Care Staff Daily Reports from 9/1/21 through 9/14/21 reflected 64% of the night nights had CNA shortages. On 9/15/21 at 10:30 AM Staff 1 (Administrator) confirmed the above CNA shortages.

No residents were negatively affected by this deficient practice All residents have the potential to be affected by this practice The facility has agreed to pay more competitive rate to contracted staffing agency to help recruit additional Certified Nursing Assistants. The facility will continue to offer extra shift bonuses, and incentives to CNAs picking up extra shifts. Facility will continue to place on-line ads for CNAs with starting wage of $17/hr., keep offering $1500 sign on bonus and $250 referral bonus to current staff member The Facility Administrator/Designee will review CNA staffing/schedule weekly to ensure the facility is meeting the minimum required CNA to resident staffing ratio per shift and no more than 25 percent of the nursing assistants assigned to residents per shift are uncertified nursing assistants. The facility administrator will ensure compliance and will report findings to QAPI for 3 months

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/12/2021 and 07/18/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.