Regency Care of Central Oregon

2. Resident 7 was admitted to the facility in 1/2019 with diagnoses including anxiety. A review of Resident 7GÇÖs orders revealed a 9/11/24 order for lorazepam (an antianxiety medication), a 11/6/22 order for escitalopram (an antidepressant medication), and an 8/20/24 order for buspirone (an antianxiety medication). A 5/22/25 pharmacy consultation report indicated Resident 7 took three psychotropic medications, lorazepam, escitalopram, and buspirone. The consultation report recommended documentation of the specific rationale for why dose reduction or discontinuation of these medications was clinically contraindicated. The pharmacy consultation report was signed by the provider on 5/27/25 with no rationale documented. A review of Resident 7GÇÖs medical record revealed no documentation of the specific rationale for why dose reduction or discontinuation of Resident 7GÇÖs psychotropic medications were clinically contraindicated. On 2/4/25 at 2:31 PM Staff 2 (DNS) acknowledged there was no clinical rationale indicated for Resident 7GÇÖs continuation without a dose reduction of her/his psychotropic medications.-á , 1. Resident 6 was re- admitted to facility 10/24/25 with diagnoses of prostate cancer , falls, and depression. -á Resident 6GÇÖs 10/24/25 physician orders revealed an order for l orazepam ( an antianxiety medication ) PRN with a start date of 10/24/25 and no stop date . -á The 11/ 2025 MAR indicated -áResident 6 received Lorazepam once per day for -áfive days -á after the 14th day of 11/6/25 :-á 11/8/25, 11/12/25, 11/16/25, 11/17/25, and 11/18/25. -á In an interview on 12/5/2025 at 10:03 AM , Staff 2 (DNS) confirmed Lorazepam was administered PRN for more than 14 days without a documented stop dat e.

F-605 Identified Persons: What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident # 6 - Psychotropic medication was reviewed. Resident # 7 - Clinical rationale was obtained and documented. Similar Residents: How will the facility identify other residents having the potential to be affected by the same deficient practice, and what corrective actions will be taken? Audit of facility residents on PRN psychotropic medications for end dates, any issues corrected. Audit of facility residents on PRN psychotropic medications for physician rational for continuing PRN psychotropic medications, any issues noted have been corrected Corrective Action: Measures taken or systems altered to ensure that the problem does not occur again Education to Social Services Director, Nursing Management, and medication administration staff on F-605 r/t use of PRN psychotropic medication by the Director of Nursing or Designee Education on need for clinical rationale from PCP conducted by the Director of Nursing Services or designee The Director of Nursing Services or designee will conduct resident audits for new PRN psychotropic medication orders for end date, weekly x 3 weeks, monthly x 2 months, and PRN thereafter The Director of Nursing Services or designee will conduct audits for PRN psychotropic orders that are extended past 14 days for PCP rational obtained weekly x 3 weeks, monthly x 2 months, and PRN thereafter Surveillance: How will the corrective actions be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? The Director of Nursing Services, or Designee will present audits on PRN psychotropic medication and clinical rationale if extended past 14 days to the QAPI committee x 2 months to validate compliance, and to identify trends and education needs. Person/People Responsible : The Director of Nursing Services Date of Compliance: 1/9/2026

Resident 5 was admitted to the facility in 4/2021 with diagnoses including diabetes. A review of physician orders revealed a 9/2/25 order for Mounjaro (a medication used to treat diabetes). An 10/16/25 pharmacy consultation report recommended an increase in Resident 5GÇÖs Mounjaro. A 11/20/25 pharmacy consultation report recommended an increase in Resident 5GÇÖs Mounjaro. A review of Resident 5GÇÖs medical record revealed no evidence Resident 5GÇÖs provider reviewed the 10/16/25 pharmacy consultation report. On 12/4/25 at 10:48 AM Staff 2 (DNS) stated the provider did not respond to the 10/16/25 report so it was reissued and sent to the provider again on 11/20/25. Staff 2 stated pharmacy consultation report recommendations must be addressed by the provider within 30 days. Staff 2 acknowledged Resident 5GÇÖs pharmacy consultation recommendation was not followed up on timely.

F-756 Identified Persons: What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident # 5 - medication order for Mounjaro and pharmacy recommendation was reviewed, physician response received and documented Similar Residents: How will the facility identify other residents having the potential to be affected by the same deficient practice, and what corrective actions will be taken? Audit of facility residents on Mounjaro was conducted for pharmacy recommendations, any issues corrected Corrective Action: Measures taken or systems altered to ensure that the problem does not occur again Nurse Managers were educated on timely pharmacy recommendations as it pertains to F-756 by the Regional Director of Clinical Operations The Director of Nursing Services or Designee will conduct audits for timely responses from pharmacy recommendations of Mounjaro weekly x 3 weeks, monthly x 2 months, and PRN thereafter Director of Nursing Services and Nursing Home Administrator have reviewed and updated facility Medication Review Timely Response Policy and reviewed it with Medical Director Surveillance: How will the corrective actions be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? The Director of Nursing Services or designee will present audits of timely responses from pharmacy recommendations by Provider to the QAPI committee  x 2 months to validate compliance and to identify trends and education needs. Person/People Responsible: The Director of Nursing Services Date of Compliance: 1/9/2026

1 . On 12/3/25 from 11:30 AM through 12: 30 PM , Staff 4 (Dietary Manager) prepared resident lunch meal trays . Staff 4 donned gloves and touched multiple surfaces including clean plates, serving utensils, refrigerator doors, be verages, and each soft taco.-á Staff 4 did not change gloves or complete hand hygiene between touching clean and contaminated surfaces during this time. In an interview on 12/4/25 at 9:48 AM, Staff 4 stated she failed to complete proper hand hygiene and change gloves after touching equipment before returning to tray line service. -á 2 . On 12/3/25 at 12:30 PM , Staff 4 (Dietary Manager) dropped a food thermometer on the floor while working the tray line for residents . Staff 4 bent down and picked up the thermometer , placed it on top of the table near the steam table , then reached for a clean tray to continue servi ce . When questioned, Staff 4 acknowledged she picked up the soiled thermometer from the ground and placed it back on the counter . -á On 12/4/25 at 9:48 AM, Staff 4 stated she should not have picked up a dropped item from the floor during tray line . Staff 4 stated i f something is retrieved from the floor during food preparation or serving, staff should complete hand hygiene and don clean gloves before continuing with meal service.

F 812 Corrective Action : Education was provided to all dietary staff on proper handwashing hygiene and proper food handling to ensure food service in a sanitary manner, to ensure resident safety, and to maintain professional standards. Identification of Others : This deficiency can affect all residents within the facility; no harm was found. Systemic Changes: All dietary staff were educated on proper hand hygiene and proper food handling to ensure food service in a sanitary manner, to ensure resident safety, and to maintain professional standards. Monitoring: Administrator and/or designee to round in the kitchen daily x 2 weeks, then daily x4 weeks to ensure staff are performing hand hygiene and proper food handling procedures. All dietary handwashing/food handling procedure audit results will be presented to the QAPI committee for review and further recommendations. Individual Responsible for Validating Compliance: Executive Director

Resident 19 was admitted to the facility in 5/2021 with diagnoses including heart failure. A review of Resident 19GÇÖs immunizations revealed she/he received a Prevnar 20 vaccine (a vaccine for pneumonia) on 8/11/24 and 9/16/24. On 12/4/25 at 12:50 PM Staff IP (LPN Infection Preventionist) stated the CDC recommendation was for Resident 19 receive a single dose of Prevnar 20 and she was unsure why Resident 19 received two doses of Prevnar 20. Staff IP acknowledged Resident 19 should have received only one dose of Prevnar 20.

F-883 Identified Persons: What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #19 - had no negative outcome related to practice Similar Residents: How will the facility identify other residents having the potential to be affected by the same deficient practice, and what corrective actions will be taken? Audit conducted by Infection Prevention Nurse of facility residents' eligibility for Prevnar 20 and documentation in ALERTIIS, any issues were addressed Corrective Action: Measures taken or systems altered to ensure that the problem does not occur again Infection Prevention Nurse was educated by Director of Nursing Services on Prevnar 20 administration and documentation in PCC and ALERTIIS The Director of Nursing Services or designee will conduct audits for Prevnar 20, PCC and ALERTIIS documentation, weekly x 3 weeks, monthly x 2 months, and PRN thereafter Surveillance: How will the corrective actions be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? The Infection Prevention Nurse or designee will present audits of Prevnar 20 to the QAPI committee x 2 months to validate compliance and to identify trends and education needs. Person/People Responsible: The Director of Nursing Services and Infection Prevention Nurse Date of Compliance: 1/9/2026

1. -á-á-á-á-á Resident 2 was admitted to the facility in 9/2024 with diagnoses including ParkinsonGÇÖs Disease. A review of Resident 2GÇÖs immunizations revealed the last COVID 19 vaccination she/he received was on 9/4/24. On 12/4/25 at 12:50 PM Staff IP (LPN Infection Preventionist) stated the CDC recommended two COVID 19 boosters for 2025. Staff IP stated all residents should be offered the COVID 19 vaccination yearly. Staff IP acknowledged there was no documentation Resident 2 received or was offered the COVID 19 vaccination in 2025. 2. -á-á-á-á-á Resident 6 was admitted to the facility in 11/2020 with diagnoses including emphysema. A review of Resident 6GÇÖs immunizations revealed the last COVID 19 vaccination she/he received was on 8/11/24. On 12/4/25 at 12:50 PM Staff IP (LPN Infection Preventionist) stated the CDC is recommending two COVID 19 boosters for 2025. Staff IP stated all residents should be offered the COVID 19 vaccination yearly. Staff IP acknowledged there was no documentation Resident 6 was offered or received the COVID 19 vaccination in 2025. 3. -á-á-á-á-á Resident 7 was admitted to the facility in 1/2019 with diagnoses including asthma. A review of Resident 7GÇÖs immunizations revealed the last COVID 19 vaccination offered to Resident 7 was on 2/1/24. On 12/4/25 at 12:50 PM Staff IP (LPN Infection Preventionist) stated the CDC recommended two COVID 19 boosters for 2025. Staff IP stated all residents should be offered the COVID 19 vaccination yearly. Staff IP acknowledged there was no documentation Resident 7 was offered or received the COVID 19 vaccination in 2025. 4. -á-á-á-á-á Resident 19 was admitted to the facility in 5/2021 with diagnoses including heart failure. A review of Resident 19GÇÖs immunizations revealed the last COVID 19 vaccination offered to Resident 19 was on 8/11/24. On 12/4/25 at 12:50 PM Staff IP (LPN Infection Preventionist) stated the CDC recommended two COVID 19 boosters for 2025. Staff IP stated all residents should be offered the COVID 19 vaccination yearly. Staff IP acknowledged there was no documentation Resident 19 was offered or received the COVID 19 vaccination in 2025.

F-887 Identified Persons : What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #2 - COVID Vaccine consent reviewed with resident – resident declined 12/9/25 then consented and received on 12/17/25 Resident #7 - discovered documentation to support declination of vaccine Resident #6 - COVID Vaccine consent reviewed with resident, resident declined Resident #19 - COVID Vaccine consent reviewed with resident, resident declined Similar Residents : How will the facility identify other residents having the potential to be affected by the same deficient practice, and what corrective actions will be taken? Audit of facility residents by Infection Prevention Nurse for COVID vaccination consent or declination Correction Action: Measures taken or systems altered to ensure that the problem does not occur again Infection Prevention Nurse educated by Director of Nursing Services or designee regarding COVID consents or declinations and documentation to be in all resident charts The Infection Prevention Nurse or designee will conduct audits for COVID vaccinations weekly x 3 weeks, monthly x 2 months, and PRN thereafter Surveillance: How will the corrective actions be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? The Infection Prevention Nurse or designee will present audits of COVID Vaccinations to the QAPI committee x 2 months to validate compliance and to identify trends and education needs Person/People Responsible: Infection Prevention Nurse and Director of Nursing Services Date of Compliance: 1/9/2026

Based on observation, interview, and record review it was determined the facility failed to provide a homelike environment for 15 of 32 sampled resident rooms observed for homelike environment. This placed residents at risk for unhomelike environment. Findings include: Observation on 9/9/24 at 1:43 PM and on 9/13/24 between the times of 8:44 AM and 9:16 AM revealed rooms 1, 3, 4, 5, 6, 15, 17, 20, 22, 24, 26, 27, 28, 33, and 35 had blinds with bent or missing slats. Resident 30 was admitted to the facility in 2/2024 with diagnoses of left-sided hemiplegia (weakness on the left side of the body). Resident 30's 6/2024 Quarterly MDS indicated the resident's cognition was intact. On 9/13/24 at 8:57 AM Resident 30 stated his/her blinds needed to be replaced due to the cord was stuck and some slats were bent. On 9/12/24 at 2:05 PM Staff 8 (Maintenance Director) confirmed the blinds in room 27 had missing slats and some were bent resulting in unhomelike environment. He stated broken blinds were an ongoing problem throughout the facility that he did not have the budget to replace. On 9/13/24 at 10:05 AM Staff 1 (Administrator) confirmed there were window blinds in disrepair resulting in an unhomelike environment.

F584 Corrective Action: The blinds in the 15 identified rooms have been repaired or replaced. Identification of Others: An audit was conducted to determine if any other blinds within the facility were broken or in disrepair. No other blinds were determined to need repair or replacement. Systemic Changes: Staff were in-serviced on the need to report broken or bent blinds to the Maintenance Director and/or Executive Director for repair or replacement. The Executive Director and Maintenance Director were in-serviced on the need to replace or repair broken blinds when identified. Monitoring: A weekly audit will be conducted x 4 weeks by the Maintenance Director or designee to identify any broken blinds or other concerns that prevent a homelike environment for the residents. Any negative findings from these audits will be presented to the QAPI Committee for review. Individual Responsible for Validating Compliance: Executive Director

Based on observation, interview, and record review it was determined the facility failed to ensure respiratory equipment was maintained for 1 of 2 sampled residents (#5) reviewed for respiratory care. This placed residents at risk for increased risk for respiratory concerns. Findings include: Resident 5 was admitted to the facility in 2017 with diagnoses including COPD (a lung disease causing restricted airflow and breathing problems) and a dependence on supplemental oxygen. The 10/11/23 Annual MDS indicated Resident 5 was cognitively intact. Resident 5's physician order dated 7/9/24 revealed the oxygen concentrator filter was to be cleaned weekly. The 9/2024 TAR indicated the external filter was cleaned weekly and it was last completed on 9/9/24. On 9/10/24 at 9:16 AM the oxygen concentrator was observed to be powered on with no external filter on the back. Resident 5 stated she/he used the oxygen concentrator while in bed. On 9/10/24 at 9:50 AM Staff 6 (RN) stated the night nurse was to clean Resident 5's oxygen concentrator filter weekly and ensure a filter was in place. On 9/10/24 at 9:59 AM Staff 3 (RNCM) observed the oxygen concentrator and acknowledged the filter was not in place.

F 695 Corrective Action: The filter in the O2 concentrator for resident #5 was replaced on 9/10/24 by the Maintenance Director. Identification of Others: An audit of O2 concentrator filters was conducted on 9/10/24 by the Maintenance Director to validate that any O2 concentrator in use has a clean and functional filter. Systemic Changes: The Executive Director and Maintenance Director were in-serviced on the need to audit and clean and/or replace O2 concentrators weekly. A task reminder to check filters was added to the TELs maintenance system as a monthly task. Monitoring: A weekly audit will be conducted x 4 weeks by the Maintenance Director or designee to validate that O2 concentrator filters are checked, cleaned and/or replaced. Any negative findings from these audits will be presented to the QAPI Committee for review. Individual Responsible for Validating Compliance: Executive Director

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing ratios were maintained for of 19 of 30 days reviewed. This placed residents at risk for delayed treatment and unmet care needs. Findings include: On 9/11/24, the facility had 9 residents approved for the bariatric rate. A review of the Direct Care Staff Daily Reports from 8/9/24 through 9/8/24 revealed the following days when staff did not meet the State minimum bariatric CNA staffing ratios: - 8/9/24 - 8/10/24 - 8/12/24 - 8/13/24 - 8/14/24 - 8/15/24 - 8/22/24 - 8/24/24 - 8/26/24 - 8/26/24 - 8/27/24 - 8/28/24 - 8/29/24 - 8/30/24 - 8/31/24 - 9/2/24 - 9/4/24 - 9/5/24 - 9/6/24 - 9/7/24 On 9/12/24 at 10:42 AM Staff 5 (Staffing Coordinator) acknowledged the state minimum bariatric CNA staffing ratios were not met for the identified dates. No further information was provided.

M 185 Corrective Action: No residents were specifically identified in this deficiency. Identification of Others: Current bariatric residents of the facility are at risk for this deficiency. Systemic Changes: The staffing coordinator or designee will monitor the schedule daily. We will use every means available to us to adequately staff our facility to comply with Bari staffing ratios-- one additional C.N.A. is staffed for every 5 bariatric residents. The staff Coordinator and designees have been educated on staffing ratio requirements for residents who qualify for the bariatric programcontinue to utilize all staffing agencies and our own Regency C.N.A. certification classes here in Bend to assist with staffing of new hires, posting ads in all possible staff advertising media to hire licensed C.N.As, asking our staff for pickups and using the differential pay increase for EVE, NOC and all Weekend shifts. Monitoring: Staffing will be reviewed in the daily clinical meeting, and we will use every means available to us to adequately staff our facility to comply with Bari staffing ratios. Any open shifts for the month will be reviewed and discussed daily. Any trends identified will be brought to the facility QAPI meetings for review and further recommendations. Individual Responsible for Validating Compliance: Executive Director

OAR 411-087-0100 Physical Environment

Refer to F584 ******************************* OAR 411-085-0110 Nursing Services: Resident Care Refer to F695 *******************************

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 12/18/2023 and 12/24/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 3 of 3 halls reviewed for environment. This placed residents at risk for a non-homelike environment. Findings include: Between 5/2/23 through 5/5/23 observations were made of the facility hallways and resident rooms. The following concerns, which detracted from a homelike environment, were identified: -Room 1 : The wall had a large scrape that needed repair and painting under the full length of the windows. There was a large scraped unpainted area behind the bed by the door and a black splattered area of an unknown substance. The paint on the walls was patchy. Doors were chipped and nicked all along the bottoms. -Room 5: The hall door and door jamb needed repair and paint. The door threshold cover was missing and the surface was not cleanable with dirt and debris stuck to the old adhesive material. The floor had multiple black scuff marks (over 20 ) and the walls looked unclean. The hall and bathroom doors were missing kick plates and needed repair and paint. The closet doors and dresser drawers had paint chipped off in multiple areas. - The Exit door on the South hallway had a bottom kickplate area which was scuffed and looked unclean. -The South hallway Laundry Room door was scraped and worn. -The South hallway Linen Supply door was worn and had multiple scraped and damaged areas. -The South hallway Sling Door frame needed paint to cover scraped areas. -Room 10: The door to the hall was scraped and needed repair and paint. -Room 11: There was a discolored worn area across the width of the door. -Room 14: The door was scraped and painted half way down from the top but the bottom of the door was left unfinished. -Room 15: The floor was very worn and looked unclean. Half of the doorway threshold moulding was missing which left an uncleanable surface. -Room 16: The entire floor was discolored and worn, the worn areas made the floor look unclean. The threshold moulding was missing which made the area uncleanable. -Room 26: Smelled musty and strongly of body odor. -Room 27: The blinds were broken. -Room 33: The closet and bathroom doors were scraped, damaged and needed repair and paint. On 5/2/23 at 9:14 AM Staff 5 (Maintenance Director) stated he was aware of the repairs the facility needed and had a plan to complete repairs. On 5/5/23 at 7:44 AM Staff 2 (DNS) observed the multiple areas of upkeep needed for the building and acknowledged the issues should be addressed.

F584- SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT Identified issues: The identified issues of the 3 halls of the facility will been addressed including; walls with scrapes, worn and scraped doors, molding, kickplates, replacing of blinds, repainting of door jamb, thresholds, and walls, and floor repairs. Similar residents: No residents were identified related to this deficiency. Measure to prevent: The maintenance department has been educated on the regulatory guidelines for providing a safe, clean, comfortable, and homelike environment for the residents of the facility. Monitor: The maintenance man or designee will conduct monthly facility round audits to ensure that the facility environment is maintained to provide a safe, clean, comfortable, and homelike environment. Any identified issues will be addressed per the facility maintenance log and follow-up. Any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determined the facility failed to protect the residents' rights to be free from physical abuse by Staff 13 or another resident for 2 of 2 sampled residents (#s 25 and 34) reviewed for physical abuse. This placed residents at risk for being physically abused. Findings include: The facility's 8/2018 Resident Abuse/Neglect/Exploitation Policy revealed, "Each resident shall have the right to be free from physical mental, or sexual abuse ..." and "Abuse means the non-accidental infliction of physical pain, injury or mental injury ...". 1. Resident 4 was admitted to the facility in 9/2020 with diagnoses including history of a stroke, aphasia (loss of ability to understand or express speech) and an altered mental status. Resident 4's 10/2021 Annual MDS assessment revealed she/he had a BIMS of 6 (severe cognitive impairment). Resident 34 was admitted to the facility in 5/2018 with diagnoses including Alzheimer's disease. She/he discharged from the facility in 2/2023. Resident 34's 11/2021 Quarterly MDS assessment revealed Resident 34 was not assessed for BIMS due to her/his Alzheimer's disease diagnosis. The facility's 12/20/21 incident investigation revealed on 12/20/21 Resident 4 yelled "get out of here!" and hit Resident 34 hard on the left arm. Staff 16 (CNA) witnessed the incident and immediately intervened. The investigation revealed both residents were roommates earlier in the year and Resident 4 did not like sharing a room with a roommate with an Alzheimer's disease diagnosis. On 5/1/23 at 9:19 AM Resident 4 stated she/he had no issues or problems with other residents. She/he did not remember Resident 34. On 5/4/23 at 11:14 AM Staff 4 (Social Service Director) stated he remembered the incident between Residents 4 and 34. He indicated he was in his office and heard Resident 4 yell "get out of here". He stated he believed the situation may have stemmed from when they both shared a room previously. Staff 4 said he talked to Resident 4 after the incident and the resident acknowledged it should not have happened. Staff 4 added, Resident 34 kept saying "I didn't do anything." On 5/4/23 at 4:43 PM Staff 16 stated she remembered both residents and the incident. She stated she witnessed Resident 4 got angry, she/he didn't like Resident 34 and swung at her/him, hitting Resident 34. She stated Resident 34 backed up against the wall with a frightful look on her/his face. She added, Resident 4 used full force when she/he hit Resident 34. Staff 16 confirmed the residents were roommates before and Resident 4 did not like anyone in her/his room. , 2. Resident 25 was admitted to the facility in 2021 with diagnoses including adjustment disorder (stress-related conditions where you feel overwhelmed and have a hard time adjusting to a stressful event or change) with mixed anxiety and depression and age related cognitive loss. Resident 25's care plan dated 3/23/21 indicated the resident was at risk for behavioral symptoms related to adjustment disorder, had impaired cognition related to cognitive loss and a psychosocial well-being problem related to anxiety. Interventions included the following: -Allow the resident to make choices about daily routine and care when possible. -Keep the resident's routine consistent and try to provide consistent caregivers in order to decrease confusion. -Provide the resident with as many situations as possible to give the resident control over their environment and care. -Explain all procedures to resident before starting and allow resident time to adjust. An Incident Report dated 2/7/22 indicated a nurse reported Staff 23 (LPN) said she gave Resident 25 a suppository without consent. When the suppository was physically inserted Staff 23 also concealed her identity from the resident by putting her scrub jacket on backwards and lowering her voice. The Incident Report dated 2/7/22 included a written statement from Staff 23 which indicated she told the resident at the beginning of the shift she needed to give her/him "something" to help her/him have a bowel movement because the resident was yelling that she/he was constipated and impacted. She did not tell the resident it was a suppository. Staff 23's written statement also indicated the resident did tell her that she/he felt violated for getting the suppository without consent and the resident screamed, yelled and told staff she/he did not like getting the suppository. The Incident Report dated 2/7/22 included a Summary which concluded Staff 23 acknowledged she gave the resident a suppository without consent and put her scrub jacket on backwards to conceal her identity from the resident. This was poor judgment on the nurse's part, poor communication towards the resident and unprofessional nursing practice by Staff 23. The act was substantiated as abuse by the facility. On 5/5/23 at 7:45 AM Staff 15 (CNA) indicated Resident 25 did not like taking any kind of medication. The resident had significant trust issues and refused to see the doctor. The resident became agitated and distressed easily and the nurse should have known the resident's reaction would be negative. The resident was not interviewed to prevent undue emotional distress to the resident. The resident was interviewed at the time of the incident by staff and reported she/he felt violated. On 5/4/23 at 1:25 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the the incident was substantiated as abuse of Resident 25 by Staff 23.

F600- FREE FROM ABUSE AND NEGLECT What corrective action was accomplished for residents affected? The Director of Nursing was notified by the other staff who were on duty at the time of the incident with resident 25. Upon initial investigation, the LPN (staff 23) was suspended from duty at that time and an investigation was initiated. The LPN no longer works for the facility. A FRI report was submitted regarding the incident for resident 25. Resident #34 no longer resides within the facility. All Staff have been in-serviced on the Abuse Policy as of January 10, 2023 at the all staff meeting. How will the facility identify other residents having the potential to be affected by the same practice and what corrective action will be taken? All residents in the facility have the potential to be affected. Social Services and the Administrator conducted interviews with each resident regarding the care and services that they receive. There were no other allegations of abuse or inappropriate care made as a result of those interviews. What measures will be put into place to ensure this practice does not recur? The Administrator will be immediately notified of any allegations of abuse. An investigation will be initiated immediately, and the alleged abuser will be suspended from the facility pending the outcome of the investigation. The IDT team will observe staff interactions with residents as part of their routine rounds throughout the facility. If any concern arises, the IDT member will intercede immediately to protect the resident and follow through with notification of the Administrator. Allegations of abuse and investigation activities and results will be discussed in the clinical meeting that meets at least 5 days a week for review of the resident’s status and any changes in condition. Those changes will be updated in the resident’s care plan. All staff will be in-serviced on types of abuse at each monthly in-service for the next 3 months in order to provide additional education and training on proper care techniques. Administrator and Social Services Director will meet with each resident weekly to discuss their care and address any concern for the next 3 months coinciding with Abuse training. How corrective Action(s) will be monitored to ensure the deficient practice will not recur? The Administrator or the Social Services Director will bring any allegations of abuse and ongoing investigations to the monthly QAPI meeting, including the timing of the notification made to the state agency, for further review and recommendations by the Committee. The QAPI Committee may decide to stop the weekly resident interviews with the Administrator and Social Services Director once the 3 months are over and when no further abuse allegations have resulted in the prior 30 days. The Administrator is responsible for the implementation and monitoring of this process.

Based on observation, interview and record review it was determined the facility failed to accurately assess the presence of a colostomy for 1 of 1 sampled resident (#16) reviewed for constipation. This placed the resident at risk for unmet colostomy (opening into the colon from the outside of the body providing new path for waste to leave the body) care needs. Findings include: Resident 16 was admitted to the facility in 4/2022 with diagnoses including history of a colostomy. Resident 16's 11/2022 and 2/2023 Quarterly MDS assessments revealed Resident 16 was coded "no" for a colostomy. While interviewing Resident 16 on 5/1/23 at 10:40 AM Resident 16 lifted her/his shirt and was observed to have a stoma (surgical opening in the skin) with a colostomy bag attached. On 5/2/23 at 4:13 PM Staff 2 (DNS) confirmed Resident 16 had a colostomy bag. On 5/3/23 at 11:27 AM Staff 3 (RCM) confirmed Resident 16 had a colostomy and the 11/2022 and 2/2023 Quarterly MDS assessments were coded inaccurately for colostomy status .

F641 – ACCUARCY OF ASSESSMENTS #1 Corrective Action for identified residents Resident #16 MDS assessment was reviewed for accurate coding of Section H and modified on May 4, 2023. #2 Identification of other residents affected by deficient practice. The Director of Nursing reviewed current residents with an MDS ARD of 2/10/2023 to 5/10/2023 to evaluate for proper MDS Coding in section H for bowel and bladder elimination MDS Coding during the MDS ARD look back time frame period. #3 Systemic Correction/Education to prevent reoccurrence. The Director of Nursing has educated the Resident Care Management and the other MDS staff on importance of MDS Coding accuracy, following the RAI guidelines including, but not limited to Section H for MDS Coding during the look back period of as outlined in the MDS RAI Manual. #4 Monitoring The Director of Nursing will audit 50% of MDSs completed for the week to validate MDS coding accuracy including but not limited to section H that covers Bowel and Bladder Elimination and other MDS Coding during the look back period weekly for four weeks, then monthly for three months. These audits will be reviewed and submitted to the QAPI committee for review and further recommendations as necessary.

Based on interview and record review it was determined the facility failed to maintain professional standards of practice related to abuse by Staff 23 (LPN) and ensure residents were free from unecessary medications and significant medication errors by Staff 9 (LPN), Staff 24 (RN) and Staff 25 (RN) for 3 of 8 sampled residents (#s 7, 8 and 25) reviewed for pharmaceutical services and abuse. This placed residents at risk for unsafe medication administration and additional abuse. Findings include: Oregon Administrative Rule 851-045-0060 Scope of Practice Standards for Registered Nurses: * Be knowledgeable of the professional nursing practice and performance standards and adhere to those standards. * Be accountable for individual RN actions, maintain competency in one's RN practice role and ensure unsafe nursing practices are addressed immediately. Scope of Practice Standards for All Licensed Nurses 851-045-0040 (1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall: (c) Self-regulate one's professional practice by: (A) Adhering to professional practice and performance standards. Oregon Administrative Rule 851-045-0070 - Conduct Derogatory to the Standards of Nursing is defined as: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (3) Conduct related to the client's safety and integrity: (8) Conduct related to other federal or state statute or rule violations: (d)Abusing a client; (q) Failing to dispense or administer medications in a manner consistent with state and federal law. 1.Resident 25 was admitted to the facility in 2021 with diagnoses including adjustment disorder (stress-related conditions where you feel overwhelmed and have a hard time adjusting to a stressful event or change) with mixed anxiety and depression and age related cognitive loss. An Incident Report dated 2/7/22 indicated a nurse reported Staff 23 (LPN) said she gave Resident 25 a suppository without consent. When the suppository was physically inserted Staff 23 also concealed her identity from the resident by putting her scrub jacket on backwards and lowering her voice. The Incident Report dated 2/7/22 included a written statement from Staff 23 which indicated she told the resident at the beginning of the shift she needed to give her/him "something" to help her/him have a bowel movement because the resident was yelling she/he was constipated and impacted. She did not tell the resident it was a suppository. Staff 23's written statement also indicated the resident told her she/he felt violated for getting the suppository without consent and the resident screamed, yelled and told staff she/he did not like getting the suppository. The Incident Report dated 2/7/22 included a Summary which concluded Staff 23 acknowledged she gave the resident a suppository without consent and put her scrub jacket on backwards to conceal her identity from the resident. This was poor judgment on the nurse's part, poor communication towards the resident and unprofessional nursing practice by Staff 23. The act was substantiated as abuse by the facility. On 5/4/23 at 1:25 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the incident was substantiated as abuse of Resident 25 by Staff 23. Refer to F600 example 2 2. Resident 7 was admitted to the facility in 2021 with diagnoses including atrial fibrillation (an irregular, often rapid heart rate which can cause poor blood flow) and post-thrombotic syndrome (a condition that can happen to people who have had a deep vein thrombosis [blood clot in a deep vein, usually in the legs]). Resident 7's care plan dated 5/19/21 included Anticoagulant (AC) Therapy secondary to post-thrombotic syndrome and atrial fibrillation. The care plan identified goals of the AC Therapy were as follows: -Will not develop signs or symptoms of abnormal bleeding or bruising -PT/INR goal range 2.0-3.0: (A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results. The INR goal for people who take warfarin is usually from 2 to 3.5. A value higher than 3.5 increases the risk of bleeding problems.) -Medication per MD orders A facility Incident Report dated 2/27/23 indicated Resident 7's bedside INR was 4.2 (high). The NP's office was notified and they attempted to fax over new order changes for the AC medication (warfarin) including an order to hold the warfarin on the evening of 2/27/23. The order was not received and Resident 7 received 12 mg of the warfarin medication which should have been held related to the high INR test. The Incident Report also noted Staff 9 (LPN) waited for the arrival of new orders instead of seeking clarification when no orders were received. Staff 9 did not utilize appropriate critical thinking skills to place the medication on hold. The CMA administered the 12 mg of warfarin. The resident had no signs or symptoms of harm from the incident. On 5/5/23 at 7:15 AM Resident 7 said she/he remembered the incident but had no concerns related to medications. On 5/4/23 at 1:25 PM Staff 1 (Administrator) and Staff 2 (DNS) indicated the provider's office tried a number of times to fax the order to the facility but were unsuccessful. The provider's office sent an email to the DNS but the DNS left for the day and did not receive the email. The DNS acknowledged Staff 9 knew the orders were to change and knew the resident's INR was too high but did not use appropriate critical thinking skills to hold the medication while she clarified the orders which put the resident at risk for bleeding issues. See F757 3. Resident 8 was admitted to the facility in 2/2023 with diagnoses including heart disease with heart failure and progressive supranuclear palsy (rare neurological disorder that affects body movements). Resident 8 had severe cognitive impairment as evidenced by a recent BIMS score of 5. A FRI dated 2/27/23 indicated two medications were given in error to Resident 8: Baclofen (skeletal muscle relaxant) and Cyclobenzaprine (skeletal muscle relaxant). The possible risks or complications of taking muscle relaxers include extreme dizziness, extreme drowsiness, blurred vision, low blood pressure, fainting, memory problems, liver damage and increased risk of overdose. An Investigation document dated 2/28/23 indicated Resident 8's level of consciousness when assessed following the receipt of the medications in error was "lethargic (drowsy)". A facility Incident Report dated 2/28/23 indicated Staff 24 (RN) was training new Staff 25 (RN) on the North Hall. Staff 24 took a cup with medications and read the Room 24 number to Staff 25. Staff 25 identified the resident of Room 24 as Resident 8. Staff 24 went to the therapy room and gave Resident 8 the medications in the cup. The two staff continued to pass medications and came across another cup labeled room 24. The two nurses determined the cup of medications given to Resident 8 in the therapy room was intended for room 29 and not room 24. Per the MD, staff were to monitor Resident 8 for additional sedation and report worsening symptoms. The staff held Resident 8's next opioid pain medication dose in case of possible side effects. The root cause of the medication errors was determined to be Staff 24 orienting a new hire Staff 25 and failed to adhere to the nursing standard of practice of requiring "3 checks/5 rights" before administering medications. The facility plan was to re-educate Staff 24 regarding the rights and "3 checks" system of medication pass which is the common nursing standard as well as the nursing standard the nurse who "pops" the medications needs to administer the medications. The facility determined the medication errors had occurred. On 5/4/23 at 1:25 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the medication errors occurred and Staff 24 and Staff 25 failed to adhere to the nursing standards of practice for administering medication. Refer to F760

F658 - PROFESSIONAL STANDARDS – MEDICATION ADMINISTRATION Identified residents: Staff #23 is no longer employed at the facility. Resident #25 has no lasting effects from the interaction with staff #23. Resident #7 has orders in place for INR monitoring and Medication Administration based on INR values. Resident #8 has no lasting effects of medication administration. Similar residents: All residents in the facility have the potential to be affected. The facility reviewed the medication administration processes with current residents for acceptable professional standards. Measure to prevent: Facility will educate the medication administration employees of the facility that complete medication orders and perform medication administration for correct application of procedures to meet professional standards by following the 3 checks, 5 rights of medication administration as it relates to the regulation. DNS will complete nurse competencies with all Licensed Nurses by 6/24/23 to ensure professional nursing practices and performance standards are adhered to. Monitor: Nursing competencies will be completed by 6/24/23 and annually thereafter. Any unsafe nursing practices will be addressed immediately. DNS or designee will monitor INR values weekly x4 weeks and monthly thereafter to ensure Anticoagulant therapy goals and orders are being followed properly. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determined the facility failed to maintain the appropriate care and services to maintain, restore or improve functional ability for 1 of 1 sampled resident (#17) reviewed for ADL's. This placed residents at risk for decreased functional ability. Findings include: Resident 17 admitted to the facility in 2/2021 with diagnoses including chronic pain syndrome and depression. Resident 17's comprehensive MDS dated 2/24/23 revealed a BIMS score of 15, indicating no cognitive impairment. Resident 17's care plan dated 3/9/23 revealed she/he was started on a restorative program on 3/9/23 three to five times per week to maintain strength of her/his upper and lower extremities. On 5/2/23 at 10:13 AM Resident 17 stated she/he participated in restorative therapy with Staff 13 (CNA/Restorative Aide) when Staff 13 had the time but did not think it was three to five times per week. On 5/3/23 at 9:19 AM, Staff 13 stated she completed two restorative therapy sessions with Resident 17 but did not plan to do any more because she felt it was unsafe due to the resident's physical limitations and she was afraid the resident would fall. She confirmed she was aware of the care planned interventions of three to five sessions per week. Staff 13 stated she had not talked to anyone at the facility about her concerns related to Resident 17's limitations. On 05/03/23 at 3:20 PM Staff 2 (DNS) stated she did not know about Staff 13's concerns for Resident 17's safety and confirmed the care plan for restorative therapy was not followed.

F676 – ADL’S FUNCTIONAL ABILITIES Identified residents: Resident #17 was evaluated by Physical Therapy for functional abilities and a proper restorative program was developed and implemented. Similar residents: The facility has screened or evaluated current residents at risk for functional decline for ADL abilities and need for restorative services. Measure to prevent: Facility will educate licensed employees on ROM and restorative program requirements as it relates to the regulation to ensure resident abilities do not diminish unless unavoidable. Monitor: The Director of Nursing or designee will review restorative programs monthly for completion and participation to ensure ongoing compliance. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure nail care was provided for 1 of 1 sampled resident (#185) reviewed for provision of nail care. This placed residents at risk for lack of nail care. Findings include: Resident 185 was admitted to the facility in 2021 with diagnoses including diabetes, kidney failure and depression. The resident's 2/1/22 care plan revealed her/his diabetes diagnosis indicated nail care was to be completed by a licensed nurse. The care plan further revealed staff were to clean and check the length of the resident's nails on bath days and report any changes to the nurse. Resident 185's TARs from 3/1/22 through 4/22/22 revealed no documented evidence of nail care information or that nail care was provided. On 5/2/23 at 11:45 AM Witness 2 (Complainant) stated the facility did not clip Resident 185's toe nails and they were growing out and over her/his toes. On 5/5/23 at 10:30 AM Staff 2 (DNS) acknowledged Resident 185's care plan lacked specific information regarding her/his nail care needs. Staff 2 stated nurses were responsible for the resident's nail care due to her/his diabetes. Staff 2 indicated provision of the nail care should be documented on the resident's TAR. Staff 2 acknowledged Resident 185's 3/2022 and 4/2022 TARs did not include documentation of nail care.

F677 – ADL care for dependent residents Identified residents: Resident 185 discharged from the facility. Similar residents: The facility has assessed and provided current residents with nail care as needed. Measure to prevent: Facility will educate licensed nursing staff on policies and procedures of ADL care requirements as it relates to the regulation regarding nail care. Monitor: The Director of Nursing or designee will complete ADL care audits weekly x 4 weeks then monthly for ADL care completion. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on observation, interview and record review it was determined the facility failed to provide services to prevent further decrease in ROM and mobility for 1 of 3 sampled residents (#12) reviewed for position and mobility. This placed residents at risk of loss of mobility, ROM and painful contractures. Findings include: Resident 12 was admitted to the facility in 2014 with diagnoses including obesity, rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet.), swan neck deformities of the fingers (laxity of the middle joint of the finger and flexion of the distal joint) and both upper and lower extremity ROM deficits. On 5/1/23 at 10:04 AM Resident 12 was observed while resting in bed. The resident's hands were malformed and appeared contracted. The resident could partially open both hands but not completely and the resident indicated they were a bit painful when she/he tried to open them. The resident was wearing soft boots on her/his feet. The resident's feet appeared to have a condition known as foot drop (inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot). Resident 12 also said she/he did not receive any ROM from staff. A Quarterly Contracture Screening dated 3/3/23 identified a contracture as a restriction of full passive ROM of any joint due to deformity, disuse, pain, etc. If the resident was unable to move them independently, nursing personnel should move the resident's limbs, but stretching a contracted or tight joint should be avoided. The screening indicated the resident had the following contractures: * Right extremity/Hip * Right Fingers * Right Thumb * Right Ankle * Left Fingers * Left Thumb * Left Ankle Staff were to determine whether functional limitation in range of motion (ROM) interfered with the resident's activities of daily living or placed resident at risk of injury. Staff selected the appropriate response for limitation that interfered with daily functions or placed resident at risk of injury as: * Impairment on both sides * Lower extremity (hip, knee, ankle, foot) * Impairment on both sides * Upper extremities (fingers, thumbs) A 2/22/23 MDS CAA Summary for ADL Functional/Rehabilitation Potential included the following: Resident 12 had bi-lateral contractures to the fingers due to swan-neck deformities, to both hands as well as bilateral ankle contractures. The resident was at risk for continued functional decline, unmet needs, falls, skin breakdown, increased contractures, muscle atrophy, continued incontinence, and depression. An MDS Indicator Facility Rate Report dated 5/2023 indicated the facility had 8 residents listed with ROM limitation and were not receiving services. Resident 12 was one of the residents listed. On 5/3/23 at 1:47 PM Staff 7 (Physical Therapist) indicated the resident had contractures to the feet (foot drop) and her/his hands and services were not provided.

F688 – INCREASE/PREVENT DECREASE IN ROM Identified residents: Resident 12 was evaluated by Physical Therapy for functional abilities and a proper restorative program was developed and implemented. Additional residents: The facility has screened or evaluated current residents on restorative for ADL functional abilities and a need for restorative services to ensure that programs are appropriate, safe, and have adequate participation. Measures to prevent: Facility educated licensed nursing employees on ROM and restorative program requirements as related to the regulation to ensure residents do not experience a limitation in range of motion unless unavoidable. Monitor: The Director of Nursing or designee will review restorative programs monthly for completion and participation to ensure ongoing compliance. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determine the facility failed to ensure care planned interventions were followed for 1 of 2 sampled residents (#18) reviewed for falls. This placed residents at risk for falls. Findings include: The facility's Incident Documentation and Investigation policy, revised 10/2022 stated incident reports would be completed for witnessed or unwitnessed falls and the resident examined by a licensed nurse and first aid or emergent care provided. Resident 18 admitted to the facility in 2020 with diagnoses including TBI (traumatic brain injury) and chronic respiratory failure. Resident 18's Quarterly MDS dated 3/3/23 revealed no BIMS score, indicating the resident was severely cognitively impaired and was a total assist for all ADL's. Resident 18's care plan indicated she/he was a fall risk due to her/his TBI diagnosis and she/he frequently rolled out of bed onto fall mats placed on the floor. A FRI dated 8/5/21 revealed Resident 18 fell out of bed due to the CNA leaving the bed in a high position while the CNA assisted the resident's roommate. Resident 18 landed on her/his face, striking her/his left forehead near the eyebrow and left cheek causing lacerations and bleeding. The facility investigated the incident and concluded the care plan was not followed. On 5/2/23 at 10:48 AM, Witness 1 (Complainant) confirmed the resident fell in 2021 and experienced another fall in March 2023. On 5/3/23 at 1:35 PM Staff 2 (DNS) and Staff 3 (RCM) confirmed Resident 18 fell out of her/his bed and the assigned CNAs did not follow the care plan.

F689 – ACCIDENTS Identified residents: Resident 18 care plan and fall interventions were reviewed and ensured they were in place and appropriate at this time. Additional residents: Facility has reviewed Plans of Care for current residents at high risk for falls to ensure appropriate interventions are in place and being followed. Measure to prevent: Licensed nursing staff will be in-serviced regarding Fall Prevention Measures and the Care Plan System for accident prevention techniques as it relates to the regulation to ensure resident environment remains as free of accidents hazards as possible. Monitor: Random weekly checks on all shifts will be conducted per the DON or DON’s designee on 3 residents who are determined high risk for falls per week to ensure that the appropriate measures are in place per the Care Plan x 4 weeks then randomly thereafter. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determined the facility failed to administer enteral feeding according to physician orders for 1 of 1 sampled resident (#18) who was reviewed for tube feeding. This placed residents at risk for nutritional complications and aspiration. Findings include: Resident 18 admitted to the facility 9/2021 with diagnoses including TBI (traumatic brain injury) and chronic respiratory failure. Resident 18's Quarterly MDS dated 3/3/23 revealed no BIMS score, indicating the resident was severely cognitively impaired and was a total dependence for all ADL's. Resident 18's care plan revealed she/he received all nutrition and hydration via PEG tube (a feeding tube inserted through the resident's stomach) due to the physician's order of not receiving food or water by mouth. The resident's head of bed was to be elevated 45 degrees during tube feeds and for thirty minutes after the tube feed. a. A 9/16/21 FRI reported Resident 18 was found lying flat in bed while the tube feed was connected and the feed was coming out of her/his mouth. The resident was immediately elevated, assessed and found with an oxygen saturation level of 89 percent and fluid in her/his lungs. Staff 18 (Former CNA) was interviewed and stated he lowered the bed to do an incontinence change, was distracted by Resident 18's roommate, assisted the roommate with cares and forgot to elevate the head of the bed. On 5/3/23 at 1:35 PM, Staff 2 (DNS) and Staff 3 (RCM) confirmed Staff 18 did not follow the care plan. b. A 11/21/22 FRI revealed Resident 18 was observed by a facility nurse to be orally fed by Staff 17 (Agency CNA). Staff 17 stated she thought she was feeding Resident 18's roommate. Resident 18 was assessed and showed no signs of aspiration or discomfort. Staff 17 was removed from the facility schedule. On 5/3/23 at 1:35 PM, Staff 2 (DNS) and Staff 3 (RCM) confirmed Staff 17 did not follow the care plan.

F693 – TUBE FEEDING Identified residents: Resident 18 MD orders were reviewed, and resident was assessed by provider and no s/sx of aspiration present. Additional residents: Facility has reviewed current residents with tube-feedings MD orders for appropriateness of tube feeding plan of care. Measure to prevent: Facility will educate licensed staff on requirements of tube feeding administration policy and procedures, obtaining and following MD orders as it relates to the regulation to ensure that residents with tube feedings have appropriate treatments and services in place. Monitor: A weekly audit through observation of random licensed nursing staff members will be completed on any residents receiving enteral feedings or medication via a G-tube x 4 weeks and then randomly thereafter. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure the resident was free from unecessary medications for 1 of 5 sampled residents (#7) reviewed for safe medication system. This placed residents at risk for adverse medication consequences. Findings include: Resident 7 was admitted to the facility in 2021 with diagnoses including atrial fibrillation (an irregular, often rapid heart rate which can cause poor blood flow) and post-thrombotic syndrome (a condition that can happen to people who have had a deep vein thrombosis [blood clot in a deep vein, usually in the legs]). Resident 7's care plan dated 5/19/21 included Anticoagulant (AC) Therapy secondary to post-thrombotic syndrome and atrial fibrillation. The care plan identified goals of the AC Therapy were as follows: -Will not develop signs or symptoms of abnormal bleeding or bruising -PT/INR goal range 2.0-3.0: (A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results. The INR goal for people who take warfarin is usually from 2 to 3.5. A value higher than 3.5 increases the risk of bleeding problems.) -Medication per MD orders A facility Incident Report dated 2/27/23 indicated Resident 7's bedside INR was 4.2 (high). The NP's office was notified and they attempted to fax over new order changes for the AC medication (warfarin) including an order to hold the warfarin on the evening of 2/27/23. The order was not received and Resident 7 received 12 mg of the warfarin medication which should have been held related to the high INR test. The Incident Report also noted Staff 9 (LPN) waited for the arrival of new orders instead of seeking clarification when no orders were received. Staff 9 did not utilize appropriate critical thinking skills to place the medication on hold. The CMA administered the 12 mg of warfarin. The resident had no signs or symptoms of harm from the incident. On 5/5/23 at 7:15 AM Resident 7 said she/he remembered the incident but had no concerns related to medications. On 5/4/23 at 1:25 PM Staff 1 (Administrator) and Staff 2 (DNS) indicated the provider's office tried a number of times to fax the order to the facility but were unsuccessful. The provider's office sent an email to the DNS but the DNS left for the day and did not receive the email. The DNS acknowledged Staff 9 knew the orders were to change and knew the resident's INR was too high but did not use appropriate critical thinking skills to hold the medication while she clarified the orders which put the resident at risk for bleeding issues.

F757 – UNNECESSARY DRUGS Identified residents: Resident 7 medication regimen review was conducted, and no changes were deemed appropriate at this time. No lasting effects were noted. Additional residents: Facility completed a medication order and administration pass review and found no other residents impacted by this deficient practice. Measure to prevent: Facility will educate the Licensed Nurses and Medication Aids on facility policy as it relates to Warfarin and other Anticoagulant medications to ensure that appropriate monitoring is in place prior for the administration of this medication. PT/INR Flow sheet will be utilized for all PT/INR lab results. Any abnormal lab results will be immediately reported to the prescribing MD. If no response from the prescribing MD, Medical Director will be notified and consulted for updated orders within the same day. Monitor: The DNS or designee will perform medication administration audits weekly for 4 weeks on accuracy of administration process as it relates to warfarin use and order clarification as necessary. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure the resident was free of significant medication errors for 1 of 5 sampled residents (#8) reviewed for safe medication system. This placed residents at risk for adverse medication consequences. Findings include: Resident 8 was admitted to the facility in 2/2023 with diagnoses including heart disease with heart failure and progressive supranuclear palsy (a rare neurological disorder that affects body movements). Resident 8 had severe cognitive impairment as evidenced by a recent BIMS score of 5. A FRI dated 2/27/23 indicated two medications were given in error to Resident 8: Baclofen (a skeletal muscle relaxant) and Cyclobenzaprine (skeletal muscle relaxant). The possible risks or complications of taking muscle relaxers include extreme dizziness, extreme drowsiness, blurred vision, low blood pressure, fainting, memory problems, liver damage and increased risk of overdose. An Investigation document dated 2/28/23 indicated Resident 8's level of consciousness when assessed following the receipt of the medications in error was "lethargic (drowsy)". A facility Incident Report dated 2/28/23 indicated Staff 24 (RN) was training new Staff 25 (RN) on the North Hall. Staff 24 took a cup with medications and read the room 24 number to Staff 25. Staff 25 identified the resident of room 24 as Resident 8. Staff 24 went to the therapy room and gave Resident 8 the medications in the cup. The two staff continued to pass medications and came across another cup labeled room 24. The two nurses determined the cup of medications given to Resident 8 in the therapy room was intended for room 29 and not room 24. Per the MD, staff were to monitor Resident 8 for additional sedation and report worsening symptoms. The staff held Resident 8's next opioid pain medication dose in case of possible side effects. The root cause of the medication errors was determined to be Staff 24 orienting a new hire Staff 25 and failed to adhere to the nursing standard of practice of requiring "3 checks/5 rights" before administering medications. The facility plan was to re-educate Staff 24 regarding the rights and "3 checks" system of medication pass which is the common nursing standard as well as the standard nursing practice the nurse who "pops" the medications needs to administer the medications. The facility determined the medication errors had occurred. On 5/4/23 at 1:25 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the medication errors occurred and Staff 24 and Staff 25 failed to adhere to the nursing standards of practice for administering medication.

F760 – SIGNIFICANT MED ERRORS Identified residents: Resident #8 medication regimen evaluated by NP with no changes determined to be appropriate. No lasting effects were noted. Additional residents: Facility completed a medication order and administration pass review and found no other residents impacted by this deficient practice. Measure to prevent: Facility will educate the Licensed Nurses and Medication Aid that complete medication orders and perform medication administration for correct application of procedures to meet professional standards by following the 3 checks and 5 rights of medication administration as it relates to the regulation. DNS will complete a comprehensive skills review with all Licensed Nurses and Medication Aids by 6/24/23 to ensure the understanding of standard nursing practices. DNS will complete a comprehensive skills review with all new Licensed Nursing staff within the first week of employment to ensure standard Nursing Practices are being adhered to in order to prevent future significant med errors. Monitor: The DNS or designee will perform medication administration audits weekly for 4 weeks on accuracy of administration process and randomly thereafter. The DNS is responsible for the implementation of the plan of correction and the Administrator is responsible for compliance. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on observation, interview and record review it was determined the facility failed to ensure meals were palatable and attractive for for 2 of 2 residents (#s 2 and 13) reviewed for food palatability. This placed residents at risk for unmet nutritional needs. Findings include: On 5/1/23 at 3:47 PM Resident 13 stated she/he did not like the food at the facility and said the main problem with the food was it was cooked in the adjacent Assisted Living Facility. Resident 13 further stated while the food was transported to the Nursing Home from the other facility it kept cooking and became "flavorless mush." The resident indicated she/he ordered out frequently. On 5/2/23 at 11:52 AM Resident 6 stated the food was bland and sometimes cold. She/he also noted the meat was tough. Resident 6 stated the food was cold about half the time. Resident Council notes were reviewed for January 2023 through April 2023. The April 2023 notes revealed the residents complained the food was cold, unappetizing, unpalatable and the CNAs did not want to reheat the food when asked by residents. On 5/3/23 at 1:00 PM a test tray consisting of pork chop, macaroni and cheese and mixed vegetables was sampled. The food temperature was adequate but the vegetable mixture was soft, mushy and not flavorful. On 5/3/23 at 11:19 AM Staff 21 (Dietary Manager) stated he had received complaints about the food and was working on resolving the issues.

F804 – NUTRITIVE VALUE Identified residents: Residents 2 and 13 were interviewed by the Dietary Services Manager and the Registered Dietitian and concerns with food was addressed. Additional residents: Current residents have the potential to be affected by this deficiency. Measure to prevent: The dietary department was educated on the regulatory guidelines for nutritional and palpable food preparation. The facility menu was reviewed updated on 5/25/23. New alternative menus have been created which will be alternated to ensure variety. Monitor: Dietary menu concerns will be addressed monthly at Resident Council. Any food related concerns will be submitted to the Food and Nutrition Services Manager for follow-up. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on observation, interview and record review it was determined the facility failed to properly store resident food for 1 of 1 resident snack refrigerators reviewed for food quality. This placed residents at risk for unmet nutritional needs. Findings include: On 5/3/23 at 9:45 AM, the refrigerator in the facility with resident food and drinks was observed. The following items were found: -Sandwiches individally bagged with stickers dated 4/30/23; -Multiple containers of prune juice dated 4/26/23; -Approximately ten containers of snack dip for a resident contained handwritten dates of 2/2023 and 3/2023 on the lids. Several containers dates were smeared off and had crusted material on top of the containers. On 5/3/23 at 10:00 AM Staff 22 (Dietary Aide) was shown the refrigerator's contents and stated the sandwiches were dated on the day they were placed in the refrigerator and it was the facility's protocol for the sandwiches to be thrown away after three days, with day one being the date the sandwiches were placed in the refrigerator. On 5/3/23 at 11:19 AM Staff 21 (Dietary Manager) confirmed it was an expectation that food and drinks should not be in the resident refrigerator after the expiration dates.

F812 FOOD PROCUREMENT Identified residents: No residents were identified related to this deficiency. Additional residents: The resident refrigerator was evaluated and all products without a date or longer than 72-hour date was removed immediately. Measure to prevent: The facility has educated the appropriate staff on the regulation regarding food procurement and storage to ensure that food items for residents are appropriately labelled and stored. Monitor: The dietary manager or designee will audit the resident refrigerator weekly x 4 weeks to ensure compliance. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure accurate medical records for bowel care for 1 of 5 sampled residents (#29) reviewed for unnecessary medications. This placed residents at risk for unmet bowel interventions. Findings include: Resident 29 was admitted to the facility in 8/2022 with diagnoses including history of a stroke, right and left sided spastic hemiplegia (muscles are in a constant state of contraction), chronic pain, gastroparesis (a condition which affects stomach muscles preventing proper stomach emptying) and constipation. Resident 29's 2/2023 Quarterly MDS revealed she/he had a BIMS of 15 (no cognitive impairment). Resident 29's 2/13/23 care plan revealed she/he required extensive assistance from one staff for toileting. The facility's undated Bowel Care Protocol instructed staff to administer the following interventions: - Day 3 anytime; 30 ml Milk of Magnesium (MOM) or bisacodyl; - Day 4 after breakfast; bisacodyl (Dulcolax) suppository; - Day 4 after lunch; Mineral oil enema, if no bowel movement within two hours call physician and get bowel care orders. The 4/2023 physician orders revealed instructions for staff to administer the following: - bisacodyl tablet delayed release give 1 tablet by mouth as needed for bowel program if no bowel movement (BM) in 3 days or give Milk of Magnesia. - MOM give by mouth as needed for bowel program day 3 if no BM or give bisacodyl tablet 5 mg. Resident 16's bowel tracking revealed she/he had no BM on the following dates: - 4/3/23, 4/4/23, 4/5/23, 4/6/23, 4/7/23 and 4/8/23; - 4/12/23, 4/13/23, 4/14/23, 4/15/23 and 4/16/23; - 4/18/23 and 4/19/23; - 4/21/23 and 4/22/23; - 4/24/23 and 4/25/23; - 4/27/23, 4/28/23 and 4/29/23. Resident 29's 4/2023 MAR revealed the following: - 4/15/23 and 4/16/23 bisacodyl was documented as administered and was "effective". - There were no documented "refusals" on the MAR when interventions were offered but declined by Resident 29 on 4/6/23, 4/9/23, 4/15/23, 4//19/23 and 4/29/23. Progress note documentation revealed the following: - 4/6/23 Resident on day four of no BM. Resident refusing suppository. Nurse offered oral alternatives for bowel care and resident refusing those as well. - 4/9/23 Resident is on day seven of no BM. Resident refused suppository tonight. - 4/15/23 Resident refused suppository or enema for day four of bowel program but agreed to bisacodyl tablet. - 4/19/23 Resident remains on bowel protocol list for no BM in nine days. Resident declining all offered PRNs at this time, will continue to encourage. - 4/20/23 Resident remains on bowel protocol list for no BM in nine days. - 4/29/23 Resident on day six of no BM and refused bowel care. On 5/4/23 at 1:04 PM Staff 2 (DNS) confirmed staff documentation regarding Resident 29's bowel program was inconsistent and inaccurate.

F842 – RESIDENT RECORDS Identified residents: Resident 29 was evaluated by the LN and NP with positive abdominal assessment documented. No lasting effects were noted. Additional residents: The facility has reviewed other current residents’ bowel protocol and documentation and no negative outcomes have been noted. Measure to prevent: Licensed nursing staff have been educated in proper documentation for refusals of medications as it relates to the regulation to ensure that resident bowel need interventions are met. Monitor: Director of Nursing or designee will audit bowel medication administration records documentation records weekly x 4 weeks than monthly thereafter for completion of documentation to ensure ongoing compliance. Any noted issues will be corrected immediately, and any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on observation, interview and record review it was determined the facility failed to ensure call lights and call light cords were in good repair and operative for 3 of 5 sampled residents (#s 11,12 and 16) reviewed for environment. This placed residents at risk for unmet needs. Findings include: On 5/1/33 at 9:33 AM Resident 11's call light cord was observed out of reach and the clip to secure the call light cord on or near the resident was broken. On 5/1/23 at 10:25 AM Resident 16 was observed sitting in her/his bed with the call light cord beside her/him. Resident 16 indicated she/he was dependent on two staff to get her/him out of bed and provide care related to her/his medical and toileting needs. Resident 16 stated in 1/2023 she/he waited over an hour for her/his call light to be answered. Resident 16 stated she/he was informed by Staff 19 (former Maintenance Director) the call light above her/his room door was not working and the electrical wiring and call light cord would need to be repaired. Resident 16 stated it took weeks to be fixed. On 5/2/23 at 9:14 AM Staff 5 (Maintenance Director) stated he worked for the facility for a week and a half. He stated there were many reports from residents and staff of unresolved issues with call lights. On 5/2/23 at 12:00 PM maintenance log requests in the binder at the nurses' station revealed the following: - 3/10/23 Room 16's call light still doesn't make any noise or light up on the call board. This was signed as completed 3/15/23. - 3/18/23 Room 35's call light not lighting. This was signed as completed on 4/12/23. - 3/28/23 Rooms 16 and 32 call lights not working. This was signed as completed 4/14/23. - 4/10/23 Room 25 call light not working. This was signed as completed on 4/11/23. - 4/13/23 Rooms 16 and 20 call light not working on board. This was signed as completed on 4/14/23. - 4/23/23 Room 18 call light keeps getting pulled out. Resident would like it taped in place. This was signed as completed on 4/24/23. On 5/2/23 at 12:26 PM Resident 12's call light was observed to have exposed electrical wires where the clip meets the cord. On 5/2/23 at 3:25 PM Staff 5 stated the facility did not have call light logs due to the age of the call light system. Staff 5 said many repairs were needed and he has ordered parts to fix them. On 5/03/23 at 8:00 AM Staff 11 (CNA) stated she worked with many residents who required assistance and staff knew residents needed assistance by the call light above the resident's door. She stated "Call lights were not working previously but we got a new maintenance guy and he's making sure things are working now." Resident Council meeting minutes revealed during 3/2023 and 4/2023 residents shared concerns of long call light wait times and maintenance issues. On 5/03/23 at 10:50 AM Staff 1 (Administrator) confirmed resident rooms had broken call lights. Staff 1 went on to say the call light system was not always working and residents complained about call light response times. Staff 1 stated broken call lights and the call light system were discussed with resident council members.

F919 – RESIDENT CALL SYSTEM Identified residents: Residents 11, 12 and 16 call lights were evaluated by maintenance and found to be in working order at this time. Additional residents: Current utilized call lights in the facility were evaluated by maintenance and repairs were conducted as required and are in working order at this time. Measure to prevent: Facility has educated the maintenance department on the federal guidelines on ensure that the resident has access to a functional communication system to call for assistance. Education provided to all staff regarding call light accessibility, function and completing work orders if any issues are discovered with the call light system. Monitor. Random audits for accessibility and function will be conducted by the administrator or designee weekly. The maintenance director or designee will conduct monthly facility round audits to ensure that the facility call light system is maintained to ensure the call light system is functional. Any identified issues will be addressed per the facility maintenance log and follow-up. Any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on observation and interview it was determined the facility failed to maintain the laundry room floor in a safe and sanitary condition for 1 of 1 laundry rooms reviewed for infection control. This created a risk for infection control concerns. Findings include: On 5/2/23 at 11:03 PM an observation of the facility's laundry room was conducted. In the center of the laundry room an approximately four foot wide by six foot long section of the flooring (linoleum) was missing. There was also a small open hole in the center of the floor for drainage which was missing a grate cover. In addition to the missing section of flooring there were additional areas of the floor which had worn off surfaces. The edges of the worn areas were not fully cleanable and had dirt and debris stuck to the old adhesive of the flooring. On 5/03/23 at 12:00 PM Staff 1 (Administrator) acknowledged the missing flooring in the laundry and the hole in the floor without a grate cover. On 5/3/23 at 1:50 PM Staff 5 (Maintenance Director) acknowledged the laundry room floor needed to be repaired or replaced and the hole in the floor should have a grate.

F921 – SANITARY ENVIRONMENT – LAUNDRY ROOM FLOOR Identified residents: No residents were identified related to this deficiency. The laundry room floor will be replaced to allow for a cleanable surface. Laundry room replacement scheduled for July 2023. Additional residents. Current residents of the facility are at risk for this deficiency. Measure to prevent. Facility has educated the maintenance department on the federal guidelines to ensure that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and public. Monitor: The maintenance director or designee will conduct monthly facility round audits to ensure that the laundry facilities is maintained to provide a cleanable floor surface. Any identified issues will be addressed per the facility maintenance log and follow-up. Any noted trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determined the facility failed to provide the minimum number of required CNA staff to ensure residents received adequate care and services for 3 of 3 halls. This placed residents at risk for unmet care needs. Findings include: On 4/27/22 at 3:36 PM Witness 2 (Complainant) stated Resident 185 told her the facility was understaffed. On 5/2/23 at 11:45 AM Witness 2 indicated there was not adequate staff to provide care for the resident's worsening skin condition and she/he required hospitalization. Review of the Direct Care Staff Daily Reports from 3/15/22 through 4/22/22 revealed the following dates when state minimum CNA staffing ratios were not met: -3/15/22 through 3/31/2022 for 12 of 51 shifts. -4/1/22 through 4/22/22 for 38 of 66 shifts. On 5/5/23 at 11:30 AM the lack of minimum required CNA staffing was reviewed with Staff 1 (Administrator) and she acknowledged the findings.

M183 Identified residents: Resident 2 was assessed and all care needs are being met at this time. Additional residents: Current residents of the facility are at risk for this deficiency. Measure to prevent: Any open C.N.A shifts will be emailed to our local staffing agencies for coverage. Bonuses will be offered to Regency staff who pick up open shifts. The Staffing Coordinator or designee will reach out to the other Regency Facilities offering open shifts to other Regency Facility C.N.A’s. Regency Recruiters will be made aware of open positions to ensure Employment Ads are advertised and updated as appropriate. Regency Recruiters will promote the paid N.A classes to help recruit additional students who will become C.N.A’s. Monitor: Staffing Coordinator or designee will monitor the CNA schedule daily in the daily clinical meeting to ensure there is the required minimum C.N.A staffing scheduled. The previous day’s staffing sheets will be reviewed daily by the Administrator or designee to ensure accuracy. Care needs in relation to staffing requirements will be addressed monthly in the resident council meetings. Any trends will be brought to the facility QAPI program as deemed appropriate.

Based on interview and record review it was determined the facility failed to ensure one additional CNA was staffed above the licensing staffing standard for every five individuals receiving the bariatric (an individual with a physician diagnosis of obesity with a body mass index greater than 40 and requires additional assistance) reimbursement rate for 3 of 3 halls. This placed bariatric residents at risk for delayed treatment and unmet care needs. Findings include: 1. Review of the 2022 Direct Care Staff Daily Reports from 3/15/22 through 4/22/22 revealed the following dates when state CNA bariatric staffing ratios were not met: -3/15/22 through 3/31/2022 for 12 of 51 shifts (eight to nine bariatric residents). -4/1/22 through 4/22/22 for 38 of 66 shifts (eight to ten bariatric residents). On 4/27/22 at 3:36 PM Witness 2 (Complainant) stated Resident 185, who qualified as a bariatric resident and received a higher rate for her/his care, told her the facility was understaffed. On 5/2/23 at 11:45 AM Witness 2 indicated there was not adequate staff to provide care for the resident's worsening skin condition and she/he required hospitalization. On 5/5/23 at 11:30 AM the lack of minimum required bariatric CNA staffing was reviewed with Staff 1 (Administrator) and she acknowledged the findings. , 2. The facility's 2023 Direct Care Staff Daily Reports from 1/1/23 through 1/17/23 and 4/1/23 through 5/1/23 revealed 29 of 48 days in which the state minimum CNA bariatric staffing ratios were not met. - 1/2/23 day shift - 1/4/23 day shift and eve shift - 1/7/23 day shift - 1/8/23 day shift - 1/9/23 day shift - 1/10/23 day shift and eve shift - 1/11/23 day shift and eve shift - 1/13/23 day shift - 1/15/23 day shift and eve shift - 4/1/23 day shift - 4/2/23 day shift - 4/5/23 night shift - 4/6/23 day shift and night shift - 4/7/23 day shift - 4/8/23 night shift - 4/9/23 night shift - 4/15/23 day shift and eve shift - 4/16/23 day shift - 4/21/23 eve shift - 4/22/23 day shift and eve shift - 4/23/23 day shift - 4/24/23 eve shift - 4/25/23 eve shift and night shift - 4/26/23 day shift - 4/27/23 day shift - 4/28/23 day shift and eve shift - 4/29/23 day shift - 4/30/23 day shift and eve shift - 5/1/23 eve shift and night shift On 5/02/23 at 10:19 AM Staff 1 (Administrator) stated the facility had 10 bariatric residents and confirmed the facility received the enhanced bariatric rate and did not meet the minimum staffing requirements.

M185 Identified residents: No residents were specifically identified in this deficiency. Additional residents: Current bariatric residents of the facility are at risk for this deficiency. Measure to prevent: Staffing Coordinator or designee will monitor the C.N.A schedule daily to ensure proper bariatric staffing ratios per the Oregon Minimum Staffing Requirements. Staffing Coordinator has been educated on staffing ratio requirements for the residents who qualify for the bariatric program. Continue utilizing staffing agencies and Regency C.N.A certification classes to assist with staffing prn. A survey will be completed with all residents by the administrator or designee to ensure care needs are being met in relation to the minimum staffing requirements by 6/24/23. Resident surveys will be conducted with a random selection of residents weekly x4 weeks by administrator or designee. Any unmet care needs will be addressed immediately. Monitor: Staffing will be reviewed in the daily clinical meeting to ensure adequate staffing for the day. Any open shifts for the month will be reviewed and discussed daily until filled. Care needs in relation to staffing requirements will be addressed monthly in the resident council meetings. Any trends identified will be brought to the facility QAPI meeting as deemed appropriate.

****************************** OAR 411-087-0100 Physical Environment Refer to F584 ************************************** OAR 411-085-0360 Abuse Refer to F600 ************************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F641 ************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F658, F676, F677, F693, F760 ************************************** OAR 411-086-0140 Nursing Services: Prob Reso and Preventative Care Refer to F688, F689, F757 ************************************** OAR 411-086-0250 Dietary Services Refer to F804, F812 ************************************** OAR 411-086-0300 Clinical Records Refer to F842 ************************************** OAR 411-087-0440 Electrical Systems: Alarm and Nurse Call Systems Refer to F919 ************************************** OAR 411-087-0100 Physical Environment Generally Refer to F921 **************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/29/2021 and 12/05/2021, 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 record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/22/2021 and 11/28/2021, 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 record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/15/2021 and 11/21/2021, 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 record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/08/2021 and 11/14/2021, 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 observation, interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 9 out 14 days reviewed for minimum CNA staffing. This placed residents at risk for unmet needs. Findings include: A review of the 9/1/21 through 9/14/21 Direct Care Staff Daily Reports revealed the facility had insufficient CNA staff 9 out of 14 days: -9/1/21 night shift; -9/2/21 night shift; -9/3/21 day shift and night shift; -9/4/21 day shift and night shift; -9/5/21 day shift and night shift; -9/7/21 evening shift and night shift; -9/9/21 day shift; -9/10/21 night shift; -9/13/21 night shift. In an interview on 1/27/21 at 2:05 PM Staff 1 (DNS) stated she was aware the facility had staff shortages. Staff 1 stated she expected minimum staff ratio requirements to be met.

1: No residents were identified to have been harmed or had their needs unmet 2: Random interviews to be completed of in-house census to determine if resident’s feel their needs have been met. Reassurance to residents that their needs will be met in a timely fashion. 3: RCCO to enhance recruiting efforts to include recruiting for PCAs and CNAs including but not limited to Facebook, Craigslist, Indeed and other sources to fill open positions. RCCO to secure additional staffing contracts to assist in meeting the state guidelines for minimal staffing with the increased requirements of the Bariatric program, (+2 q shift). Managers will be assigned to resident rooms to round periodically to ensure resident’s needs are met. 4: RCCO interdisciplinary team to review the staffing ratios and resident audits in QAPI monthly for effectiveness and make improvement adjustments as needed to ensure ongoing and substantiated compliance to staffing ratio along with increased CNA requirements per Bariatric Program. 5: 10/29/2021