Tierra Rose Care Center

Resident 5 was admitted to the facility in 2024 with diagnoses including dementia.-áAn 8/3/25 Significant Change MDS indicated Resident 5 was not cognitively intact and was at high risk for developing sores. Resident 5 was on a turning/repositioning program.An 8/22/25 Care Plan indicated the following:- Resident 5 required limited assistance by one staff to turn and reposition in bed two to three times a shift and as necessary.-á- Resident 5 was assisted to reposition often to reduce the risk of pressure related skin breakdown.-á- Staff were to follow facility policies/protocols for the prevention/treatment of skin breakdown.-áAn 10/5/25 physician order indicated Resident 5 had a MASD (Moisture-Associated Skin Damage) wound in her/his coccyx. -áFrom 10/13/25 through 10/16/25, on eleven occasions between 9:00 AM and 4:00 PM, the surveyor observed Resident 5 to lay flat on her/his back with no offloading or other pressure relieving devices present.-á-áOn 10/14/25 at 2:43 PM, Staff 9 (RN) stated Resident 5's wound was healed and closed.On 10/15/25 at 4:16 PM, Resident 5 was observed in her/his bed and was lying flat. Resident 5 was awake and stated her/his bottom was painful and she/he was not comfortable. Resident 5 was unable to lift her/his legs and was unable to wiggle her/his toes.On 10/16/25 at 1:20 PM, Staff 7 (CNA) stated a turning/repositioning program indicated staff turned residents in bed to the left and right side and onto their backs with pillow support every two hours. Staff 7 stated she was informed by the CNA lead staff and/or the nurses when a resident was on a turning/repositioning program. Staff 7 stated Resident 5 was bed bound and had limited ROM to her/his left and right arm. Staff 7 stated Resident 5 required repositioning when she/he slid down in bed. Staff 7 stated she noticed a small sore on Resident 5's bottom and notified nursing. Staff 7 stated she applied barrier cream to her/his bottom and she notified staff when the dressing was soiled. Staff 7 stated Resident 5 was not on a turning/repositioning program.On 10/16/25 at 1:46 PM, Staff 8 (CNA) stated a turning/repositioning program indicated staff turned residents in bed to the left and right side with pillow support every one to two hours. Staff 8 stated there no residents on a turning/repositioning program. Staff 8 stated Resident 5 had dementia, was bed bound, slept most of the time and refused to get out of bed. Staff 8 stated Resident 5 did not have any skin issues and was not on a turning/repositioning program. Staff 8 stated she was informed about residents on a turning/repositioning program during shift change and/or the resident's care plan.-áOn 10/16/25 at 1:52 PM, Staff 9 stated all residents who had wound care treatment orders were on a turning/reposition program. Staff 9 stated Resident 5 required maximum assistance when turned to the side. Staff 9 stated Resident 5 was on a turning/repositioning program and expected staff repositioned Resident 5 to the right, left and on her/his back every one to two hours. Staff 9 stated she ensure staff implemented repositioning interventions by listening on the radios used by floor staff and observed the residents throughout the day and indicated, ""But I have three halls.""-áOn 10/17/25 at 8:50 AM, Staff 11 (RN) was observed performing wound care on Resident 5. Resident 5 was lying flat and Staff 10 (CNA) turned her/him to the right side. The wound was observed to be open, with a pink wound bed and non-blanchable on the resident's coccyx. Staff 11 acknowledged the open, non-blanchable, pink wound. Resident 5 verbalized pain when the wound was touched and during the wound care dressing change. Staff 11 placed a new dressing, positioned Resident 5 onto her/his back and placed pillows under her/his knees.On 10/17/25 at 9:04 AM, Staff 11 stated residents on a turning/repositioning program were repositioned every two hours and she was unsure if Resident 5 had repositioning orders. Staff 11 returned to the surveyor a few minutes later and said Resident 5 was on a turning/repositioning program.-áOn 10/17/25 at 9:09 AM, Staff 10 (CNA) stated Resident 5 was not on a turning/repositioning program.-áOn 10/17/25 at 10:25 AM, Staff 6 (LPN Resident Care Manager) stated Resident 5 was bed bound. Staff 6 stated Resident 5 had one wound that was classified as MASD and stated the pictures taken by staff showed a closed wound. Staff 6 stated Resident 5 received incontinence care several times per shift and had scheduled wound care treatment. Staff 6 stated she expected staff to reposition Resident 5 every one to two hours with pillow support. Staff 6 stated she considered Resident 5's wound to be unavoidable due to Resident 5's lack of memory and the inability for Resident 5 to communicate needs. Staff 6 acknowledged Resident 5 did not use the call light and depended on staff to reposition her/him in bed.-áOn 10/17/25 at 10:41 AM, Staff 3 (LPN, Assistant DNS) stated there was no specific program that required using pillow support when staff repositioned residents. Staff 3 stated she expected staff to check residents regularly for skin breakdown. Staff 3 acknowledged using pressure relieving devices to offload Resident 5's coccyx was beneficial for wound healing.-á

1. The CDCGÇÖs 6/24/24 Infection Control Guidance: SAS-CoV-2 indicated staff who provided care to residents with confirmed COVID-19 were to wear a respirator with N95 filters and a barrier face covering.-áResident 39 was admitted to the facility in 9/2/25 with a diagnosis of ParkinsonGÇÖs disease.-áA review of Resident 39GÇÖs Progress Notes revealed she/he tested positive for COVID-19 on 10/14/25 at 10:23 AM.-áOn 10/14/25 at 12:25 PM Resident 39GÇÖs room was observed to have contact and droplet precaution signage on the door.-áOn 10/14/25 at 12:25 PM Staff 12 (CNA) donned a gown, gloves, and surgical mask, but did not don eye protection and a N95 respirator before entering Resident 39's room. Staff 12 stated Resident 39 was on transmission-based precautions for COVID-19. Staff 12 stated he used contact precautions without eye protection because he did not provide direct care to Resident 39.-áOn 10/15/25 at 11:48 AM Staff 13 (CNA) donned a gown, gloves, surgical mask, and a face shield hanging on the wall next to the doorway inside Room 209. Staff 13 was observed to enter Room 209 to deliver a meal tray, proceeded to doff her PPE at the doorway, hung the face shield on the wall next to the doorway inside the resident's room and did not disinfect the face shield prior to exit.-áOn 10/15/25 at 12:14 PM Staff 14 (CNA) stated a face shield was stored inside the room of a resident with COVID-19 and she used it when she provided care.-áOn 10/15/25 at 1:58 PM Staff 2 (DNS) and Staff 3 (Assistant DNS) confirmed re-usable face shields should not be stored inside resident rooms and staff needed to wear both N95 respirators and eye protection when they entered the rooms of residents with COVID-19.-á -á2.-áOn 10/13/25 at 12:05 PM during the lunch meal service on the South Unit Hallway, Staff 15 was observed to place his hands inside a garbage bag to dispose of trash then prepared and delivered a cup of coffee to Room 312 without completing hand hygiene.-áOn 10/13/25 at 12:19 PM Staff 15 acknowledged he did not perform the needed hand hygiene.-áIn a concurrent interview on 10/15/25 at 1:58 PM Staff 2 and Staff 3 confirmed staff were expected to complete hand hygiene as needed.

Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 3 sampled residents (#66) reviewed for ADLs. This placed residents at risk for lack of nail care and skin impairments. Finding include:

Resident 66 admitted to the facility in 2024 with diagnoses including heart failure and weakness.

Resident 66's 5/7/24 care plan indicated staff were to check nail length, trim and clean on bath days and as necessary and report any changes to the nurse.

On 6/25/24 at 9:33 AM Resident 66 was observed wearing sandals and had thick toenails extending past the end of her/his toes.

The 6/26/24 bathing records indicated Resident 66 had a bath on 6/26/24 at 11:52 AM.

On 6/26/24 at 2:22 PM Staff 4 (CNA) stated nail care was to be provided to residents weekly and the nurse was responsible for giving CNA staff a list of who needed nail care.

On 6/26/24 at 2:30 PM Staff 5 (LPN) observed Resident 66 and confirmed Resident 66's toenails were long, thick, and extended past the end of her/his toes.

Based on observation, interview and record review it was determined the facility failed to follow care planned interventions and revise care plans to prevent falls for 3 of 6 sampled residents (#s 1, 64 and 66) reviewed for falls and during a random observation. This placed residents at risk for injury from falls. Findings include:

1. Resident 64 admitted to the facility in 2024 with diagnoses including stroke and dementia.

a. The 3/1/24 care plan indicated Resident 64 was to have a fall mat on the left side of the bed.

Resident 64's 6/10/24 fall investigation indicated the following:
- Resident 64 had dementia and a history of falls.
- Resident 64 had a non-injury fall. The Resident was found on the right side of her/his bed and stated she/he attempted to transfer to the wheelchair and fell.
-Resident 64 had weakness and balance issues and overestimated the ability to transfer independently. Though the call light was in reach, the resident had poor safety awareness as evidenced by all of her/his previous falls and chose to attempt to transfer and fell. Ongoing resident education on safety was provided.

There was no indication in the clinical record to indicate an assessment was completed to determine if current interventions were effective, or if additional interventions including a right sided fall mat, were needed.

On 6/24/24 at 12:08 PM Resident 64 was observed to be in bed with a fall mat to the left side of the bed only.

On 6/24/24 at 12:21 PM Staff 8 (CNA) stated she observed Resident 64 attempt to get out of bed in the past and the resident only attempted to get up on the right side of the bed.

On 6/26/24 at 2:35 PM Staff 11 (RNCM) reviewed the 6/10/24 fall progress note and stated Resident 64 had a fall on the right side of the bed. Staff 11 stated after the fall no new interventions were put in place and a new intervention of bilateral fall mats was warranted after the 6/10/24 fall.

b. The 6/26/24 updated care plan indicated Resident 64 was to have bilateral fall mats in place.

On 6/27/24 at 9:16 AM Staff 12 (CNA) was observed to assist Resident 64 into bed and exited the room without placing bilateral fall mats.

On 6/27/24 at 9:16 AM Staff 12 was asked to review Resident 64's care plan. Staff 12 stated the care plan indicated the resident was supposed to have bilateral fall mats. Staff 12 entered the room and placed a fall mat on the left side of the bed only and then exited the room.

On 6/27/24 at 9:27 AM Staff 3 (Assistant DNS) acknowledged Resident 64 was care planned for bilateral fall mats and she/he had a fall mat on the left side of the bed but not the right side.

2. Resident 66 admitted to the facility in 2024 with diagnoses including heart failure and weakness.

The 5/29/24 care plan indicated Resident 66 was to have a fall mat on the right side of the bed.

On 6/24/24 at 12:05 PM Resident 66 was observed to be in bed with a fall mat on the left side of the bed and no fall mat on the right side of the bed.

On 6/24/24 at 12:19 PM Staff 8 (CNA) observed Resident 66 and acknowledged the fall mat was on the left side of the bed and no fall mat was located on the right side of the bed.

On 6/26/24 at 2:30 PM Resident 66 was observed in bed and had a fall mat on the left side of the bed. There was no fall mat located on the right side of the bed.

On 6/26/24 at 2:30 PM Staff 5 (LPN) observed Resident 66 and acknowledged the fall mat was on the left side of the bed and no fall mat was located on the right side of the bed. Staff 5 acknowledged the care plan indicated she/he was to have a right sided fall mat.

On 6/26/24 at 2:35 PM Staff 11 (RNCM) stated Resident 66's care plan indicated a fall mat was to be on the right side of the bed. Staff 11 stated Resident 66 was to have bilateral fall mats in place and the care plan was not updated.

3. Resident 1 admitted to the facility in 2009 with diagnoses including weakness and stroke.

The 7/28/21 care plan indicated Resident 1 had a history of falls and was to have bilateral fall mats in place.

On 6/27/24 at 9:16 AM Resident 1 was observed to have one fall mat to the right side of the bed and no fall mat on the left side of the bed.

On 6/27/24 at 9:16 AM Staff 12 (CNA) was observed to remove Resident 1's fall mat on the right side of the bed and place it across the room next to the bed of the resident's roommate.

On 6/27/24 at 9:27 AM Staff 3 (Assistant DNS) observed Resident 1 and acknowledged her/his care plan indicated she/he was to have bilateral fall mats and acknowledged there were no fall mats in place for Resident 1.

Based on observation, interview, and record review it was determined the facility failed to ensure proper storage and labeling of medication and biologicals for 1 of 2 medication carts and 1 of 1 medication and biologicals refrigerator reviewed for biologicals and medication storage. This placed residents at risk for inaccurate tuberculosis testing, decreased vaccine efficacy, improper medication administration, and reduced efficacy of medication. Findings include:

According to the facility Medication Labeling and Storage Policy Statement, Revised 2/23, Multi-dose vials that are opened were dated and discarded within 28 days unless the manufacturer specified a shorter or longer date for the open vial. The policy also stated that medications may not be transferred between containers, and medications and biologicals were stored in the packaging, containers, or other dispensing systems in which they were received.

On 6/26/24 at 10:15 AM a review of the biologicals and medication storage area was conducted with Staff 5 (LPN). One medication cart, and one refrigerator were reviewed for proper medication and biologicals storage and labeling.

On 6/26/24 at 10:19 AM the refrigerator was noted to contain one sealed multi-dose vial of Tubersol (solution used in testing for Tuberculosis), and one opened multi-dose vial of Tubersol. Staff 5 (LPN) and Staff 10 (CMA) verified the opened vial of Tubersol did not have a date on the box or the vial.

On 6/26/24 at 10:33 AM the medication cart was noted to have a small cup that contained multiple round white pills with no markings and another small cup placed on top of the pills. The bottom small cup was labeled with the word, "Loratadine."

On 6/26/24 at 10:33 AM Staff 5 (LPN) indicated the white pills were improperly stored and, "we shouldn't be doing that, we need to get rid of those."

On 6/26/24 at 2:45 PM Staff 3 (Assistant DNS) acknowledged the vial of Tubersol and the cup of white pills were not labeled and stored appropriately.

Based on observation and interview it was determined the facility failed to ensure food was stored appropriately and discarded in a timely manner, and failed to maintain a clean freezer for 1 of 1 kitchen and 1 of 1 resident refrigerator reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include:

1. On 6/24/24 at 7:48 AM during the initial tour of the facility's walk-in refrigerator and walk-in freezer the following was observed:

Walk-in refrigerator:
*An opened half-gallon heavy whipping cream container with a manufacturer use by date of 6/3/24.
*A red and brown liquid approximately 60 inches in length on the floor directly under a metal rack with food items including raw meat defrosting.

Walk-in freezer:
*An opened bag of pre-made egg and cheese omelets, undated.
*Food crumbs and small dirt clumps approximately one centimeter and smaller on the floor throughout the entire freezer.

On 6/24/24 at 8:05 AM Staff 6 (Dietary Manager) acknowledged the identified findings.

2. On 6/27/24 at 12:54 PM the resident refrigerator located in the therapy gym was reviewed. The following was observed:

-Opened bottle of sriracha mustard, expired 4/22/2022.
-Undated plastic container of moldy strawberries.
-Undated plastic sandwich bag of moldy blueberries and strawberries.
-Styrofoam container with a lid of chocolate pudding with a use by date of 6/24/24.

On 6/27/24 at 1:03 PM Staff 1 (Administrator) and Staff 3 (Assistant DNS) acknowledged the identified items. Staff 3 stated food was to be labeled and discarded after three days or after the "use by dates."

Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 1 sampled resident (#7) reviewed for therapy services. This placed residents at risk for inaccurate medical records and unassessed needs. Findings include:

Resident 7 was admitted to the facility in 4/2024 with diagnoses including arthritis, gait and mobility abnormalities and muscle weakness.

Resident 7's Comprehensive Care Plan, dated 5/29/24, indicated the resident had an ADL self-care performance deficit. Interventions included the provision of a restorative nursing program with range of motion exercises for the resident's lower extremities.

Resident 7 did not have active orders for Physical Therapy, Occupational Therapy, or Restorative Aid Therapy.

On 6/26/24 at 12:55 PM Resident 7 stated she/he did not receive any therapy services or Restorative Aid Therapy services since her/his admission.

On 6/26/24 at 1:46 Staff 13 (CNA/RA) stated Resident 7 was not receiving Restorative Aid Therapy at this time.

On 6/27/24 at 1:49 PM Staff 15 (LPN/Resident Care Manager) stated all resident care plans were revised and kept up to date by the Resident Care Manager, and Resident 7 did not have a Restorative Aid Therapy program on her/his care plan.

On 6/27/24 at 2:01 PM Staff 15 (LPN/Resident Care Manager) acknowledged Resident 7's care plan included a plan for Restorative Aid Therapy services, with an initiation date of 5/29/24. She stated "I don't know how that got there, she/he doesn't do Restorative Aid Therapy."

On 6/27/24 at 2:41 PM Staff 3 (Assistant DNS) stated the intervention related to a Restorative Aid Therapy plan was placed in Resident 7's care plan in error and was intended for a different resident in the facility.

Based on observation, interview, and record review it was determined the facility failed to maintain essential kitchen equipment in a safe operating condition for 1 of 1 kitchen reviewed for kitchen services. Findings include:

On 6/24/24 at 7:48 AM an observation of the walk-in freezer in the kitchen revealed long vertical ice crystals approximately 15 inches in length attached to a pipe that connected to the freezer temperature unit.

On 6/24/24 at 8:05 AM Staff 6 (Dietary Manager) acknowledged the identified findings. He stated the facility had two repair companies look at the walk-in freezer and each were unsuccessful with repairs. Staff 6 stated Staff 7 (Plant Manager) broke the ice crystals in the walk-in freezer weekly as the ice crystals accumulated rapidly and a log of this was kept.

On 6/26/24 at 9:25 AM Staff 6 provided the facility's Kitchen Freezer Maintenance log and it revealed Staff 7 completed weekly maintenance in the walk-in freezer related to the ice crystals since 9/2023.

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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F687
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventative Care

Refer to F689
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OAR 411-086-0260 Pharmaceutical Services

Refer to F761
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OAR 411-086-0250 Dietary Services

Refer to F812
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OAR 411-086-0300 Clinical Records

Refer to F842
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OAR 411-087-0100 Physical Environment Generally

Refer to F908
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Based on observation, interview and record review it was determined the facility failed to ensure residents received reasonable accommodation of needs for 1 of 1 sampled resident (#62) reviewed for accommodation of needs. This placed residents at risk for being dependent on bed mobility and repositioning in bed. Findings include:

Resident 62 was admitted to the facility in 2/2022 with diagnoses including a stroke with left-sided weakness.

The 2/2023 Annual MDS revealed Resident 62 was cognitively intact and required total two-person assistance with bed mobility.

At 12:14 PM observed Resident 62 in bed attempting to use the bedrail to reposition herself/himself. Resident 62 stated she/he had a doctor's order for an over the bed trapeze bar to assist with repositioning and bed mobility. No trapeze bar was observed in Resident 62's room.

Resident 62's 3/2023 physician's order revealed a trapeze bar for bed mobility order dated 2/22/22.

On 4/19/23 at 2:30 PM Staff 3 (RNCM) stated she was aware Resident 62 had an order for a trapeze bar and thought the trapeze bar was ordered sometime in 3/2023 by Staff 19 (Staffing Coordinator/Unit Clerk). Staff 3 started at facility in 11/2022 and was unable to provide explanation of why the order was not addressed prior 3/2023.

On 4/20/23 at 2:56 PM Staff 19 (Staff Coordinator/Unit Clerk) stated she ordered the trapeze bar in 3/2023 but was notified by the manufacturer the type of trapeze bar ordered was no longer made and was not ordered.

Based on interview and record review it was determined the facility failed to ensure a resident centered care plan was developed for 1 of 1 sampled resident (#17) reviewed for hospice. This placed residents at risk for lack of care planning. Findings include:

Resident 17 admitted to the facility in 2022 with diagnoses including heart disease.

An active physician order dated 12/8/22 indicated Resident 17 was administered lorazepam (an anti-anxiety) PRN for nausea and agitation.

A review of Resident 17's clinical record did not include indications for use of lorazepam or indications to monitor for side effects related to the use of lorazepam

On 4/20/23 at 3:50 PM Staff 2 (Assistant DNS) confirmed Resident 17 received PRN lorazepam for nausea and agitation from 12/15/22 to 4/20/23 without a care plan in place.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 7 sampled residents (#s 5 and 63) reviewed of medications. This placed residents at risk for worsening medical conditions. Findings include:

1. Resident 5 admitted to the facility in 2022 with diagnoses including hypo-osmolality/hyponatremia (abnormally low concentration of sodium in the blood).

The 7/5/22 Care Plan indicated Resident 5 received Samsca related to hypo-osmolality/hyponatremia. Interventions included to administer medications as ordered by the physician.

A 10/5/22 physician order indicated Resident 5 was to be given 15 mg of Samsca (treats low sodium levels) at bedtime every other day for hypo-osmolality/hyponatremia.

Review of the 2/2023 and 3/2023 MARs indicated Resident 5 did not receive Samsca from 2/26/23 through 3/12/23 (eight doses).

Review of progress notes revealed the following:
- 3/3/23 at 8:54 AM the Samsca medication for the resident was not covered by insurance. Due to non-coverage of the medication, the pharmacy will not be sending the medication.
- 3/3/23 at 3:43 PM communication from the resident's provider was received about Samsca. The provider ordered the resident to continue to take the medication.
- 3/8/23 the resident was on alert for the missing medication of Samsca. No negative effects were noted.

On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) acknowledged Resident 5 was not administered Samsca from 2/26/23 through 3/12/23 as ordered.

2. Resident 63 was admitted to the facility in 2022 with diagnoses including diabetes and hypertension.

The 12/5/22 Care Plan indicated Resident 63 had hypertension and received eplerenone (treats high blood pressure). Interventions included to administer hypertensive medications as ordered.

A physician order dated 1/28/23 indicated Resident 63 was to receive eplerenone 50 mg BID for hypertension.

Review of the 2/2023 and 3/2023 MARs indicated Resident 63 did not receive eplerenone from 2/28/23 through 3/8/23 (nine days).

Review of progress notes revealed the following:
- 2/16/23 pharmacy faxed a non-covered medication notification form stating resident's medication eplerenone was not covered.
- 2/28/23 eplerenone medication was not available. Waiting on delivery from the pharmacy.
- 3/1/23 eplerenone was unavailable. Waiting on delivery from Pharmacy.
- 3/2/23 eplerenone unavailable.
- 3/3/23 eplerenone unavailable.
- 3/4/23 eplerenone unavailable.        

- 3/5/23 eplerenone unavailable.
- 3/6/23 eplerenone not available.
- 3/7/23 eplerenone not available.
- 3/8/23 eplerenone not available.

On 4/17/23 at 9:26 AM Witness 3 (Complainant) stated Resident 63 went without her/his medication for nine days.

On 4/17/23 at 11:07 AM and 4/19/23 at 10:02 AM Resident 63 stated in 3/2023 the facility ran out of her/his eplerenone medication because it was not ordered timely. Resident 63 stated the medication was not new and she/he took the medication for a few years. Resident 63 stated she/he was not informed the medication was unavailable for the nine days in 2/2023 and 3/2023.

On 4/19/23 at 8:40 AM and 9:28 AM Staff 10 (CMA) stated there were issues with the pharmacy sending medications or staff did not order medications on time.

On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) acknowledged Resident 63 did not receive the eplerenone medication as ordered for the identified dates.

Based on observation, interview and record review it was determined the facility failed to ensure fall safey interventions were in place for 1 of 2 sampled residents (#9) reviewed for accidents. This placed residents at risk for falls. Findings include:

Resident 9 admitted to the facility in 2/2022 with diagnoses including multiple sclerosis, anxiety and dementia.

The current Care Plan revised on 2/11/23 revealed Resident 9 was a moderate fall risk related to confusion, incontinence and gait/balance problems. Resident 9 had a non-injury fall out of bed on 1/21/23. Staff were directed to have her/his call light within reach and to encourage the resident to use the call light for assistance. A fall mat was to be placed on the right side of her/his bed and the bed kept in a low position when not working with her/him.

On 4/17/23 at 12:29 PM Resident 9 was observed in bed asleep with her/his bed in the lowest position but no fall mat was on the right side of her/his bed.

On 4/17/23 at 11:27 AM Witness 2 (Family Member) indicated he had concerns with appropriate care plan interventions being in place for Resident 9 who was a fall risk.

Random observation from 4/18/23 through 4/20/23 revealed Resident 9 in bed asleep and her/his bed was approximately two feet from the floor. Resident 9 had a fall mat down on the right side of her/his bed.

On 4/19/22 at 9:22 AM Staff 16 (CNA) and at 12:44 PM Staff 14 (CNA) both stated Resident 9 was a fall risk and her/his bed was to be in the lowest position when not providing cares and a fall mat was to be placed on the right side of her/his bed.

On 4/20/23 at 9:14 AM Staff 17 (LPN) stated Resident 9 was a fall risk and staff were to keep her/his bed in the lowest position when not providing ADL care and a fall mat was to be placed to the right side of her/his bed. Staff 17 stated he had to lower Resident 9's bed down because the bed was not in the lowest position on more than one occasion.

On 4/20/23 at 10:29 AM Staff 3 (RNCM) stated Resident 9 was to have her/his bed in the lowest position and a fall mat to the right side of the bed. At 10:35 AM Staff 3 entered Resident 9's room with the surveyor and acknowledged her/his bed was not in the lowest position and was approximately two feet from the floor. Staff 3 acknowledged the bed was not in the lowest position and staff were expected to follow the care plan.

Based on interview and record review it was determined the facility failed to ensure physician visits occurred at least every 60 days for 2 of 7 sampled residents (#s 17 and 65) reviewed for medications. This placed residents at risk for unmet care needs. Findings include:

1. Resident 65 admitted to the facility in 10/2022 with diagnoses including atrial fibrillation.

A review of Resident 65's clinical record on 4/19/22 revealed the last physician visit occurred on 1/24/23 (85 days prior). No evidence was found to indicate physician visits occurred every 60 days.

On 4/19/23 at 12:00 PM Staff 2 (Assistant DNS) acknowledged Resident 65's last physician visit was on 1/24/23 and there was no evidence to indicate Resident 65 had a physician visit every 60 days.

, 2. Resident 17 was admitted to the facility in 2022 with diagnoses including heart disease.

A review of Resident 17's clinical record on 4/20/23 revealed the last documented physician visit occurred in 11/2022. No evidence was found to indicate physician visits occurred every 60 days.

On 4/20/23 at 3:43 PM Staff 2 (Assistant DNS) acknowledged there was no evidence to indicate Resident 17 had a physician visit every 60 days.

Based on observation, interview and record review it was determined the facility failed to provide sufficient nursing staff to attain and maintain the highest practicable well-being for 3 of 3 halls (100, 200, 300) reviewed for staffing. This placed residents at risk for unmet needs. Findings include:

Interviews with residents revealed the following concerns:
-On 4/17/23 at 10:53 AM Resident 23 stated call light response times could take over an hour during shift change especially when staff were leaving the night shift and day shift was beginning their shift.

-On 4/17/23 at 11:03 AM Resident 63 stated right after lunch and shift change was difficult to receive assistance. Resident 63 indicated call light response times were 30 minutes or greater and she/he needed assistance with incontinence care, emptying of her/his urinal or adjusting the heat in her/his room.

-On 4/17/23 at 11:10 AM Resident 43 stated call light response times were 30 minutes or greater and she/he used the call light to receive assistance with incontinence care and for her/his urinal to be emptied.

-On 4/17/23 at 11:40 AM Witness 2 (Family Member) stated call light response times were 30 minutes or greater for Resident 9 and she/he sat in a wet and soiled brief on more than one occasion. Witness 2 stated he changed Resident 9 "at times" because of long call light response times which often occurred during mealtime or evening shift.

-On 4/17/23 at 12:36 PM Resident 28 stated call light response times were greater than 30 minutes on any shift.

-On 4/17/23 at 2:06 PM Resident 16 stated call light response times "especially" after 10:00 PM were 30 minutes or greater to receive help.

Random observations of call light response times:
-On 4/18/23 at 10:15 AM Room 302, 306, 311 and 312 call lights were activated.

-Staff answered Room 306's call light at 10:26 AM (11 minutes later) and the resident requested a pain pill. The CNA indicated she would let the nurse know regarding the pain pill request. At 10:34 AM (18 minutes later) the resident was saying "hello, hello." At 10:40 AM (24 minutes later) the resident was asleep in her/his bed and no staff returned to her/his room.

-Staff answered Room 302's call light at 10:29 AM (13 minutes later).

-Staff answered Room 311's call light at 10:34 AM (18 minutes later) and the resident wanted coffee.

-Staff answered Room 312's call light at 10:35 AM (19 minutes later) and the resident requested some water.

On 4/18/23 at 10:34 AM Room 211's (Bed A) call light was activated and the resident needed assistance to use the bathroom for a bowel movement. Multiple staff were in and out of the room from 10:35 AM to 11:00 AM. The resident was not assisted to the bathroom until 11:07 AM (33 minutes later) when two CNAs entered the room to assist her/him to the bathroom.

Staff interviews revealed the following:
-On 4/19/23 at 9:22 AM Staff 16 (CNA) stated call lights were to be answered within seven minutes and was difficult at times because not all staff assisted with answering call lights. Staff 16 stated during mealtimes call lights were a struggle to answer timely.

-On 4/19/23 at 9:46 AM Staff 8 (CNA) stated call lights were to be answered within five minutes if possible and this was not always the case. Staff 8 stated not all staff assisted answering call lights which made it difficult to assist all residents timely.

-On 4/19/23 at 12:44 PM Staff 14 (CNA) stated call lights were to be answered within five minutes and no longer than 15 minutes. Staff 14 stated this was difficult during mealtime, during shift change or when residents required two-person assistance.

-On 4/20/23 at 3:16 PM Staff 2 (Assistant DNS) stated all staff were expected to answer call lights as quickly as possible and ideally to answer within five minutes. Staff 2 stated the facility struggled at times with call light response times during meals and at shift change.

Based on interview and record review it was determined the facility failed to follow pharmacy recommendations for 2 of 5 sampled residents (#s 17 and 65) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include:

1. Resident 65 admitted to the facility in 10/2022 with diagnoses including atrial fibrillation.

The 1/18/23 pharmacy recommendation indicated the following:
*Resident 65 received Eliquis (anticoagulant medication) 2.5 mg BID and cilostazol (antiplatelet medication) 50 mg BID.
*Please evaluate the above combined therapy and if appropriate consider discontinuing the cilostazol.
*Rationale for recommendation: concomitant [occuring at the same time] use of apixaban [Eliquis] and select medications may further increase the risk for serious, potentially fatal bleeding. Combination therapy with an antiplatelet agency may be an appropriate choice in select higher risk individuals.

The pharmacy recommendation was not signed by the provider until 2/3/23 (16 days later) and indicated the recommendations were accepted and "please implement as written."

The 2/2023 MARs record indicated the cilostazol was discontinued on 2/4/23 at 12:33 PM.

On 4/19/23 at 12:00 PM Staff 2 (Assistant DNS) stated her expectation for follow up of pharmacy recommendations was to be completed within 72 hours and acknowledged the facility did not follow up with the pharmacy recommendation timely.

, 2. Resident 17 admitted to the facility in 2022 with diagnoses including heart disease.

A 2/8/23 Physician Order indicated Resident 17 received carvedilol for high blood pressure.

A 2/16/23 Pharmacy Recommendation recommended carvedilol should have been taken with meals. The recommendation was left blank and not signed by the physician.

A 3/16/23 Pharmacy Recommendation again recommended carvedilol should have been taken with meals. The recommendation was left blank and not signed by the physician.

On 4/20/23 at 3:50 PM Staff 2 (Assistant DNS) confirmed the facility did not act upon the pharmacist recommendation.

Based on interview and record review it was determined the facility failed to ensure gradual dose reductions (GDRs) were attempted for residents on psychotropic medications for 1 of 5 sampled residents (#62) reviewed for unnecessary psychotropic medications. This placed residents at risk for side effects of unnecessary medications. Findings include:

Resident 62 was admitted to the facility in 2/2022 with diagnoses including a stroke and depression.

An admit order dated 2/11/22 revealed Resident 62 received 30 mg of duloxetine (an antidepressant) one time a day for depression.

An 8/18/22 pharmacist recommendation revealed a GDR from 30 mg of duloxetine to 20 mg one time a day.

On 9/19/22 Resident 62's physician agreed to the pharmacist's GDR recommendation.

Resident 62's 9/2022, 10/2022 and 11/2022 MARs revealed no GDR was completed.

On 4/19/23 at 2:17 PM Staff 3 (RNCM) stated she was not aware a GDR for the duloxetine was not completed.

Based on interview and record review it was determined the facility failed to provide adequate meal portions and honoring preferences timely for 2 of 6 sampled residents (#s 43 and 63) reviewed for food. This place residents at risk for weight loss and lessened quality of life. Findings include:

1. Resident 43 admitted to the facility in 2019 with diagnoses including diabetes and depression.

The revised 10/6/22 Care Plan indicated Resident 43 had a potential for nutritional issues related to co-morbidities of diabetes, pain, depression and a pressure ulcer. Interventions included to provide and serve diet as ordered.

On 4/17/23 at 11:03 AM Resident 43 stated the facility's food was the "worst food" she/he had ever ate. Resident 43 stated the facility ran out of food and she/he was not served enough food on multiple occasions.

On 4/19/23 at 10:10 AM Resident 43 indicated records were kept by Resident 63 of the food from recent meals and those records included the following observations:
-One dinner roll, a half scoop of a white food substance and approximately less than half of a portion size of lasagna.
-A scoop of white rice and a half of a quesadilla.
-One dinner roll and approximately less than half a portion of lasagna.
-A small scoop of corn and a small scoop of a casserole type food.
-One dinner roll, a small scoop of beans, seven brussels sprouts and three slices of sausage.
-A dinner roll, with two raviolis and a scoop of spinach.
-One dinner roll, a small scoop of white rice and a small scoop of a meat vegetable medley.
- A half of a sandwich, a small scoop of watery coleslaw and a small side of fries.

On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) reviewed the documented records of the food and indicated the meals were not the "normal" portion size for what residents should have received.

On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) stated she was aware of the food issue related to portion size and stated she once observed residents being served one ravioli.

2. Resident 63 admitted to the facility in 2022 with diagnoses including heart failure and hypertension.

On 4/17/23 at 9:26 AM Witness 3 (Complainant) stated the facility often ran out of food. Witness 1 stated on 4/16/23 Resident 63 was only served a half of a sandwich and a roll. Witness 3 stated she took the resident fruit and snacks when she could as she lived 45 minutes away and it was difficult for her to get to the facility.

On 4/17/23 at 11:04 AM Resident 63 stated she/he was often served not enough food. Resident 63 stated on 4/16/23 for dinner she/he only received a half of a grilled cheese sandwich and a few tater tots.

On 4/19/23 at 10:10 AM Resident 63 indicated she/he kept records of recent meals which included the following observations:
-One dinner roll, a half scoop of a white food substance and approximately less than half of a portion size of lasagna.
-A scoop of white rice and a half of a quesadilla.
-One dinner roll and approximately less than half a portion of lasagna.
-A small scoop of corn and a small scoop of a casserole type food.
-One dinner roll, a small scoop of beans, seven brussels sprouts and three slices of sausage.
-A dinner roll, with two raviolis and a scoop of spinach.
-One dinner roll, a small scoop of white rice and a small scoop of a meat vegetable medley.
- A half of a sandwich, a small scoop of watery coleslaw and a small side of fries.

On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) stated reviewed the pictures of the food and indicated the meals were not the "normal" portion size for what residents should have received.

On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) stated she was aware of the food issue related to portion size and stated she once observed residents being served one ravioli.

Based on interview and record review it was determined the facility failed to provide meals at a palatable temperature for 2 of 6 sampled residents (#s 43 and 63) reviewed for food. This placed residents at risk for receiving unpalatable food. Findings include:

1. Resident 43 admitted to the facility in 2019 with diagnoses including diabetes and depression.

The 2001 facility Food Preparation and Service Policy indicated proper hot and cold temperatures were to be maintained during food distribution and service.

The revised 10/6/22 Care Plan indicated Resident 43 had a potential for nutritional issues related to co-morbidities of diabetes, pain, depression and a pressure ulcer. Interventions included to provide and serve diet as ordered.

On 4/17/23 at 10:19 AM Resident 43 stated the facility's food was the "worst food" she/he ever ate. Resident 43 stated at times the food was cold. Resident 43 stated she/he was informed by CNA staff the food was unable to be reheated because it was a "burn hazard" and they needed to have a food handlers card.

On 4/19/23 at 12:10 PM Staff 8 (CNA) stated she was unable to reheat resident's food for sanitary reasons.

On 4/19/23 at 2:45 PM Staff 20 (CNA) stated she believed CNAs needed to have a food handlers card to be able to reheat residents' food.

On 4/20/23 at 9:10 AM Staff 9 (CNA) stated she was not able to reheat resident food due to the inability to ensure the correct temperature and she needed to have a food handlers card.

On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) stated he was aware of complaints related to the temperature of the food. Staff 7 stated he encouraged residents to eat in the dining room to avoid potential food temperature issues. Staff 7 further stated he believed CNA staff were not able to reheat resident food because the microwave was removed.

On 4/19/23 at 2:30 PM and 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) stated she was aware of the food issue reported by residents. Staff 2 stated CNA staff were able to reheat residents food and did not require a food handlers card.

2. Resident 63 admitted to the facility in 2022 with diagnoses including heart failure and hypertension.

A 3/1/23 Care Conference note indicated Resident 63 complained about the food. The solutions provided were for the resident to change rooms or eat in the dining room.

On 4/17/23 at 9:26 AM Witness 3 (Complainant) stated the food served to Resident 63 was not always hot. Witness 3 stated she brought up food issues during the care conference but nothing was done.

On 4/17/23 at 11:04 AM Resident 63 stated due to being at the end of the hall her/his food was often cold. Resident 63 stated she/he was informed by CNA staff they were unable to reheat her/his food.

On 4/19/23 at 12:10 PM Staff 8 (CNA) stated she was unable to reheat residents food for sanitary reasons.

On 4/19/23 at 2:45 PM Staff 20 (CNA) stated she believed CNAs needed to have a food handlers card to be able to reheat residents' food.

On 4/20/23 at 9:10 AM Staff 9 (CNA) stated she was not able to reheat resident food due to the inability to ensure the correct temperature and she needed a food handlers card.

On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) stated he was aware of complaints related to the temperature of the food. Staff 7 stated he encouraged residents to eat in the dining room to avoid potential food temperature issues. Staff 7 further stated he believed CNA staff were not able to reheat resident food because the microwave was removed.

On 4/19/23 at 2:30 PM and 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) stated she was aware of the food issue reported by residents. Staff 2 stated CNA staff were able to reheat resident food and they did not require a food handlers card.

Based on interview and record review it was determined the facility failed to honor meal preferences for 1 of 6 sampled residents (#54) reviwed for food. This placed residents at risk for lessened quality of life. Findings include:

1. Resident 54 admitted to the facility in 4/2019 with diagnoses including stroke and dementia.

The revised 5/19/22 Care Plan indicated Resident 54 was at risk for weight loss. Interventions included to offer alternates of disliked food.

On 4/17/23 at 10:47 AM and 4/19/23 at 2:37 PM Resident 54 stated the food was "terrible" and she/he did not feel meal requests were honored timely. Resident 54 stated she/he often refused lunch and would then request a quesadilla from the alternative menu. Resident 54 stated residents could not request an alternative meal unless they "refused" the lunch meal and then had to request food from the alternative meal ticket which was completed by a CNA and returned to the kitchen. Resident 54 stated and it took the kitchen "forever" for her/him to receive the quesadilla and at times when she/he received the quesadilla the cheese was not "even melted."

On 4/19/23 at 9:22 AM Staff 16 (CNA) stated Resident 54 often refused her/his lunch meal and requested a quesadilla from the alternative meal ticket. Staff 16 stated the kitchen honored the request but Resident 54 was the last to be served her/his alterative preference or at times did not receive the alternative meal at all. Staff 16 stated the week of 4/10/23 Resident 54 did not receive her/his quesadilla until 1:30 PM and lunch started being served at around 11:30 AM.

On 4/19/23 at 9:46 AM Staff 8 (CNA) stated residents did not have a choice of what they received for lunch until they refused the meal that was delivered to them. Staff 8 stated Resident 54 usually refused her/his lunch meal and then she assisted Resident 54 with completing an alternate meal ticket, which was returned to the kitchen but Resident 54 did not get her/his meal sometimes until 1:30 PM in the afternoon. Staff 8 stated Resident 54 requested quesadillas "a lot."

On 4/19/23 at 1:08 PM Staff 7 (Dietary Manager) stated he was new to the position and residents did not have a choice for breakfast, lunch or dinner but the facility provided an alternative meal ticket that was completed when a resident refused the regular meal. Staff 7 stated all regular meals were served first and residents had to refuse the current meal and request something from the alternative meal ticket. Staff 7 stated the alternative meal ticket was returned to the kitchen but resident's requests/preferences were not honored from the alternative meal ticket until all other regular meals were delivered. Staff 7 stated this process took time and was not efficient for the kitchen or residents.

On 4/20/23 at 3:16 PM Staff 2 (Assistant DNS) stated she was aware of concerns regarding the kitchen and the facility recently hired Staff 7 to assist with addressing concerns in the kitchen including residents preferences being honored timely.

Based on interview and record review it was determined the facility failed to provide rehabilitation services for 2 of 4 sampled residents (#s 10 and 63) reviewed for rehabilitation services. This placed residents at risk for declined mobility and lack of quality of life. Findings include:

1. Resident 63 was admitted to the facility in 2022 with diagnoses including diabetes and hypertension.

A 2/24/22 physician order indicated a referral for physical and occupational therapy for Resident 63.

The 3/15/22 Care Plan indicated Resident 63 had an ADL performance deficit related to limited mobility.

A rehabilitation provider note dated 11/21/22 indicated Resident 63 was progressing well. Physical therapy was to be discharged due to a changed in staffing and the inability of therapy to continue. The note indicated Resident 63 was "resume therapy services that was medically necessary to allow the resident to transfer with a slide board and to improve independence of mobility and social engagement." The note indicated therapy was to be discontinued with the expectation Resident 63 was to continue with therapy.

The 2/21/23 Annual MDS indicated Resident 63 received two-person assistance using mechanical lift for transfer. The resident previously worked with physical therapy in learning how to perform a slide-board transfer. Resident 63 previously participated in physical therapy but was discharged from physical therapy in November 2022. The resident "expressed wanting to restart physical therapy and an order from his primary care provider to restart physical therapy."

A 3/7/23 progress note indicated the resident was spoken to about therapy coming into the facility to work with her/him. The note indicated Resident 63 had a current order for therapy.

A 3/8/23 Care Conference note indicated Witness 3 (Complainant) stated she wanted Resident 63 in therapy and was informed it was "in the works."

On 4/17/23 at 9:26 AM Witness 3 stated Resident 63 went four months without therapy. Witness 3 stated the facility indicated the resident had therapy but she/he did not.

On 4/17/23 at 10:12 AM Resident 63 stated she/he went four months without any therapy. The resident stated there was no therapy staff to provide any therapy services. Resident 63 stated the facility also had no RA program therefore that was not an option.

On 4/20/23 at 9:30 AM Staff 6 (Social Service Director) stated she recently was able to get therapy services for Resident 63 due to a therapy agency reaching out to her. Staff 6 stated Resident 63 wanted therapy and she was unaware why she/he did not have therapy prior.

On 4/20/23 at 10:00 AM Staff 2 (Assistant DNS) indicated due to not having therapy staff, residents were not able to have therapy services provided. Staff 2 acknowledged Resident 63 did not receive therapy from 11/21/22 until recently due to staffing. Staff 2 stated the facility also had no RA program to offer residents as an alternative to therapy.
, 2. Resident 10 was admitted to the facility on 3/9/23 with diagnoses including weakness complicated by quadriplegia (paralysis of all four limbs from spinal injury).

On 4/17/23 at 9:16 AM Resident 10 was observed attempting to sit up in bed.

On 4/18/23 at 9:20 AM Resident 10 was observed attempting to sit at the edge of the bed. Resident 10 stated she/he was sent to the facility for therapy but did not receive any therapy services and had to do her/his own rehab in the exercise room.

A 3/8/23 hospital discharge orders included orders for physical and occupational therapy.

On 4/19/23 at 3:12 PM Staff 4 (LPN/Resident Care Manager) stated the hospital discharge orders is used as the facility admission orders. Staff 4 stated she overlooked Resident 10's physical and occupational therapy orders in the 3/8/23 hospital discharge orders.

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing ratios were maintained for 22 of 47 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

On 4/17/23 the facility had eight residents approved for the bariatric rate.

A review of the Direct Care Staff Daily Reports from 3/1/23 through 4/16/23 revealed the following days when the state minimum bariatric CNA staffing ratios were not met for one or more shifts:

3/2023 and 4/2023 revealed the following:
-3/2/23
-3/3/22
-3/3/23
-3/5/23
-3/13/23
-3/17/23
-3/18/23
-3/19/23
-3/23/23
-3/26/23
-4/1/23
-4/2/23
-4/2/23
-4/3/23
-4/6/23
-4/7/23
-4/8/23
-4/9/23
-4/10/23
-4/12/22
-4/15/23
-4/16/23

On 4/20/23 at 2:59 PM Staff 19 (Staff Coordinator) stated she attempted to schedule additional CNAs but continued to struggle with CNA coverage which caused the bariatric staffing shortage.

On 4/20/23 at 3:56 PM Staff 2 (Assistant DNS) stated she was aware of the the failure to meet the state minimum bariatric CNA staffing ratios for the identified dates.

OAR-411-086-0360: Resident Furnishings, Equipment

Refer to F558
*****
OAR-411-086-0060: Comprehensive Assessment and Care Plan

Refer to F656
*****
OAR-411-086-0110: Nuring Services: Resident Care

Refer to F684
*****
OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care

Refer to F689 and F758
*****
OAR-411-086-0200: Physician Services

Refer to F712
*****
OAR-411-086-0100: Nursing Services: Staffing

Refer to F725
*****
OAR-411-086-0260: Parmaceutical Services

Refer to F756
*****
OAR-411-086-0250: Dietary Services

Refer to F803, F804 and 806
*****
OAR-411-086-0220: Rehabilitative Services

Refer to F825
*****

Based on interview and record review it was determined the facility failed to ensure a resident and resident's representative had the right to direct her/his own care, refuse hospice and be aware of all treatment options for 1 of 3 sampled residents (#5) reviewed for hospice. This caused Resident 5 to be admitted to hospice and sustained a distressing and diminshed quality of life prior to death. Finding include:

Resident 5 admitted to the facility on 3/4/22 with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). The resident died on 3/21/22.

On 3/4/22 Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space). [All licensed nurses within the State of Oregon may drain the catheter with proper training.]

The 3/4/22 Admission Orders directed staff to drain the PleurX catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%.

The 3/7/22 Physician Order indicated the catheter was to be drained at a clinic or hospital only; every Monday, Wednesday and Friday. [There was no documentation the facility informed the physicin it was within the nurse's scope of practice to drain the catheter.]

The facility's staffing records revealed between 3/4/22 through 3/22/22 one and a half to three RN's were on duty daily in addition to multiple LPN's.

A 3/9/22 provider encounter noted revealed there was a concern with getting Resident 5's PleurX catheter drained. The provider noted the resident had "great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it." The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital.

The 3/9/22 Progress Note's revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath. The hospital drained 2,000 cc from the catheter.

A 3/11/22 provider note indicated she spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining at the facility it was decided to update the POLST form for DNR comfort only and refer Resident 5 to hospice.

A 3/11/22 Hospice note reveals Resident 5 was admitted to hospice services.

A 3/16/22 Progress Note revealed the resident made comments about harming her/himself, asked for a hammer because she/he hurt so bad and asked the CNA if she could help her/him kill her/himself.

A 3/17/22 Progress Note revealed Resident 5's healthcare POA was upset because she was not told why the facilty could not drain Resident 5's PleurX catheter. The note further stated the goal was to transition the resident off of hospice so they could obtain aggressive treatment with a specialist but they needed home health set up first so the resident would not have to go to the hospital to get the PleurX catheter drained. The healthcare POA stated she understood the resident may not live much longer but still did not want hospice "at this time".

A 3/21/22 Progress note revealed they spoke with Resident 5's daughter about the PleurX catheter and "how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it." Options were discussed and it was decided the facility would look for alternative placement but to keep the resident on hospice so they could manage the drain.

The 3/21/22 Discharge Summary note indicated the funeral home picked the resident up. [There were no notes related to the residents passing in the medical record.]

On 12/28/22 at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the PleurX catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out the the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facility stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and "even lay people can be taught to do it."

On 12/28/22 at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter, did not have sufficient RN staffing to care for the resident and the facility was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork which they reviewed prior to the resident's admission. Staff 1 stated she declined training offered by the Resident's Case Manger and verified the resident went on hospice to avoid hospital emergency room visits.

On 12/29/22 in the AM Staff 1 and Staff 3 stated they were unaware LPN's were allowed to provide care and services related to the PleurX catheter with proper training. Staff 1 verified when treatment alternatives to hospice were discussed training the LPN's was not discussed.

Based on observation and interview it was determined the facility failed to provide a clean, sanitary and homelike environment for 1 of 3 sampled residents (#1) reviewed for clean resident rooms. This placed residents at risk for cross-contamination and an unclean room. Findings include:

Resident 1 admitted to the facility in 2020 with diagnoses including paraplegia (paralysis of the legs and lower body).

On 12/15/22 at 2:00 PM a CNA was observed to exit Resident 1's room. The surveyor entered the room and observed a dirty towel on the floor.

On 12/15/22 at 2:00 PM Resident 1 stated her/his room was not cleaned to her/his satisfaction, pointed to a dirty towel on the floor and stated the CNA put the towel on the floor and left it.

On 12/15/22 at 2:25 PM Staff 16 (LPN) was observed to be talking to the resident in her/his room. Staff 16 verified the dirty towel was on the floor.

Based on observation, interview and record review the facility failed to ensure residents were free from neglect. The facility failed to ensure a resident had the right to receive skilled care from trained nurses and refuse hospice, failed to ensure resident assessments were completed timely, care plans were reviewed, interventions in place and implemented, failed to assess and monitor pressure ulcers and follow physician orders for skin conditions, failed to recognize and act on a change of condition, and failed to ensure residents did not elope from the facility. The cumulative effect of these failures in providing care and services contributed to an environment of neglect for 8 of 15 sampled residents (#s 2, 3, 4, 5, 9, 11, 13 and 15) reviewed for care and services. This caused Resident 5 to not get physician ordered treatment and coerced to agree to hospice services and placed all residents at risk for neglect of care. Findings include:


According to the Centers for Medicare & Medicaid Services (CMS), §483.5, "Neglect," means "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress."

CHANGE OF CONDITION

Resident 2

Resident 2 admitted to the facility in 4/2022 with diagnoses including intellectual disabilities and neurogenic bladder.

The 3/11/22 Risk For Infection related to the use of a urinary catheter care plan included the following interventions: change catheter and Foley (catheter) bag as scheduled or as ordered by the physician, monitor the indwelling catheter and report to the physician signs and symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns.

The 4/6/22 Return From Hospital care plan interventions included to monitor appetite and document the percentage eaten each meal and to monitor pain and discomfort.

A 4/29/22 Progress note revealed Resident 2's urine was cloudy with foul smell, had increased agitation and a UA (urinalysis) was collected.

A 5/4/22 Progress note revealed a negative UA result.

The 5/4/22 task documentation revealed Resident 2's UOP (urine output) was 1150 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and dinner was refused. Fluid intake was 980 cc.

A 5/6/22 Progress note revealed Resident 2 was "very irritable" and refused the catheter change. Blood Pressure was 71/49 [No evidence of physician notification or assessment or monitoring was completed.]

The 5/6/22 task documentation revealed Resident 2's UOP was 675 cc, fluid intake was 460 cc and meal intake for breakfast and lunch was zero to 25% and dinner 26 to 50%.

A 5/7/22 Progress Note revealed Resident 2 was on alert due to having cloudy urine, having increased sediment and foul odor.

The 5/8/22 task documentation revealed fluid intake was 540 cc.

The 5/9/22 task documentation revealed the resident consumed zero to 25% of all meals and fluid intake was 360 cc.

The 5/10/22 task documentation revealed fluid intake was 270 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and refused dinner.

The 5/11/22 task documentation revealed 500 cc UOP, 780 cc fluid intake and meal intake varied from zero to 75%.

The 5/12/22 task documentation revealed 475 cc UOP, 120 cc fluid intake, meal intake for breakfast and dinner was refused, lunch was zero to 25%. The resident took in additional nutrition in the evening between 75-100%.

The 5/13/22 task documentation revealed 950 cc UOP, Fluid intake was 240 cc with one meal intake not documented and meal intake zero to 25% for breakfast and dinner and lunch was not documented.

The 5/14/22 task documentation revealed 560 cc UOP, 740 cc fluid intake, breakfast and dinner refused with zero to 25% lunch meal intake.

The 5/16/22 task documentation revealed UOP was 25 cc on night shift and 260 cc on day shift. Fluid intake was 20 cc for breakfast and 120 cc for lunch. Meal intake was zero to 25% for breakfast and lunch.

The 5/16/22 12:01 PM Progress note revealed a CNA reported Resident 2 was "not acting like [her/himself] today. Blood pressure was 94/59, resident stated she/he felt unwell and was unable to describe any specific symptoms. The urine was red/brown tinged and mucus was present. The residents speech was slurred. The provider was called and staff were waiting for a call-back.

The 5/16/22 2:00 PM Progress note revealed the provider called back and gave orders to push fluids, administer an antibiotic shot, change the indwelling catheter and to obtain a stat [immediate] UA.

The 5/16/22 provider encounter note revealed the resident was seen for a concern of a possible UTI. The urine was reported to have foul odor and was cloudy with a dark color. The catheter was changed and the urine was clear after the indwelling catheter change. The resident complained of stomach and ear pain.

The 5/16/22 2:38 PM indicated the resident was transported to the hospital for altered mental status and hypotension (low blood pressure).

The 5/17/22 Progress note revealed the hospital notified the facility the resident passed away with a small bowel obstruction, UTI, sepsis (full body infection) and acute renal failure.

The 5/17/22 Hospital Records revealed Resident 2 was transferred to the hospital for malaise, fatigue and low blood pressure. The resident was diagnosed with UTI , septic syndrome secondary to UTI, acute kidney injury, anemia, hypoalbuminemia (abnormally low blood level of albumin (type of protein)), gastric outlet obstruction, gastrointestinal bleed and severe anion gap metabolic acidosis (imbalanced electrolytes). On 5/16/22, after discussion of options with the family, the residents POLST was changed to DNR and the resident passed away on 5/17/22.

The 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death, five days. Other significant conditions contributing to death gastric outlet obstruction.

There was no evidence in the medical record the provider was notified of the residents decreased appetite, fluid intake, urine output, low blood pressure, increased confusion, irritability or malaise. There was no evidence of monitoring of signs and symptoms of UTI.

On 12/21/22 at 9:25 AM Resident 16 (roommate) verified she was Resident 2's roommate and stated the week prior to her/his transfer to the hospital Resident 2 had increased irritability and was in pain.

On 12/19/22 12:30 PM Staff 6 (Former NA) stated the week prior to Resident 2 transferring to the hospital her/his urine was brown in color and had increased confusion.

On 12/19/22 at 2:21 PM Staff 11 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he was "pretty confused", tired, had a poor appetite, irritable, "pretty out of it" and the urine bag "was not looking like it should". Staff 11 stated she recalled the nurses looking at the resident's urine bag but "had no idea what the nurses did".

On 12/19/22 at 3:10 PM Staff 13 (LPN) stated staff were monitoring Resident 2's urine for amber color.

On 12/20/22 at 2:00 PM Staff 4 (Administrator in Training) recalled talking the Resident 2's sister about her concerns of Resident 2's health related to cognition, loss of appetite, getting up less and concerns of UTI. Staff 4 stated "I finally asked [staff] to send her out so they did."

On 12/20/22 at 3:30 PM Staff 16 (LPN) verified she wrote the 5/6/22 progress note, confirmed the resident was "very irritable", refused the catheter change and had a blood pressure of 71/49. Staff 16 verified she did not further assess the resident or notify the physician of the low blood pressure, irritability or refusal of the catheter change.

On 12/20/22 at 3:35 PM Staff 16 (LPN) stated the week prior to Resident 2's hospital transfer she/he was very irritable which was not normal because she/he was usually sweet and pleasant.

On 12/21/22 at 9:50 AM Staff 7 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he ate less because she didn't feel good enough to eat and needed more encouragement to attempt to eat and drink. Staff 7 further stated she noted a decline in Resident 2's overall abilities.

On 12/21/22 at 9:59 AM Staff 5 (Support RN) verified between 5/2/22 through 5/16/22 there was only one alert note related to monitoring the resident's urine or for signs of UTI.

On 12/21/22 at 10:10 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 2's care plans were not followed and the low blood pressure was not reported to the physician or assessed. Staff 1 and Staff 2 acknowledged the resident's decline in condition was not assessed and the physician was not notified until 5/16/22. Staff 1 acknowledged the 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death five days. Other significant conditions contributing to death gastric outlet obstruction.

On 12/21/22 at 12:08 PM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested.

Refer to F690

ELOPEMENT

Resident 9

Resident 9 admitted to the facility in 2022 with diagnoses including symptoms involving cognitive functions following other nontraumatic intracranial hemorrhage and cataracts. Prior to admission, the resident was homeless.

The Elopement Risk Care Plan, last revised on 12/28/22, revealed Resident 9 was a high elopement risk related to impaired safety awareness; both physical and environmental. The resident had eloped on 11/17/22, 12/12/22 and 12/27/22.
The interventions included to remind the resident to notify staff if she/he planned to leave the facility as needed (11/18/22), resident was high fall risk (11/18/22), to not seat the resident in the lobby near the doors without supervision at any time of the day or night. If the resident was up during late night hours to have her/him close to the nurse's station where she/he could be monitored. To walk with the resident if she/he wanted to walk, sit and talk with the resident, attempt to engage the resident to watch television, look at a magazine, offer fluids and snack. If not redirectable, alert the charge nurse, RN, resident care manager or DNS (12/14/22). Remind the resident of the sign posted in her/his room to not leave the facility without assistance for her/his safety and to show her/him the sign above the television (12/15/22). Activities to check in with the resident regularly to see if she/he needed anything from the store and to let nursing know to minimize the desire to exit the facility (12/16/22). Offer Resident 9 a bowl of ice cream (rocky road) every evening sometime after dinner and before bed time. If Resident 9 ambulated toward the front lobby late at night offer the ice cream again (12/28/22).

The 9/27/22 Communication Care Plan revealed Resident 9 had a communication problem related to expressive aphasia (a form of aphasia when the person knows what they want to say but are unable to produce the words or sentence. Can be mild to severe), slurring, stroke, weak or absent voice. Interventions included to allow adequate time to respond, face the resident when speaking and make eye contact, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. The resident was able to say yes or no and very short sentences and could shake/nod her/his head. Speak to the resident in a calm, quiet voice because she/he responded better with this approach. Speak on an adult level, speak clearly and slower than normal.

The 11/17/22 Incident Note revealed staff noted Resident 9 was not in her/his room, was assisted to bed at 7:00 PM, last seen between 8:15 and 8:30 PM and found on the lawn outside the 200 hall door.

The 11/18/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, independent with aid for mobility, early dementia, on antidepressants and had a history of wandering.

The 11/18/22 facility investigation revealed the resident was found outside. When interviewed the resident indicated she/he was going to "Fred Meyers" for rocky road ice cream. [Fred Meyers is a store 0.6 miles away from the facility. The resident would have to walk up Weathers Street, which facility resides on, towards Lancaster Drive which is a highly congested four lane road. The intersection of Weathers and Lancaster has no intersection and both roads offer minimal lighting.]

The 12/6/22 BIMs score was 9 which suggested the resident had moderately impaired cognition.

The 12/12/22 Progress Note revealed Resident 9 walked out of the facility around 8:00 PM. The resident wore a sweater, was found down the street walking with her/his walker. The temperature was "around 40 degrees and [she/he] was not dressed appropriately." The resident was non-verbal; unable to say why she/he left or where she/he was going.

The 12/12/22 Elopement Event identified Resident 9 as an elopement risk, the resident eloped off facility grounds when she/he was left unattended in the front lobby and the resident was disoriented to "some-spheres" some of the time. The assessment revealed the resident was homeless prior to admission and was not afraid to go out at night. The resident was alert and able to converse most of the time, was slow to answer and very soft spoken which could be misconstrued for non-responsive or cognitive impairment.

The 12/13/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, ambulated with one person assistance, early dementia, on antidepressants and had a history of wandering.

The 12/13/22 Incident Note revealed Resident 9 was alert and able to converse most of the time but was slow to answer and very soft spoken. Resident 9 stated she/he was going to "Fred Meyer's" for ice cream. Resident 9 stated rocky road was her/his favorite ice cream. The resident stated she/he did not have money for ice cream and stopped responding to the interviewer when repeatedly asked how she/he would have paid for the ice cream.

The 12/13/22 BIMs was 14 which indicated the resident was cognitively intact.

The 12/14/22 Care Conference Notes revealed safety concerns as the resident had exited the facility twice since admission. The resident stated she/he was going to "Fred Meyer's" to get ice cream. It was arranged the resident would be asked weekly if she/he needed anything and ice cream would be available.

The 12/28/22 Progress Note revealed Resident 9 walked down the hall around 11:20 PM [on 11/27/22]. The resident walked to the lobby and sat down. Staff asked what she/he needed but the resident did not respond. The CNA sat with the resident for a few minutes "but when she went to answer another call light [she/he] left out the front door." The nurse went to check on the resident five minutes later and the resident was "gone". Four staff initiated a search, first searching the facility and then outside. Resident 9 was found walking past the park on Weathers Street. The resident was non-verbal and would not answer any questions. The temperature outside was 50 degrees and raining; the resident wore sweat pants and a T-shirt.

The 12/28/22 Progress Note revealed the resident care manager spoke with the resident in the morning and the resident stated she/he was walking to "Fred Meyer" for ice cream. When asked if she/he had a bowl of ice cream every night would keep her/him from wanting to go outside, the resident nodded yes.

The 12/28/22 Wandering Risk Assessment revealed Resident 9 was a moderate risk for wandering. The resident was forgetful, had a short attention span, did not understand surroundings, independent with mobility, on antidepressants and had a history of wandering.

The 12/28/22 facility investigation revealed when Resident 9 eloped staff had not followed the care plan.

On 12/28/22 at 5:04 PM Staff 21 (Resident Care Manager) stated Resident 9 exit sought at night between 8:00 PM and 11:00 PM, was homeless prior to admission and did not feel any danger when outside at night. Staff 21 stated Resident 9 always wanted to go to Fred Meyers to get rocky road ice cream when interviewed. Resident 9 knew she/he did not have any money and would not state how she/he would pay for the ice cream. Staff 21 stated the ice cream was in the activity room but hadn't had any of it. Staff 21 stated although Resident 9 had some cognitive issues she/he had not "lost everything" and waited until no staff was looking before exiting the building. Staff 21 confirmed Resident 9's care plan instructed not to leave her/him unsupervised in the front lobby which staff did on 12/27/22 when she/he eloped.

On 12/28/22 at 5:16 PM Staff 22 (CNA) stated he and another staff member observed Resident 9 walk to the front lobby so he went to check on her/him. Resident 9 was "ok and I didn't know [she/he] was going to try to escape". Staff 22 further stated ten or 15 minutes after he checked on the resident a nurse called him and informed him she thought Resident 9 got out so the staff started to look for her/him. Staff 22 stated this was the first time he worked with Resident 9, was not aware to not leave Resident 9 alone in the front lobby and had not read the care plan.

On 12/28/22 at 5:33 PM Staff 16 (LPN) verified she worked on 12/27/22 when the resident eloped and stated there was no ice cream available after hours and she could not get into the activity room at night or if she was she was unaware of it. Staff 16 verified Resident 9 was left alone for approximately five minutes in the lobby prior to her/his elopement and stated she was not aware Resident 9's care plan instructed staff she/he was not to be left alone there. Staff 16 stated Resident 9 exit seeked at least once a week at night.

On 12/28/22 at 7:30 PM Staff 20 (Social Service Director) confirmed Resident 9 eloped on 12/27/22 because the care plan was not followed.

On 12/29/22 at 8:04 AM Staff 2 (DNS) stated the facility had identified 14 residents who were a moderate to high wander risk. Staff 2 confirmed on 12/27/22 Resident 9 was left alone in the front lobby and the resident's care plan was not followed which resulted in Resident 9's elopement off the facility grounds.

On 12/29/22 at 9:16 AM Resident 9 stated when she/he left the facility, it was to go to either Fred Meyer or Walmart to get ice cream. Resident 9 stated if staff offered her/him ice cream she/he would not leave.

On 12/29/22 at 10:06 AM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested.

Refer to F689

QUALITY OF CARE

The 2/12/22 Facility Assessment indicated the facility cared for residents with the following respiratory conditions: chronic obstructive pulmonary disease, pneumonia, asthma, chronic lung disease and respiratory failure. The assessment indicated for decisions related to caring for residents with conditions not listed above, the facility would review documentation and when there was a condition they were not familiar with they would ask questions and "do some research to see if the care they would need would be something we could manage." If training was needed prior to admission the facility world request training from the hospital. If a condition developed during a resident's stay they were not familiar with the facility "could" reach out to the pharmacy or Medical Director for any education which could be offered. Finally, the Facility Assessment revealed six to nine licensed nurses would be scheduled every day to provide direct care to the residents. Additional licensed nursing staff included one DNS, one Assistant DNS and two Resident Care managers.

Resident 5 admitted to the facilty on 3/4/22 with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space.) [All licensed nurses within the State of Oregon may drain the catheter with proper training.]

The facility's staffing records revealed between 3/4/22 through 3/22/22 one and a half to three RN's were on duty daily in addition to multiple LPNs.

The 3/4/22 Admission orders directed staff to drain the Pleurx catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%.

The 3/4/22 Progress Note revealed a nurse to nurse report was received from the hospital and indicated Resident had a chronic right lung pleural effusion with a drain. It was last drained on 3/3/22, was scheduled to be drained every other day and to not remove more than one liter of fluid (1,000 cc).

The 3/4/22 Nursing Admission Assessment did not reveal the presence of the PleurX catheter. The skin integrity assessment documented a "bandage on chest; did not remove."

The March 2022 TARs revealed the following orders:
* 3/6/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. The 3/6/22 entry was blank.
* 3/7/22 through 3/9/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. On 3/7/22 documentation revealed 1,000 cc of fluid was drained from the catheter. The 3/9/22 entry was blank.
*3/7/22: sterile dressing change weekly and PRN with dry gauze and occlusive dressing to PleurX site. Every Monday day shift. It was documented as completed on 3/7/22 and 3/21/22. On 3/14/22 it was documented as "9" and left blank on 3/28/22.
* 3/9/22: Drain PleurX catheter only at clinic or hospital.

The 3/9/22 provider encounter note revealed there was a concern with getting Resident 5's PleurX catheter drained and [the provider] was requested to "see patient urgently via telemedicine in order to do a face-to-face for home health for assistance with Pleurx [sic] catheter related to recurrent pleural effusions." The provider noted the resident had "great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it." The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The provider further noted the "effort to leave their domicile to obtain outpatient services would be taxing and overburdensome for this patient." [There was no evidence the facility informed the physician it was within the nurse's scope of practice to drain the catheter.]

The 3/9/22 Progress Notes revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath at 9:37 AM, the hospital drained 2,000 cc from the catheter and the resident returned to the facilty at 3:00 PM.

The 3/9/22 updated Physician Order indicated the catheter was to be drained at a clinic or hospital only. Every Monday, Wednesday and Friday.

The 3/11/22 provider note indicated Resident 5 experienced shortness of breath although 2,000 cc was drained from the catheter two days prior. The provider spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining at the facility it was decided to update the POLST form for DNR comfort only and refer Resident 5 to hospice.

The 3/11/22 Progress Note revealed Hospice was ordered and they would manage and drain the PleurX catheter.

The 3/17/22 Progress Note revealed Resident 5 healthcare POA was upset because she was not told why the facility could not drain Resident 5's PleurX catheter and wanted to transition Resident 5 off of hospice but needed home health set up first so the resident would not have to go to the hospital to get the catheter drained.

The 3/21/22 Progress Note revealed the facility spoke with Resident 5's daughter about the PleurX catheter and "how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it." Options were discussed and it was decided the facilty would look for alternative placement but to keep the resident on hospice so they could manage the drain.

On 12/28/22 at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the PleurX catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out to the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facilty stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and "even lay people can be taught to do it."

On 12/25/22 at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter, did not have sufficient RN staffing to care for the resident and the facilty was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork which they reviewed prior to the resident's admission. Staff 1 stated she declined training offered by the Resident's Case Manager and verified the resident went on hospice to avoid hospital emergency room visits.

On 12/29/22 in the AM Staff 1 and Staff 3 stated they were unaware LPN's were allowed to provide care and services related to the PleurX catheter with proper training.

F684 and F726

RESIDENT ASSESSMENTS, CARE PLAN INTERVENTIONS

Resident 15 admitted to the facility in 2020 with diagnoses including end stage renal disease and a hip fracture.

The 10/14/22 Annual MDS indicated the resident was cognitively intact, required extensive assistance with bed mobility, was non-ambulatory, and had a history of falls.

An 11/24/22 Fall Investigation indicated Resident 15 fell out of bed while reaching down for something and hit her/his head on the floor. The resident stated, "I was laying on the edge of the bed and I felt myself sliding down and I tried to grab for something, and I fell." The resident's call light was noted to be initiated. The investigation did not indicate how long the call light had been on. The resident was noted to have been last toileted and repositioned two hours prior to the fall. The resident's air mattress was noted to be "a bit high" so the air in the mattress was decreased. The resident requested side rails for her/his bed.

On 1/3/23 at 9:25 AM Resident 15 stated she/he had pressed her/his call light as she/he was close to the edge of the bed. The resident stated she/he yelled "I am going to fall", but by the time staff came to the room the resident was on the floor. Resident 15 stated her/his call light had been initiated for 30 minute and stated the long call light time "happened all the time." Resident 15 stated right after the fall she/he had requested bed mobility bars, but she/he never received them. The resident's bed was observed to be without any bed mobility bars or side rails. Resident 15 further stated she/he almost fell out of bed a few days prior, but a staff member was able to prevent the fall and helped reposition the resident in the center of the bed.

On 1/3/23 at 11:29 AM and 11:55 AM Staff 3 (LPN, Assistant DNS) acknowledged the investigation did not include how long Resident 15's call light was initiated. Staff 3 further stated the expectation was for the resident to have mobility bars per the resident's request and the resident did not currently have mobility bars on her/his bed.

Refer to F689

Resident 11 admitted to the facility on 10/8/22 with diagnoses including osteoarthritis.

The 10/15/22 Admission MDS was completed on 10/25/22; three days late.

On 12/30/22 at 12:51 PM Staff 2 (DNS) verified the 10/15/22 Admission MDS was completed late.

Refer to F636

Resident 3 admitted to the facility in 2020 with diagnoses including paraplegia (paralysis of the legs and lower body).

Resident 3's 9/20/22 Annual MDS was completed on 10/5/22; one day late.

On 12/28/22 at 9:12 AM Staff 2 (DNS) verified the 9/20/22 Annual MDS was completed one day late.

Refer to F636

Resident 13 admitted to the facility on 7/19/22 with diagnoses including hypertension.

The 7/26/22 Admission MDS was completed on 8/3/22; one day late.

On 12/30/22 at 12:52 PM Staff 2 (DNS) verified the 7/26/22 Admission MDS was completed late.

Refer to F636

ASSESSMENT AND MONITORING OF PRESSURE ULCERS

Resident 3 admitted to the facility in 2020 with diagnoses including paraplegia (paralysis of the legs and lower body) and a chronic Stage 4 (full thickness skin and tissue loss) pressure ulcer.

The August 2022 and September 2022 TARs revealed wound care was completed for Resident 3's coccyx wound.

The Weekly Skin Evaluations revealed the following:
*8/5/22: Stage 4 coccyx pressure wound which measured 0.5 cm x 0.5 cm x 0 cm. Treatment was in place and it appeared to be healing. [The assessment was not comprehensive.]
*8/12/22: Stage 4 coccyx pressure wound which measured 3 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, no foul odor, no complaints of pain. [The assessment was not comprehensive.]
*8/19/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm.
Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, no foul odor, no complaints of pain. [The assessment was not comprehensive.]
*8/26/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, odor present, no complaints of pain. [The assessment was not comprehensive.]
*9/2/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, odor present, no complaints of pain. [The assessment was not comprehensive.]

Review of Resident 3's medical record revealed no further skin assessments until the 10/20/22 RN Wound Assessment.

The RN Wound Assessments revealed the following:
*10/20/22: Stage 3 (full thickness skin loss, may extend into the subcutaneous tissue layer) coccyx pressure wound which measured 4 cm x 1.2 cm x 0/7 cm. This was a chronic wound the resident had "for years". Tunneling present at 6 o'clock measured 0.7 cm. The wound bed was 50% slough and 50% pale pink tissue. [Not a comprehensive assessment; downstaged wound.]
*10/27/22: Stage 3 coccyx pressure wound which measured 3 cm x 1 cm x 0.6 cm. Tunnel at 6 o'clock was deeper and slough at wound base was thicker and covered most of the wound bed. [Not a comprehensive assessment; downstaged wound.]
*10/29/22: Stage 3 coccyx pressure wound 90% slough and 10% pink tissue. [Not a comprehensive assessment; downstaged wound.]
11/3/22: Stage 3 coccyx pressure wound which measured 3 cm x 1 cm x 0.5 cm. Macerated thick skin, tunnel at 6 o'clock which measured 1.5 cm. Would bed had 75% slough and 25% pale pink tissue. Wound circumference was slightly smaller but tunnel was deeper and slough at the wound base was decreased. Surrounding tissue remained thick and white macerated. [Not a comprehensive assessment; downstaged wound.]
*11/10/22 Stage 3 coccyx pressure ulcer which measured 3.5 cm x 0.6 cm x 0.3 cm. Tunnel at 6 o'clock measured 0.3 cm. Wound bed was 75% slough and 25% pale pink tissue; some debridement at wound clinic...Surrounding tissue remained thick and white macerated. [Not a comprehensive assessment; downstaged wound.]
*11/15/22 Stage 3 coccyx pressure ulcer which measured 3.5 cm x 0.6 cm x 0.3 cm. The area is surrounded with macerated thick skin with a tunnel at 6 o'clock which measured 0.3 cm. Wound bed was 75% slough and 25% pale pink tissue. Some debridement at wound clinic. Tunnel is smaller but no overall change to wound bed. Resident was discharged from wound clinic this week. Referral obtained for [alternative] wound clinic. [Not a comprehensive assessment; downstaged wound.]
*11/20/22 Stage 3 coccyx pressure ulcer which measured 3.5 cm x 0.6 cm x 0.3 cm. Area surrounded with macerated thick skin and had a tunnel at 6 o'clock which measured 0.5 cm. Wound bed was 75% slough and 25% pale pink tissue; some debridement at wound clinic. Tunnel was smaller but no overall change to wound bed. Resident goes out to wound clinic weekly, had debridement at last appointment. Surrounding tissue remained thick and white macerated. [Not a comprehensive assessment; downstaged wound.]
*11/22/22 Stage 3 coccyx pressure ulcer which measured 3.2 cm x 1 cm x 0.5 cm. New assessor with new wound clinic today. Approximately 70% epithelial tissue, 20% granulation tissue and 105 slough, wound debrided. Tunnel changed to undermining form 6 to 7 o'clock and measured 1.6 cm....new orders received. [Not a comprehensive assessment; downstaged wound.]

On 12/28/22 at 9:12 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the 8/5/22, 8/12/22, 8/19/22, 8/26/22 and 9/22 Weekly Skin assessments were not comprehensive. Additionally Staff 2 confirmed the 10/20/22, 10/27/22, 10/29/22, 11/3/22, 11/10/22, 11/15/22, 11/20/22 and 11/22/22 RN Wound assessments were not comprehensive and the wound stage was incorrectly downgraded from a Stage 4 to a Stage 3 pressure ulcer.

Refer to F686

FOLLOW PHYSICIAN ORDERS

Resident 4 admitted to the facility in 3/2022 with diagnoses including heart failure and dementia.

An 8/12/22 Physician Order instructed staff to clean Resident 4's wounds daily in the first, second and third right webspaces with saline or wound cleanser and then to apply Bacitracin (antibiotic ointment). Place gauze between the webspaces. Clean the wound on the dorsal aspect of the right second toe, apply Bacitracin and cover with gauze. Secure the gauze with Kerlex dressing.

The August 2022 TARs revealed the wound treatment was not initiated until 8/14/22.

On 12/28/22 at 9:26 PM Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS) confirmed the 8/12/22 physician order was not started until 8/14/22.

Refer to F684

Based on interview and record review it was determined the facility failed to complete a MDS in the required timeframe for 3 of 8 sampled residents (#s 3, 11 and 13) reviewed for skin conditions, hospice and infection control. This placed residents at risk for unassessed and unmet care needs. Findings include:

1. Resident 11 admitted to the facilty on 10/8/22 with diagnoses including osteoarthritis.

The 10/15/22 Admission MDS was completed on 10/25/22; three days late.

On 12/30/22 at 12:51 PM Staff 2 (DNS) verified the 10/15/22 Admission MDS was completed late.

2. Resident 3 admitted to the facility in 2020 with diagnoses including paraplegia (paralysis of the legs and lower body).

Resident 3's 9/20/22 Annual MDS was completed on 10/5/22; one day late.

On 12/28/22 at 9:12 AM Staff 2 (DNS) verified the 9/20/22 Annual MDS was completed one day late.

3. Resident 13 admitted to the facility on 7/19/22 with diagnoses including hypertension.

The 7/26/22 Admission MDS was completed on 8/3/22; one day late.

On 12/30/22 at 12:52 PM Staff 2 (DNS) verified the 7/26/22 Admission MDS was completed late.

Based on interview and record review it was determined the facility failed to ensure a resident received the required care and services related to a drainage catheter and to follow physician orders for 2 of 4 sampled residents (#s 4 and 5) reviewed for catheters and skin conditions. This caused Resident 5 to experience an avoidable hospital transfer, pain, shortness of breath and an increased pulse rate. The facility failures placed residents at risk for delayed treatment and worsening wounds. Findings include:

1. The 2/12/22 Facility Assessment indicated the facility cared for residents with the following respiratory conditions: chronic obstructive pulmonary disease, pneumonia, asthma, chronic lung disease and respiratory failure. The assessment indicated for decisions related to caring for residents with conditions not listed above, the facility would review documentation and when there was a condition they were not familiar with they would ask questions and "do some research to see if the care they would need would be something we could manage." If training was needed prior to admission the facility world request training from the hospital. If a condition developed during a resident's stay they were not familiar with the facility "could" reach out to the pharmacy or Medical Director for any education which could be offered. Finally, the Facility Assessment revealed six to nine licensed nurses would be scheduled every day to provide direct care to the residents. Additional licensed nursing staff included one DNS, one Assistant DNS and two Resident Care managers.

Resident 5 admitted to the facilty on 3/4/22 with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space.) [All licensed nurses within the State of Oregon may drain the catheter with proper training.]

The facility's staffing records revealed between 3/4/22 through 3/22/22 one and a half to three RN's were on duty daily in addition to multiple LPNs.

The 3/4/22 Admission orders directed staff to drain the Pleurx catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%.

The 3/4/22 Progress Note revealed a nurse to nurse report was received from the hospital and indicated Resident had a chronic right lung pleural effusion with a drain. It was last drained on 3/3/22, was scheduled to be drained every other day and to not remove more than one liter of fluid (1,000 cc).

The 3/4/22 Nursing Admission Assessment did not reveal the presence of the PleurX catheter. The skin integrity assessment documented a "bandage on chest; did not remove."

The March 2022 TARs revealed the following orders:
* 3/6/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. The 3/6/22 entry was blank.
* 3/7/22 through 3/9/22: Drain the PleurX catheter a maximum of 1,000 cc at a time and to record the amount drained. Note if Resident 5 had a SpO2 under 90%. On 3/7/22 documentation revealed 1,000 cc of fluid was drained from the catheter. The 3/9/22 entry was blank.
*3/7/22: sterile dressing change weekly and PRN with dry gauze and occlusive dressing to PleurX site. Every Monday day shift. It was documented as completed on 3/7/22 and 3/21/22. On 3/14/22 it was documented as "9" and left blank on 3/28/22.
* 3/9/22: Drain PleurX catheter only at clinic or hospital.

The 3/9/22 provider encounter note revealed there was a concern with getting Resident 5's PleurX catheter drained and [the provider] was requested to "see patient urgently via telemedicine in order to do a face-to-face for home health for assistance with Pleurx [sic] catheter related to recurrent pleural effusions." The provider noted the resident had "great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it." The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital. The provider further noted the "effort to leave their domicile to obtain outpatient services would be taxing and overburdensome for this patient." [There was no evidence the facility informed the physician it was within the nurse's scope of practice to drain the catheter.]

The 3/9/22 Progress Notes revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath at 9:37 AM, the hospital drained 2,000 cc from the catheter and the resident returned to the facilty at 3:00 PM.

The 3/9/22 updated Physician Order indicated the catheter was to be drained at a clinic or hospital only. Every Monday, Wednesday and Friday.

The 3/11/22 provider note indicated Resident 5 experienced shortness of breath although 2,000 cc was drained from the catheter two days prior. The provider spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining at the facility it was decided to update the POLST form for DNR comfort only and refer Resident 5 to hospice.

The 3/11/22 Progress Note revealed Hospice was ordered and they would manage and drain the PleurX catheter.

The 3/17/22 Progress Note revealed Resident 5 healthcare POA was upset because she was not told why the facility could not drain Resident 5's PleurX catheter and wanted to transition Resident 5 off of hospice but needed home health set up first so the resident would not have to go to the hospital to get the catheter drained.

The 3/21/22 Progress Note revealed the facility spoke with Resident 5's daughter about the PleurX catheter and "how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it." Options were discussed and it was decided the facilty would look for alternative placement but to keep the resident on hospice so they could manage the drain.

On 12/28/22 at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the PleurX catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out to the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facilty stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and "even lay people can be taught to do it."

On 12/25/22 at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter, did not have sufficient RN staffing to care for the resident and the facilty was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork which they reviewed prior to the resident's admission. Staff 1 stated she declined training offered by the Resident's Case Manager and verified the resident went on hospice to avoid hospital emergency room visits.

On 12/29/22 in the AM Staff 1 and Staff 3 stated they were unaware LPN's were allowed to provide care and services related to the PleurX catheter with proper training.

2. Resident 4 admitted to the facility in 3/2022 with diagnoses including heart failure and dementia.

An 8/12/22 Physician Order instructed staff to clean Resident 4's wounds daily in the first, second and third right webspaces with saline or wound cleanser and then to apply Bacitracin (antibiotic ointment). Place gauze between the webspaces. Clean the wound on the dorsal aspect of the right second toe, apply Bacitracin and cover with gauze. Secure the gauze with Kerlex dressing.

The August 2022 TARs revealed the wound treatment was not initiated until 8/14/22.

On 12/28/22 at 9:26 PM Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS) confirmed the 8/12/22 Physician Order was not started until 8/14/22.

Based on interview and record review it was determined the facility failed to assess and monitor a pressure ulcer for 1 of 3 sampled residents (#3) reviewed for skin conditions. This placed residents at risk for worsening of wounds. Findings include:

CMS instructed pressure ulcers were to be comprehensively assessed and documented with each dressing change or at minimum weekly. The documentation should include the following:
*the type of injury;
*the stage and location of the wound;
*a description of the wound's characteristics: presence, location and extent of any undermining (erosion occurs underneath the outwardly visible wound margins) or tunneling (extends from the skin surface to various underlying tissues), exudate (drainage) if present/type, color, odor and approximate amount;
*pain, if present, nature and frequency;
*wound bed: color and type of tissue/character including evidence of healing (granulation tissue: new vascular tissue) or necrosis (slough [yellow/white material in the wound bed; usually wet] or eschar [dead tissue]);
*description of wound edges and surrounding tissue.

Resident 3 admitted to the facility in 2020 with diagnoses including paraplegia (paralysis of the legs and lower body) and a chronic Stage 4 (full thickness skin and tissue loss) pressure ulcer.

The August 2022 and September 2022 TARs revealed wound care was completed for Resident 3's coccyx wound.

The Weekly Skin Evaluations revealed the following:
*8/5/22: Stage 4 coccyx pressure wound which measured 0.5 cm x 0.5 cm x 0 cm. Treatment was in place and it appeared to be healing. [The assessment was not comprehensive.]
*8/12/22: Stage 4 coccyx pressure wound which measured 3 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, no foul odor, no complaints of pain. [The assessment was not comprehensive.]
*8/19/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm.
Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, no foul odor, no complaints of pain. [The assessment was not comprehensive.]
*8/26/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, odor present, no complaints of pain. [The assessment was not comprehensive.]
*9/2/22: Stage 4 coccyx pressure wound which measured 33.5 cm x 5 cm x 0.5 cm. Treatment in place. Wound was larger, periwound was macerated, wound bed had slough, odor present, no complaints of pain. [The assessment was not comprehensive.]

Review of Resident 3's medical record revealed no further skin assessments until the 10/20/22 RN Wound Assessment.

The RN Wound Assessments revealed the following:
*10/20/22: Stage 3 (full thickness skin loss, may extend into the subcutaneous tissue layer) coccyx pressure wound which measured 4 cm x 1.2 cm x 0/7 cm. This was a chronic wound the resident had "for years". Tunneling present at 6 o'clock measured 0.7 cm. The wound bed was 50% slough and 50% pale pink tissue. [Not a comprehensive assessment; downstaged wound.]
*10/27/22: Stage 3 coccyx pressure wound which measured 3 cm x 1 cm x 0.6 cm. Tunnel at 6 o'clock was deeper and slough at wound base was thicker and covered most of the wound bed. [Not a comprehensive assessment; downstaged wound.]
*10/29/22: Stage 3 coccyx pressure wound 90% slough and 10% pink tissue. [Not a comprehensive assessment; downstaged wound.]
11/3/22: Stage 3 coccyx pressure wound which measured 3 cm x 1 cm x 0.5 cm. Macerated thick skin, tunnel at 6 o'clock which measured 1.5 cm. Would bed had 75% slough and 25% pale pink tissue. Wound circumference was slightly smaller but tunnel was deeper and slough at the wound base was decreased. Surrounding tissue remained thick and white macerated. [Not a comprehensive assessment; downstaged wound.]
*11/10/22 Stage 3 coccyx pressure ulcer which measured 3.5 cm x 0.6 cm x 0.3 cm. Tunnel at 6 o'clock measured 0.3 cm. Wound bed was 75% slough and 25% pale pink tissue; some debridement at wound clinic...surrounding tissue remained thick and white macerated. [Not a comprehensive assessment; downstaged wound.]
*11/15/22 Stage 3 coccyx pressure ulcer which measured 3.5 cm x 0.6 cm x 0.3 cm. The area is surrounded with macerated thick skin with a tunnel at 6 o'clock which measured 0.3 cm. Wound bed was 75% slough and 25% pale pink tissue. Some debridement at wound clinic. Tunnel is smaller but no overall change to wound bed. Resident was discharged from wound clinic this week. Referral obtained for [alternative] wound clinic. [Not a comprehensive assessment; downstaged wound.]
*11/20/22 Stage 3 coccyx pressure ulcer which measured 3.5 cm x 0.6 cm x 0.3 cm. Area surrounded with macerated thick skin and had a tunnel at 6 o'clock which measured 0.5 cm. Wound bed was 75% slough and 25% pale pink tissue; some debridement at wound clinic. Tunnel was smaller but no overall change to wound bed. Resident goes out to wound clinic weekly, had debridement at last appointment. Surrounding tissue remained thick and white macerated. [Not a comprehensive assessment; downstaged wound.]
*11/22/22 Stage 3 coccyx pressure ulcer which measured 3.2 cm x 1 cm x 0.5 cm. New assessor with new wound clinic today. Approximately 70% epithelial tissue, 20% granulation tissue and 105 slough, wound debrided. Tunnel changed to undermining form 6 to 7 o'clock and measured 1.6 cm....new orders received. [Not a comprehensive assessment; downstaged wound.]

On 12/28/22 at 9:12 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed the 8/5/22, 8/12/22, 8/19/22, 8/26/22 and 9/22 Weekly Skin assessments were not comprehensive. Additionally Staff 2 confirmed the 10/20/22, 10/27/22, 10/29/22, 11/3/22, 11/10/22, 11/15/22, 11/20/22 and 11/22/22 RN Wound assessments were not comprehensive and the wound stage was incorrectly downgraded from a Stage 4 to a Stage 3 pressure ulcer.

1. Based on interview and record review it was determined the facility failed to ensure Resident 9 did not elope from the facility for 1 of 1 sampled residents (#9) reviewed for elopement. This failure was determined to be an immediate jeopardy situation because the facility failed to follow the residents care plan and provide supervision which resulted in Resident 9's elopement from the facility. Findings include:

Resident 9 admitted to the facility in 2022 with diagnoses including symptoms involving cognitive functions following other nontraumatic intracranial hemorrhage and cataracts. Prior to admission, the resident was homeless.

The 9/27/22 Communication Care Plan revealed Resident 9 had a communication problem related to expressive aphasia (a form of aphasia when the person knows what they want to say but are unable to produce the words or sentence. Can be mild to severe), slurring, stroke, weak or absent voice. Interventions included to allow adequate time to respond, face the resident when speaking and make eye contact, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. The resident was able to say yes or no and very short sentences and could shake/nod her/his head. Speak to the resident in a calm, quiet voice because she/he responded better with this approach. Speak on an adult level, speak clearly and slower than normal.

The 9/27/22 Fall Care Plan revealed Resident 9 was a high risk for falls related to gait and balance problems.

The 11/18/22 Vision Care Plan revealed Resident 9 was at risk for poor vision related to cataracts.

The Elopement Risk Care Plan, last revised on 12/28/22, revealed Resident 9 was a high elopement risk related to impaired safety awareness; both physical and environmental. The resident had eloped on 11/17/22, 12/12/22 and 12/27/22. The interventions included to remind the resident to notify staff if she/he planned to leave the facility as needed (11/18/22), resident was high fall risk (11/18/22), to not seat the resident in the lobby near the doors without supervision at any time of the day or night. If the resident was up during late night hours to have her/him close to the nurse's station where she/he could be monitored. To walk with the resident if she/he wanted to walk, sit and talk with the resident, attempt to engage the resident to watch television, look at a magazine, offer fluids and snack. If not redirectable, alert the charge nurse, RN, resident care manager or DNS (12/14/22). Remind the resident of the sign posted in her/his room to not leave the facility without assistance for her/his safety and to show her/him the sign above the television (12/15/22). Activities to check in with the resident regularly to see if she/he needed anything from the store and to let nursing know to minimize the desire to exit the facility (12/16/22). Offer Resident 9 a bowl of ice cream (rocky road) every evening sometime after dinner and before bed time. If Resident 9 ambulated toward the front lobby late at night offer the ice cream again (12/28/22).

The 11/17/22 at 9:34 PM Incident Note revealed staff noted Resident 9 was not in her/his room, was assisted to bed at 7:00 PM, last seen between 8:15 PM and 8:30 PM and found on the lawn outside the 200 hall door.

The 11/18/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, independent with aid for mobility, early dementia, on antidepressants and had a history of wandering.

The 11/18/22 facility investigation revealed the resident was found outside. When interviewed the resident indicated she/he was going to "Fred Meyers" for rocky road ice cream. [Fred Meyers is a store 0.6 miles away from the facility. The resident would have to walk up Weathers Street, which facility resides on, towards Lancaster Drive which is a highly congested four lane road. The intersection of Weathers and Lancaster has no intersection and both roads offer minimal lighting.]

The 12/6/22 BIMs score was 9 which suggested the resident had moderately impaired cognition.

The 12/12/22 Progress Note revealed Resident 9 walked out of the facility around 8:00 PM. The resident wore a sweater, was found down the street walking with her/his walker. The temperature was "around 40 degrees and [she/he] was not dressed appropriately." The resident was non-verbal; unable to say why she/he left or where she/he was going.

The 12/12/22 Elopement Event identified Resident 9 as an elopement risk, the resident eloped off facility grounds when she/he was left unattended in the front lobby and the resident was disoriented to "some-spheres" some of the time. The assessment revealed the resident was homeless prior to admission and was not afraid to go out at night. The resident was alert and able to converse most of the time, was slow to answer and very soft spoken which could be misconstrued for non-responsive or cognitive impairment.

The 12/13/22 Wandering Risk Assessment identified Resident 9 as a moderate wander risk. Resident 9 was forgetful, had a short attention span, ambulated with one person assistance, early dementia, on antidepressants and had a history of wandering.

The 12/13/22 Incident Note revealed Resident 9 was alert and able to converse most of the time but was slow to answer and very soft spoken. Resident 9 stated she/he was going to "Fred Meyer's" for ice cream. Resident 9 stated rocky road was her/his favorite ice cream. The resident stated she/he did not have money for ice cream and stopped responding to the interviewer when repeatedly asked how she/he would have paid for the ice cream.

The 12/13/22 BIMs was 14 which indicated the resident was cognitively intact.

The 12/14/22 Care Conference Notes revealed safety concerns as the resident had exited the facility twice since admission. The resident stated she/he was going to "Fred Meyer's" to get ice cream. It was arranged the resident would be asked weekly if she/he needed anything and ice cream would be available.

The 12/28/22 Progress Note revealed Resident 9 walked down the hall around 11:20 PM [on 11/27/22]. The resident walked to the lobby and sat down. Staff asked what she/he needed but the resident did not respond. The CNA sat with the resident for a few minutes "but when she went to answer another call light [she/he] left out the front door." The nurse went to check on the resident five minutes later and the resident was "gone". Four staff initiated a search, first searching the facility and then outside. Resident 9 was found walking past the park on Weathers Street. The resident was non-verbal and would not answer any questions. The temperature outside was 50 degrees and raining; the resident wore sweat pants and a T-shirt.

The 12/28/22 Progress Note revealed the resident care manager spoke with the resident in the morning and the resident stated she/he was walking to "Fred Meyer" for ice cream. When asked if she/he had a bowl of ice cream every night would keep her/him from wanting to go outside, the resident nodded yes.

The 12/28/22 Wandering Risk Assessment revealed Resident 9 was a moderate risk for wandering. The resident was forgetful, had a short attention span, did not understand surroundings, independent with mobility, on antidepressants and had a history of wandering.

The 12/28/22 facility investigation revealed when Resident 9 eloped staff had not followed the care plan.

On 12/28/22 at 5:04 PM Staff 21 (Resident Care Manager) stated Resident 9 exit sought at night between 8:00 PM and 11:00 PM, was homeless prior to admission and did not feel any danger when outside at night. Staff 21 stated Resident 9 always wanted to go to Fred Meyers to get rocky road ice cream when interviewed. Resident 9 knew she/he did not have any money and would not state how she/he would pay for the ice cream. Staff 21 stated the ice cream had been in the activity room but hadn't had any of it. Staff 21 stated although Resident 9 had some cognitive issues she/he had not "lost everything" and waited until no staff was looking before exiting the building. Staff 21 confirmed Resident 9's care plan instructed not to leave her/him unsupervised in the front lobby which staff did on 12/27/22 when she/he eloped.

On 12/28/22 at 5:16 PM Staff 22 (CNA) stated he and another staff member observed Resident 9 walk to the front lobby so he went to check on her/him. Resident 9 was "ok and I didn't know [she/he] was going to try to escape". Staff 22 further stated ten or 15 minutes after he checked on the resident a nurse called him and informed him she thought Resident 9 got out so the staff started to look for her/him. Staff 22 stated this was the first time he worked with Resident 9, was not aware to not leave Resident 9 alone in the front lobby and had not read the care plan.

On 12/28/22 at 5:33 PM Staff 16 (LPN) verified she worked on 12/27/22 when the resident eloped and stated there was no ice cream available after hours and she could not get into the activity room at night or if she was she was unaware of it. Staff 16 verified Resident 9 was left alone for approximately five minutes in the lobby prior to her/his elopement and stated she was not aware Resident 9's care plan instructed staff she/he was not to be left alone there. Staff 16 stated Resident 9 exit seeked at least once a week at night.

On 12/28/22 at 7:30 PM Staff 20 (Social Service Director) confirmed Resident 9 eloped on 12/27/22 because the care plan was not followed.

On 12/29/22 at 8:04 AM Staff 2 (DNS) stated the facility had identified 14 residents who were a moderate to high wander risk. Staff 2 confirmed on 12/27/22 Resident 9 was left alone in the front lobby and the resident's care plan was to followed which resulted in Resident 9's elopement off the facility grounds.

On 12/29/22 at 9:16 AM Resident 9 stated when she/he left the facility, it was to go to either Fred Meyer or Walmart to get ice cream. Resident 9 stated if staff offered her/him ice cream she/he would not leave.

On 12/29/22 at 10:06 AM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested.

On 12/29/22 at 12:40 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation.

The immediacy removal plan included the following:
*Resident 9 would be visually monitored by staff at all times from dinner until 2:00 AM. Ice ream would be offered every evening before bed. The visual monitoring would remain in place until the wander guard that was ordered arrived and was put into place.
*The elopement care plans for the 13 residents who were moderate to high risk for wandering would be printed and required to be reviewed by the nursing staff prior to them working with the residents.
*The facility had identified on 12/20/22 some staff had not read care plan changes and a new system of notifying staff was implemented.
*All residents had a potential to be affected.
*All staff would be informed of what residents were at risk for wandering/elopement. All nursing staff would receive education on the new system for notifying staff of care plan changes and the expectation to read the care plan prior to providing care to the resident. Education would begin on 12/29/22 and would by completed by 12/30/22 at 3:00 PM or upon return if on a leave of absence prior to working with residents.
*Random weekly audits of care plans would be completed to ensure staff were notified of changes per the new system for 30 days. Results of the audits would be reviewed by the QAPI (Quality Assurance and Performance Improvement) team to determine if further auditing was necessary

On 12/30/22 staff interviews verified re-education per the immediacy removal plan was competed. A review of facility documentation revealed all aspects of the immediacy removal plan was implemented.

On 12/30/22 at 2:50 PM it was determined the IJ immediacy was removed.

, 2. Based on observation, interview and record review it was determined the facility failed to ensure interventions were in place to prevent accidents for 1 of 3 sampled residents (#15) reviewed for falls. This placed residents at risk for injury. Findings include:

Resident 15 admitted to the facility in 2020 with diagnoses including end stage renal disease and a hip fracture.

The 10/14/22 Annual MDS indicated the resident was cognitively intact, required extensive assistance with bed mobility, was non-ambulatory, and had a history of falls.

An 11/24/22 Fall Investigation indicated Resident 15 fell out of bed while reaching down for something and hit her/his head on the floor. The resident stated, "I was laying on the edge of the bed and I felt myself sliding down and I tried to grab for something, and I fell." The resident's call light was noted to be initiated. The investigation did not indicate how long the call light had been on. The resident was noted to have been last toileted and repositioned two hours prior to the fall. The resident's air mattress was noted to be "a bit high" so the air in the mattress was decreased. The resident requested side rails for her/his bed.

On 1/3/23 at 9:25 AM Resident 15 stated she/he had pressed her/his call light as she/he was close to the edge of the bed. The resident stated she/he yelled "I am going to fall", but by the time staff came to the room the resident was on the floor. Resident 15 stated her/his call light had been initiated for 30 minute and stated the long call light time "happened all the time." Resident 15 stated right after the fall she/he had requested bed mobility bars, but she/he never received them. The resident's bed was observed to be without any bed mobility bars or side rails. Resident 15 further stated she/he almost fell out of bed a few days prior, but a staff member was able to prevent the fall and helped reposition the resident in the center of the bed.

On 1/3/23 at 11:29 AM ad 11:55 AM Staff 3 (LPN, Assistant DNS) acknowledged the investigation did not include how long Resident 15's call light was initiated. Staff 3 further stated the expectation was for the resident to have mobility bars per the resident's request and the resident did not currently have mobility bars on her/his bed.

Based on interview and record review it was determined the the facility failed to monitor and assess Resident 2 for signs of UTI (urinary tract infection) such as decreased food and fluid intake and decreased urine output and failed to notify the provider of condition changes for 1 of 3 sampled residents (#2) reviewed for change of condition. This failure was determined to be an immediate jeopardy situation because the facility failed to recognize and treat a UTI which resulted in severe sepsis and death. Findings include:

Resident 2 admitted to the facility in 4/2022 with diagnoses including intellectual disabilities and neurogenic bladder.

The 3/11/22 Risk For Infection related to the use of a urinary catheter care plan included the following interventions: change catheter and Foley (catheter) bag as scheduled or as ordered by the physician, monitor the indwelling catheter and report to the physician signs and symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns.

The 4/6/22 Return From Hospital care plan interventions included to monitor appetite and document the percentage eaten each meal and to monitor pain and discomfort.

A 4/29/22 Progress note revealed Resident 2's urine was cloudy with foul smell, had increased agitation and a UA (urinalysis) was collected.

A 5/4/22 Progress note revealed a negative UA result.

The 5/4/22 task documentation revealed Resident 2's UOP (urine output) was 1150 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and dinner was refused. Fluid intake was 980 cc.

A 5/6/22 Progress note revealed Resident 2 was "very irritable" and refused the catheter change. Blood Pressure was 71/49 [No evidence of physician notification, assessment or monitoring was completed or offered additional food and fluids.]

The 5/6/22 task documentation revealed Resident 2's UOP was 675 cc, fluid intake was 460 cc and meal intake for breakfast and lunch was zero to 25% and dinner 26 to 50%.

A 5/7/22 Progress Note revealed Resident 2 was on alert due to having cloudy urine, having increased sediment and foul odor.

The 5/8/22 task documentation revealed fluid intake was 540 cc.

The 5/9/22 task documentation revealed the resident consumed zero to 25% of all meals and fluid intake was 360 cc.

The 5/10/22 task documentation revealed fluid intake was 270 cc. Meal intake for breakfast was 26 to 50%, lunch zero to 25% and refused dinner.

The 5/11/22 task documentation revealed 500 cc UOP, 780 cc fluid intake and meal intake varied from zero to 75%.

The 5/12/22 task documentation revealed 475 cc UOP, 120 cc fluid intake, meal intake for breakfast and dinner was refused, lunch was zero to 25%. The resident took in additional nutrition in the evening between 75-100%.

The 5/13/22 task documentation revealed 950 cc UOP, Fluid intake was 240 cc with one meal intake not documented and meal intake zero to 25% for breakfast and dinner and lunch was not documented.

The 5/14/22 task documentation revealed 560 cc UOP, 740 cc fluid intake, breakfast and dinner refused with zero to 25% lunch meal intake.

The 5/16/22 task documentation revealed UOP was 25 cc on night shift and 260 cc on day shift. Fluid intake was 20 cc for breakfast and 120 cc for lunch. Meal intake was zero to 25% for breakfast and lunch.

The 5/16/22 12:01 PM Progress note revealed a CNA reported Resident 2 was "not acting like [her/himself] today. Blood pressure was 94/59, resident stated she/he felt unwell and was unable to describe any specific symptoms. The urine was red/brown tinged and mucus was present. The residents speech was slurred. The provider was called and staff were waiting for a call-back.

The 5/16/22 2:00 PM Progress note revealed the provider called back and gave orders to push fluids, administer an antibiotic shot, change the indwelling catheter and to obtain a stat [immediate] UA.

The 5/16/22 provider encounter note revealed the resident was seen for a concern of a possible UTI. The urine was reported to have foul odor and was cloudy with a dark color. The catheter was changed and the urine was clear after the indwelling catheter change. The resident complained of stomach and ear pain.

The 5/16/22 2:38 PM indicated the resident was transported to the hospital for altered mental status and hypotension (low blood pressure).

The 5/17/22 Progress note revealed the hospital notified the facility the resident passed away with a small bowel obstruction, UTI, sepsis (full body infection) and acute renal failure.

The 5/17/22 Hospital Records revealed Resident 2 was transferred to the hospital for malaise, fatigue and low blood pressure. The resident was diagnosed with UTI , septic syndrome secondary to UTI, acute kidney injury, anemia, hypoalbuminemia (abnormally low blood level of albumin (type of protein)), gastric outlet obstruction, gastrointestinal bleed and severe anion gap metabolic acidosis (imbalanced electrolytes). On 5/16/22, after discussion of options with the family, the residents POLST was changed to DNR and the resident passed away on 5/17/22.

The 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death, five days. Other significant conditions contributing to death gastric outlet obstruction.

There was no evidence in the medical record the provider was notified of the residents decreased appetite, fluid intake, urine output, low blood pressure, increased confusion, irritability or malaise. There was no evidence of monitoring of signs and symptoms of UTI.

On 12/21/22 at 9:25 AM Resident 16 (roommate) verified she was Resident 2's roommate and stated the week prior to her/his transfer to the hospital Resident 2 had increased irritability and was in pain.

On 12/19/22 12:30 PM Staff 6 (Former NA) stated the week prior to Resident 2 transferring to the hospital her/his urine was brown in color and had increased confusion.

On 12/19/22 at 2:21 PM Staff 11 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he was "pretty confused", tired, had a poor appetite, irritable, "pretty out of it" and the urine bag "was not looking like it should". Staff 11 stated she recalled the nurses looking at the resident's urine bag but "had no idea what the nurses did".

On 12/19/22 at 3:10 PM Staff 13 (LPN) stated staff were monitoring Resident 2's urine for amber color.

On 12/20/22 at 2:00 PM Staff 4 (Administrator in Training) recalled talking the Resident 2's sister about her concerns of Resident 2's health related to cognition, loss of appetite, getting up less and concerns of UTI. Staff 4 stated "I finally asked [staff] to send her out so they did."

On 12/20/22 at 3:30 PM Staff 16 (LPN) verified she wrote the 5/6/22 progress note, confirmed the resident was "very irritable", refused the catheter change and had a blood pressure of 71/49. Staff 16 verified she did not further assess the resident or notify the physician of the low blood pressure, irritability or refusal of the catheter change.

On 12/20/22 at 3:35 PM Staff 35 (LPN) stated the week prior to Resident 2's hospital transfer she/he was very irritable which was not normal because she/he was usually sweet and pleasant.

On 12/21/22 at 9:50 AM Staff 7 (CNA) stated in the two weeks prior to Resident 2's hospital transfer she/he ate less because she didn't feel good enough to eat and needed more encouragement to attempt to eat and drink. Staff 7 further stated she noted a decline in Resident 2's overall abilities.

On 12/21/22 at 9:59 AM Staff 5 (Support RN) verified between 5/2/22 through 5/16/22 there was only one alert note related to monitoring the resident's urine or for signs of UTI.

On 12/21/22 at 10:10 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 2's care plans were not followed and the low blood pressure was not reported to the physician or assessed. Staff 1 and Staff 2 acknowledged the resident's decline in condition was not assessed and the physician was not notified until 5/16/22. Staff 1 acknowledged the 5/24/22 Death Certificate revealed Resident 2's immediate cause of death was severe sepsis with septic shock, approximate onset to death, one day, due to pseudomonas UTI, approximate onset to death five days. Other significant conditions contributing to death gastric outlet obstruction.

On 12/21/22 at 12:08 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested.

On 12/21/22 at 2:44 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation.

The immediacy removal plan included the following:
*All residents with signs and symptoms of UTI will be monitored and provider would be notified via "SBAR" to assure residents were being treated timely and appropriately. RCM's (Resident Care Managers) would monitor residents who ate less than 50% for two or more meals. The RCMs would assess if the resident needed to stay on alert or if it was an indication of a problem that needed to be further assessed by the provider.
*All residents had the potential to be affected.
*All licensed nurses would be re-educated on the signs and symptoms of UTI including decreased urine output, pain, burning, blood-tinged urine, cloudiness, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating pattern. The nurses would be re-educated on the new alert process, when to notify the provider and how it relates to addressing a resident with any of the above symptoms. Education would begin on 12/21/22 and be completed by 12/22/22 at 12:00 PM.
*Random weekly audits of resident progress notes would be done for 30 days by the DNS or designee to ensure any reports of signs and symptoms of UTI were addressed appropriately.
*Results of these audits would be reviewed by the QAPI (Quality Assurance Process and Improvement) team to determine if further auditing was necessary.

On 12/21/22 3:06 PM through 12/22/22 7:58 PM staff interviews were completed and verified re-education per the POC was completed. A review of facility documentation revealed all aspects of the POC was implemented.

On 12/22/22 at 7:58 AM it was determined the immediacy was removed.

1. Based on interview and record review it was determined the facility failed to ensure the licensed nursing staff had the appropriate competencies and skill sets to provide nursing care for a resident with a PleurX Catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space) for 1 of 3 sampled residents (#5) reviewed for hospice. This caused Resident 5 to have increased pain, shortness of breath, psychosocial harm and experienced sustained a distressing and diminished quality of life prior to death. Finding include:

Resident 5 admitted to the facility on 3/4/22 with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). The resident had a PleurX catheter in place and died on 3/21/22.

The facility's staffing records revealed between 3/4/22 through 3/22/22 one to three RN's were on duty daily in addition to LPN's.

The 3/4/22 Admission Orders directed staff to drain the PleurX catheter to a maximum 1,000 cc removal at a time, note the amount drained and to notify the physician if the SpO2 (oxygen saturation) was less than 90%. [All licensed nurses within the State of Oregon may care for and drain the catheter with proper training.]

The 3/7/22 Physician Order indicated the catheter was to be drained at a clinic or hospital only every Monday, Wednesday and Friday. [There was no documentation the facility informed the physician it was within the nurses scope of practice to drain the catheter onsite.]

A 3/9/22 provider encounter note revealed there was a concern with getting Resident 5's PleurX catheter drained. The provider noted the resident had "great self awareness of when this needs to happen. And reporting that [she/he] is having difficulty breathing and needing it." The provider spoke with the DNS and it was determined if the facility had no staff available to drain the catheter then to transfer the resident to the hospital.

The 3/9/22 Progress Note's revealed Resident 5 was transferred to the hospital for increased pulse and shortness of breath. The hospital drained 2,000 cc from the catheter.

A 3/11/22 provider note indicated she spoke with Resident 5's healthcare POA, discussed concerns of ongoing draining of the PleurX catheter and after a long discussion of options for draining (the catheter) at the facility it was decided to update the resident's POLST form to DNR comfort measures only and refer to hospice.

A 3/11/22 Hospice note revealed Resident 5 was admitted to hospice services.

A 3/12/22 Hospice note revealed the hospice nurse drained 1,000 cc of fluid from the PleurX catheter.

A 3/16/22 Progress note revealed the resident made comments about harming her/himself, asked for a hammer because she/he hurt so bad and asked the CNA if she could help her/him kill her/himself.

A 3/17/22 Progress note revealed Resident 5's healthcare POA was upset because she was not told why the facility could not drain Resident 5's PleurX catheter. The note further stated the goal was to transition the resident off of hospice so they could obtain aggressive treatment with a specialist but they needed home health set up first so the resident would not have to go to the hospital to get the PleurX catheter drained. The healthcare POA stated she understood the resident may not live much longer but still did not want hospice "at this time".

A 3/18/22 Progress note revealed home health would not come to the facility.

A 3/21/22 Progress note revealed they spoke with Resident 5's daughter about the PleurX catheter and "how we were unable to meet [her/his] needs due to the licensing of our nurses and not having an RN to do it. Options were discussed and it was decided the facility would look for alternative placement but to keep the resident on hospice so they could manage the drain.

The 3/21/22 Discharge Summary note indicated the funeral home picked the resident up. [There were no notes related to the residents passing in the medical record.]

Hospice Notes revealed the PleurX catheter was drained on March 12, 13, 14, 16 and 20.

On 12/28/22 at 8:47 AM Witness 7 (Complainant) stated the facility did not want to provide care and services for the Pleurx catheter and placed the resident on hospice against her/his will. Resident 5's family notified Witness 7 that they did not want hospice but felt like their back was against the wall. The resident was admitted to the facility specifically for the facility to manage the catheter however care did not happen and she/he was sent to the hospital for catheter care. Resident 5 and family were given the decision to either send the resident to the hospital for routine catheter care or go onto hospice. Witness 7 stated she reached out the the facility to coordinate nurse education if that was what was needed and offered to have a provider or the catheter company provide a tutorial which the facility declined. The facility stated this [PleurX catheter] was something they did not do. Witness 7 stated care facilities should be able to manage the catheter and "even lay people can be taught to do it."

On 12/28/22 at 8:58 AM an interview was conducted with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS). Staff 1 stated the facility did not know how to care for the catheter and did not have sufficient RN staffing to care for the resident as the majority of the RN's were agency personnel. Staff 1 stated the facility was unaware the resident had a PleurX catheter on admission but verified this information was in the resident's admission paperwork. Staff 1 verified the resident went on hospice to avoid hospital emergency room visits.

On 12/28/22 an email was received from the Oregon State Board of Nursing which revealed LPN's could drain and care for PleurX catheters if they had the appropriate training.

On 12/29/22 in the AM Staff 1 and Staff 3 stated they believed LPN's were not able to perform PleurX catheter care and services. The LPN scope of practice information listed PleurX catheter care as something LPN's were unable to complete and did not realize this LPN task list was from Alabama.

, 2. Based on interview and record review, it was determined the facility failed to ensure nursing staff received and demonstrated the appropriate competencies and skills to provide nursing services to assure resident safety and maintain highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 4 staff (#s 9, 17, 18 and 19) reviewed for training. This placed residents at risk for lack of care by competent staff. Findings include:

On 1/9/23 at 9:43 AM Staff 24 (Assistant administrator/HR) was asked to provide completed documentation of a competency checklist for Staff 9, Staff 17, Staff 18, and Staff 24. Employee paperwork provided for these employee's did not include a competency checklist of any kind.

On 1/9/23 at 12:39 PM Staff 3 (Assistant DNS) stated no checklist for skills had been completed.

Based on interview and record review it was determined the facility failed to ensure a RN served as the charge nurse no less than eight consecutive hours each day for 25 of 27 days reviewed for RN staffing. This placed residents at risk for unassessed and unmet care needs. Findings include:

The Direct Care Staff Daily Report revealed between 11/15/22 through 12/12/22 an RN was on duty twice (11/20/22 and 11/123/22) for a minimum of eight consecutive hours.

On 1/3/22 at 12:58 PM Staff 2 (DNS) acknowledged 25 days between 11/15/22 through 12/12/22 there was not an RN on duty working as the charge nurse.

, Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 9, 17, 18, 19) reviewed for training. This placed residents at risk for a lack of competent staff. Findings include:

On 1/9/23 at 9:43 AM Staff 24 (Assistant administrator/HR) was asked to provide completed documentation of an annual performance review for Staff 9, Staff 17, Staff 18, and Staff 24. Employee paperwork provided for these employee's did not include a performance review of any kind.

On 1/10/23 at 11:28 AM Staff 1 (Administrator), staff 2 (DNS), and staff 3 (Assistant DNS) could not verify or provide documentation of annual performance reviews.

Based on interview and record review the facility failed to ensure facility staff had the appropriate competencies to work with residents with mental and psychosocial disorders for 4 of 4 sampled residents (#s 9, 17, 18, 19) reviewed for training. This placed residents at risk for diminished physical, mental, and psychosocial well-being. Findings include:

On 1/10/23 at 11:10 AM Staff 37 (Unit coordinator) stated the only orientation staff received was in the "blue packet" and the employee handbook. Staff 37 stated behavioral health training did not occur at orientation, it was performed at monthly all staff meetings.

A review of all In-services between 4/2022 and 1/2023 revealed no behavioral health training was completed.

On 1/10/23 Staff 1 (Administrator) confirmed there were no other in-services completed between 4/2022 and 1/2023.

Based on observation and interview it was determined the facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service for 2 of 3 meals observed for dining. This placed residents at risk of being served luke-warm food on disposable tableware. Findings include:

1. On 12/22/22 at 7:55 AM Staff 41 (CNA) was observed to take a food tray with a styrofoam clamshell container on it to the resident in room 206b.

On 12/22/22 at 8:43 AM Staff 41 was observed to take food on a paper plate to a resident in the 200 hall.

On 12/22/22 at 7:55 AM Staff 41 verified the food was in a disposable styrofoam container and not a normal plate and stated she did not know why as the resident had no medical reason for disposable items.

On 12/22/22 at 7:57 AM Staff 8 (LPN) stated someone from the kitchen called and told him some meals would be delivered on disposable items instead of normal plates but did not state why.

On 12/22/22 at 7:59 AM and 10:45 AM Staff 3 (LPN, Assistant DNS) stated previously using disposable dishware was a constant problem but now only happened randomly. Staff 3 stated there was a "huge turnover" in the kitchen, confirmed the kitchen staff utilized the disposable items because they had no dishwasher (staff) and were short staffed.

On 12/22/22 at 9:05 AM Staff 42 (Assistant Dietary Manager) stated that morning she had no cook or dishwasher and had trouble with call-in's which was why she used styrofoam and paper plates for the breakfast meal.

On 12/28/22 at 10:15 AM Resident 3 stated her/his food was cold and often served on paper plates.

2. On 12/29/22 at 8:45 AM and 9:00 AM all residents in the common dining room were observed to have their food on disposable, styrofoam clamshells.

On 12/29/22 Staff 43 (Dietary Manager) stated she did not make the decision to serve the meals on the disposable styrofoam clamshells, the 5:00 AM dishwasher called in and it was a panic decision from the morning staff. Staff 43 verified breakfast should have been served on regular dishware.

Based on interview and record review it was determined the facility to accurately document in the resident medical records for 3 of 6 sampled residents (#s 3, 4 and 5) reviewed for skin conditions and hospice. This placed residents at risk for inaccurate wound assessments and being uniformed of CNA staffing. Findings include:

1. Resident 3 admitted to the facility in 2020 with diagnoses including a chronic Stage 4 pressure ulcer.

Resident 3's Weekly Skin evaluations revealed the following wound measurements:
*8/5/22: 0.5 cm x 0.5 cm x 0
*8/12/22: 3 cm x 5 cm x 0.5 cm
*8/19/22: 33.5 cm x 5 cm x 0.5 cm
*8/26/22: 33.5 cm x 5 cm x 0.5 cm
*9/2/22: 33.5 cm x 5 cm x 0.5 cm

On 12/28/22 at 9:12 AM Staff 1 (Administrator) and Staff 2 (DNS) verified the 8/19/22, 8/26/22 and 9/2/22 wound measurements were inaccurate.

2. Resident 4 admitted to the facility in 3/2022 with diagnoses including heart failure and dementia.

The 9/30/22 Weekly Skin Evaluation revealed the following skin issues:
*Right antecubital bruising
*Left antecubital bruising
*Right thigh front skin tear
*Right thigh rear skin tear
*Right lower leg front skin tear
*Left knee front bruising, scab
*Left lower leg front skin tear

The 10/6/22 Weekly Skin Evaluation revealed the following skin issues:
*Right antecubital blister [bruising previous assessment]
*Left antecubital blister [bruising previous assessment]
*Right thigh front blister [skin tear previous assessment]
*Right thigh rear blister [skin tear previous assessment]
*Right lower leg front blister [skin tear previous assessment]
*Left lower leg front blister [skin tear previous assessment]
*All skin issues above documented as "unstageable" -

On 12/28/22 at 9:26 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS) acknowledged the 10/6/22 Skin Evaluations were not accurate and should have not been marked unstageable.

3. Resident 5 admitted to the facility in 2022 with diagnoses including heart failure.

The 3/21/22 Discharge Summary note indicated the funeral home picked the resident up.

There was no evidence in Resident 5's medical record she/he had passed away including her/his condition prior to her/his death.

On 1/4/23 at 11:53 AM Staff 2 (DNS) verified Resident 5's medical record was incomplete.

Based on interview and record review it was determined the facility failed to implement and maintain an effective, comprehensive, data-driven QAPI program for 1 of 1 QAPI committees reviewed for QA. This placed residents at risk for elopement, unmet care needs, decreased quality of life and lack of resident choice. Findings include:

The 10/21/22 State Operations Manual, Appendix PP, directs the facility to make a good faith attempt to correct an identified quality deficiency. The facility must do more than subjectively assert it made a good faith attempt but rather, the facility's actions, taken as a whole, must evidence a good faith attempt to identify and correct quality deficiencies.

The 3/28/22 Annual Survey identified a resident elopement as an immediate jeopardy situation.

The 4/21/22 QAPI meeting notes revealed the QAPI team discussed the 3/28/22 Survey results. No other discussion or plan was documented related to elopement.

The 7/21/22 QAPI meeting notes revealed a review of weekly elopement audits were completed to ensure the elopements were reported as necessary and monthly audits of residents who were at risk for elopement to ensure interventions were in place to prevent elopement.

The 10/20/22 QAPI meeting notes revealed a review of the monthly audits of residents who were at risk for elopement to ensure interventions were in place to prevent elopement. Audits revealed not all resident care plans were up to date. The Administrator's report revealed audits of elopements were completed to ensure they were reported as necessary. Two elopements (Resident 20 and Resident 21) occurred and were reported. The recommendation was to discontinue further auditing the following month.

A review of the facilities QAPI meeting notes revealed no formal action plan for resident elopement.

Resident 9 eloped from the facility on 11/17/22, 12/12/22 and 12/27/22. On 12/12/22 and 12/27/22 which was identified as an immediate jeopardy situation.

There was no evidence the QAPI team met after Resident 9's elopement.

Review of facility records revealed the facility failed to collect relevant data and monitor their system for resident elopement. There was no evidence the facility made a food faith effort to correct the identified deficiency related to elopement from the 3/28/22 Annual Survey.

On 1/9/23 at 1:30 PM Staff 39 (anonymous QAPI member) stated the follow-up to identified concerns was a mess as they were mentioned in "title" but the team did not analyze the collected data.

On 1/10/23 at 8:27 AM Staff 40 (anonymous QAPI member) stated much of the QAPI meeting conversations went over her/his head and she/he did not understand much of the conversation. Staff 40 was unable to explain the QAPI process for reviewing identified concerns, stated the QAPI team "could do better" at monitoring and analyzing the data brought to the team and stated communication was a problem.

On 11/10/23 at 11:30 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS) were interviewed for QAPI. Staff 1 stated she considered the POC (plan of correction) for the 3/28/22 Annual Survey to be the Action Plan. Staff 1 acknowledged while resident elopement had been reviewed in QAPI since the 3/28/22 survey, resident elopement had not been corrected and further stated she did not know if the facility would ever stop people from eloping. Staff 1, Staff 2 and Staff 3 confirmed a formal QAPI meeting was not held after any of Resident 9's facility elopements. Staff 1 confirmed the goals from the facility audits changed each quarter and acknowledged no long-term goals related to the prevention of elopement were in place. Staff 1 stated, "Our good faith effort is we tried to keep [her/him] from eloping but it was not successful."

Refer to F867

Based on interview and record review it was determined the facility failed to correct and monitor a quality deficiency identified on the previous survey related to resident elopement and to respond to adverse events timely. This failure was determined to be an immediate jeopardy situation because the facility failed to prevent Resident 9's elopement from the facility three times since the 10/20/22 QAPI committee meeting. Findings Include:

The 10/21/22 State Operations Manual, Appendix PP instructs facilities to create a formal action plan for identified deficiencies which included determining contribution causes of the problem; measurable goals, step by step interventions to correct the problem and achieve stable goals, and a description of how the QAPI committee would monitor the concern to ensure changes yield the expected results.

The 3/28/22 Annual Survey identified a resident elopement as an immediate jeopardy situation.

The 4/21/22 QAPI meeting notes revealed the QAPI team discussed the 3/28/22 Survey results. No other discussion or plan was documented related to elopement.

The 7/21/22 QAPI meeting notes revealed a review of weekly elopement audits were completed to ensure the elopements were reported as necessary and monthly audits of residents who were at risk for elopement to ensure interventions were in place to prevent elopement.

The 10/20/22 QAPI meeting notes revealed a review of the monthly audits of residents who were at risk for elopement to ensure interventions were in place to prevent elopement. Audits revealed not all resident care plans were up to date. The Administrator's report revealed audits of elopements were completed to ensure they were reported as necessary. Two elopements (Resident 20 and Resident 21) occurred and were reported. The recommendation was to discontinue further auditing the following month.

A review of the facilities QAPI meeting notes revealed no formal action plan for resident elopement.

Resident 9 eloped from the facility on 11/17/22, 12/12/22 and 12/27/22. On 12/12/22 and 12/27/22 Resident 9 was found on Weathers street heading toward Lancaster Road which is a highly congested four lane road. There is no crosswalk at the intersection of Weathers and Lancaster and both roads offer minimal lighting. The resident was walking outside, inappropriately dressed, in the winter weather late at night. The resident's goal was to walk the 0.6 miles to Fred Meyer to obtain rocky road ice cream although she/he was aware she/he did not have any money. Resident 9's elopement from the facility on 11/17/22, 12/12/22 and 12/27/22 was identified as an immediate jeopardy situation.

There was no evidence the QAPI team met after Resident 9's elopement.

There was no evidence the facility made a good faith effort to correct the identified deficiency related to elopement from the 3/28/22 Annual Survey.

Review of facility records revealed the facility failed to collect relevant data and monitor their system for resident elopement. This resulted in a lack of adequate action to correct the systemic high risk issue which created a situation where residents were likely to experience serious injury, harm or death.

On 1/9/23 at 1:30 PM Staff 39 (anonymous QAPI member) stated the follow-up to identified concerns was a mess as they were mentioned in "title" but the QAPI team did not analyze the data which was collected.

On 1/10/23 at 8:27 AM Staff 40 (anonymous QAPI member) stated much of the QAPI meeting conversations went over her/his head and she/he did not understand much of the conversation. Staff 40 was unable to explain the QAPI process for reviewing identified concerns, stated the QAPI team "could do better" at monitoring and analyzing the data brought to the team and stated communication was a problem.

On 11/10/23 at 11:30 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (LPN, Assistant DNS) were interviewed for QAPI. Staff 1 stated she considered the POC (plan of correction) for the 3/28/22 Annual Survey to be the Action Plan. Staff 1 acknowledged while resident elopement had been reviewed in QAPI since the 3/28/22 survey, resident elopement had not been corrected and further stated she did not know if the facility would ever stop people from eloping. Staff 1 stated the facility was trying to ensure there was no bad outcome, the focus was to prevent harm and the prevention of resident elopement "might not be ever 100%." Staff 1 acknowledged the QAPI committee may meet quarterly, monthly or as needed. Staff 1 and Staff 3 did not answer what would trigger an as need QAPI meeting. Staff 1, Staff 2 and Staff 3 confirmed a formal QAPI meeting was not held after any of Resident 9's facility elopements. Staff 1 confirmed the goals from the facilty audits changed each quarter and included both reporting elopements, adding moderate elopement risk residents to the Code Green book and ensuring care plan interventions were in place to prevent elopements. Staff 1 acknowledged no long-term goals related to the prevention of elopement were in place.

On 1/10/23 at 1:55 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested.

On 1/10/23 at 3:37 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation.

The immediacy removal plan included the following:
*A formal action plan would be developed and implemented by the QAPI team to include: contributing causes of the problem, measurable goals, step by step interventions to correct the problem, achieve stable goals and description of how the QAPI committee would monitor to ensure changes yield the expected results.
*All residents who are at risk for elopement have a potential to be affected by this.
*QAPI team would received education on the formal action plan.
*Education would begin on 1/1/23 and would be completed by 1/11/23 at 3:00 PM or upon return if on leave of absence prior to working with residents.
*Random weekly audits of the action plan would be done to ensure that relevant data was collected and the elopement system was being followed for 30 days. The audits would continue monthly until next QAPI meeting. Results of the audits would be reviewed by the QAPI team at the time to determine if further auditing was necessary.

On 1/11/23 from 12:15 PM through 1/11/23 at 1:06 PM staff interviews were completed which verified re-education per the immediacy removal plan was completed. A review of facility documentation revealed all aspects of the immediacy removal plan was implemented.

On 1/11/23 PM at 1:08 it was determined the IJ situation was abated.

Based on observation and interview it was determined the facility failed to follow standard infection control guidelines for 3 of 3 random observations of infection control. This placed residents at risk for cross-contamination and respiratory illness. Findings include:

1. a. On 12/13/22 at 12:30 PM the surveyor entered the building and observed Staff 8 (LPN) to sit at the nursing station with his face mask below his chin. Staff 8 verified he did not wear the face mask correctly.

b. On 12/13/22 at 12:33 AM Staff 11 (CNA) was observed to wear her face mask over her mouth but under her nose. Staff 11 verified the face mask was did not cover her nose and corrected the placement of the mask.

2. On 12/19/22 at 2:35 PM Staff 44 (Housekeeper) was observed to bring the entire housekeeping cart into resident room 205.

On 12/19/22 at 2:37 PM Staff 44 stated she took the housekeeping cart into room 205 "to clean it" and proceeded to enter resident room 202 and take the cart inside that room. [Cart was not cleaned between rooms.]

Based on interview and record review the facility failed to ensure staff had the appropriate compliance and ethics training prior to working independently for 4 of 4 sampled staff (#s 9, 17, 18, 19) reviewed for training. This placed residents at risk for non-compliant and unethical treatment. Findings include:

On 1/9/23 a review of the facility's new employee packet and employee handbook did not indicate there was any compliance and ethics training at orientation.

On 1/10/23 at 11:10 AM Staff 37 (Unit Coordinator) stated the only orientation staff received was in the "blue packet" and the employee handbook. Staff 37 stated any training that did not occur at orientation was performed at monthly all-staff meetings.

On 1/10/23 at 11:28 AM Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Assistant DNS) confirmed compliance and ethics training had been added to the in-service schedule but had not been completed.

Based on interview and record review it was determined the facility failed to ensure a RN served as the charge nurse no less than eight consecutive hours between day and evening shift for 25 of 27 days reviewed for RN staffing. This placed residents at risk for unassessed and unmet care needs. Findings include:

The Direct Care Staff Daily Report revealed between 11/15/22 through 12/12/22 a RN was on duty twice (11/20/22 and 11/23/22) for a minimum of eight consecutive hours between day and evening shifts.

On 1/3/22 at 12:58 PM Staff 2 (DNS) acknowledged 25 days between 11/15/22 through 12/12/22 there was not an RN on duty working as the charge nurse.

Based on interview and record review it was determined the facility failed to ensure the state minimum CNA staffing ratios were maintained for 27 of 48 days reviewed for staffing. This placed residents at risk for a delay in care and unmet care needs. Findings include:

The 10/13/22 Resident Council Notes revealed resident concerns of lengthy call light times.

A review of the Direct Care Staff Daily Report (DCSDR) revealed between 11/15/22 through 12/12/22 six shifts over five days the facility did not maintain the state minimum staffing ratio on the following dates:

November: 24, 25-27, 30

A review of the DCSDR from 11/15/22 through 1/2/23 revealed 27 days out of 48 days reviewed when the facilty did not maintain the State minimum bariatric CNA staffing ratio for the following dates:

November 2022: 18-27, 30
December 2022: 1-4, 13, 16-17, 22-25, 28, 30-31
January 2023: 1-2

On 1/3/23 at 12:58 PM Staff 2 (DNS) acknowledged the facility did not meet the state minimum staffing ratios for five days between 11/15/22 through 12/12/22 on the following dates:

On 1/3/23 at at 2:08 PM Staff 1 (Administrator) acknowledged the failure to meet the state minimum bariatric CNA staffing ratios for the 27 of 48 days reviewed between 11/15/22 through 1/2/23.

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing ratios were maintained for 27 of the 48 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

On 1/3/23, the facility had nine residents approved for the bariatric rate.

A review of the Direct Care Staff Daily Reports from 11/15/22 through 1/2/23 revealed the following days when one or more shifts did not meet the state minimum bariatric CNA staffing ratios on the following dates:

November 2022: 18-27, 30
December 2022: 1-4, 13, 16-17, 22-25, 28, 30-31
January 2023: 1-2

On 1/3/23 at at 2:08 PM Staff 1 (Administrator) acknowledged the failure to meet the state minimum bariatric CNA staffing ratios for the identified dates.

************************
OAR 411-085-0310 Residents' Rights: Generally

Refer to F552
************************

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 F636
***********************

OAR411-086-0110 Nursing Services: Resident Care

Refer to F684
***********************

OAR411-086-0140 Nursing Services: Problem Resolution & Prevntative Care

Refer to F686, 689 and 690
***********************

OAR 411-086-0100 Nursing Services: Staffing

Refer to F726 and F727
***********************

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

Refer to F730 and F946
***********************

OAR 411-086-0240 Social Services

Refer to F741
***********************

OAR 411-086-0250 Dietary Services

Refer to F802
***********************

OAR 411-086-0300 Clinical Records

Refer to F842
**********************

OAR 411-085-0220 Quality Assurance

Refer to F865 and F867
**********************

OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880
**********************

Based on interview and record review, the facility failed to develop and implement influenza vaccine program for 1 of 5 sampled residents (R)(R52) reviewed for influenza immunizations when there was no documented evidence that R52 was offered, screened or provided education on risks and benefits for influenza vaccine. R52 did not receive influenza vaccine. These failures increased resident's risks for contracting pneumonia and flu with its associated complications.

Findings include


Resident 52

Review of records showed R52 was admitted on 1/31/22, was almost 90 years old with diagnosis including chronic atrial fibrillation (abnormal heart rhythm). There was no documented evidence that R58 received influenza vaccine, nor was there documented evidence that R52 was offered, screened or provided education on risks and benefits for influenza vaccine.

During concurrent record review and interview on 5/3/22 at 9:57 AM when asked about documentation of influenza screening and offering vaccine, Director of Nursing (DON) reviewed facility electronic medical record system and stated that only tuberculosis skin testing was documented. DON then accessed state ALERT system and provided document, ALERT Immunization Information System for R52, dated 5/3/22, which showed under "Vaccines Recommended by Selected Tracking Schedule" that influenza had a "past due date" of 12/31/2021. DON stated that the facility practice was for RCM (Resident Care Manager) to review resident files and offer any needed vaccines, but this was not done because of staffing issues and lack of RCMs. DON confirmed there was no documented evidence that the facility offered or discussed influenza vaccination with the resident. DON further stated the staffing issues with the RCMs started last year and when resident was admitted in January 2022 (flu season) the resident should have been screened and offered flu vaccination but this was not done.

During an interview on 5/3/22 at 2:11 PM Staff Development Coordinator, who also was facility's Infection Preventionist, (SDC/IP) stated that facility was in the midst of covid outbreak when R52 was admitted so it was super busy and probably got overlooked, but also acknowledged that it's been five months since resident was admitted and by this time resident should have been screened/offered vaccine but this had not happened yet. SDC/IP and Administrator looked for written influenza policy for resident screening and education on risks and benefits but was not able to locate policy. SDC/IP stated that it is facility's expectation and processes for all residents to be screened for immunizations, including influenza, upon admission with education of risks and benefits as part of offering vaccinations.

Based on observation, interview and record review the facility failed to ensure implementation of their healthcare staff vaccination policy when additional precautions were not implemented for 6 of 6 covid unvaccinated staff (S) (S1, S2, S3, S4, S5 and S6) with non-medical exemptions. The additional precautions were intended to mitigate the transmission and spread of COVID-19. This failure created the potential for increased risk for SARS-CoV-2 exposure and COVID-19 infection for staff and residents.

Findings include:


During an interview on 5/2/22 at 10:55 AM when entering the facility, Assistant Administrator stated that the facility census was 60 and there were no known or suspected covid cases.

Review of facility's Staff Vaccination Policy, dated 12/30/21, showed "[Name of facility] strives to have all staff be fully vaccinated ....All staff who provide direct resident care, or who have the potential for direct or indirect exposure to residents were required to be fully vaccinated by October 18, 2021 or have submitted a qualified exemption form ....Testing will be required as recommended by Marion County (county facility was located in), if a person with exemption is testing more frequently that what the fully vaccinated staff are testing, it is their responsibility to notify the Administrator of results, either positive or negative ..."

During a concurrent interview and record review on 5/2/22 at about 3:00 PM Administrator stated that facility has not done any covid testing since 2/24/22 when the county told them it was no longer necessary because their vaccination rates were high and their covid numbers were so low. Review of document, undated, provided by Administrator showed "Attached is how I was tracking county positivity before 9/10/21. We continued to test weekly as we were on Executive Order from 8/11/21-11/16/21. We then went on Executive Order again on 12/29/21-2/22/22. Our last all staff testing was on 2/24/22 when we finished our outbreak with the county. At that time, they told us the numbers were so low and our vaccination rates were high so we didn't need to continue routine testing. They just recommended testing for symptoms." Attachment titled Positivity rate for Marion county from CMS.GOV website showed three columns with column heading of "date", "positivity rate" and "test frequency". The document showed the last date with positivity rate and test frequency was 8/18/2021. Administrator further stated that county contact was County 1.

On 5/2/22 at 3:13 PM and 3:16 PM phone calls were made to County 1 and County 1 manager, a message was left for County 1 manager with request for call back. No call back was received as of 5/3/22 5:32 PM.


Review of facility's COVID-19 Staff Vaccination Status for Providers, received on 5/2/22, showed 213 total staff. Of 213 staff, 207 were completely vaccinated and 6 were granted non-medical exemptions; therefore, the facility had 100% staff vaccination rate.

S4

Review of facility's response to Staff (S)4's request for non-medical exemption, dated 9/20/21, documented exemption was approved and showed "you may be required by your employer or other responsible party to take additional steps to protect you and others from contracting and spreading COVID-19."

During a face-to-face interview on 5/2/22 at 4:58 PM S4 stated they worked full time as certified nursing aide at the facility and had never received any covid vaccine doses/boosters and had tested positive for covid at the very beginning of January 2022. S4 was wearing a surgical face mask. S4 was not wearing a N95 mask or eye protection such as face shield or goggles. When asked if there was any difference in PPE (personal protective equipment), frequency of testing or work assignment because staff was unvaccinated, S4 shook head and stated there was no extra precautions or PPE for unvaccinated staff. If a resident was in isolation, a N95 mask needed to be worn over surgical face mask and face shield was worn. When asked about covid testing, S4 stated that they had a positive covid test at the beginning of January so have two more weeks before can do any covid testing.

Facility provided document showing that S4's positive covid test was on 1/4/22; therefore 90 days ended on 4/4/22 and S4 would have been eligible to resume covid testing again on 4/4/22.

Observation on 5/2/22 at 5:00 PM showed S4 providing cares to resident within six feet of unmasked residents while S4 wore surgical face mask and no other PPE (personal protection equipment such as N95 mask, face shield/goggles, gown).

S5

Review of facility's response to Staff (S)5's request for non-medical exemption, dated 9/15/21, documented exemption was approved and showed "you may be required by your employer or other responsible party to take additional steps to protect you and others from contracting and spreading COVID-19."

During a face-to-face interview on 5/2/22 at 5:55 PM S5 stated they worked full time as licensed nurse at the facility and had never received any covid vaccine doses/boosters and had tested positive for covid twice with the most recent positive test before Thanksgiving. S5 was wearing a surgical face mask. S5 was not wearing a N95 mask or eye protection such as face shield or goggles. When asked if there was any difference in PPE (personal protective equipment), frequency of testing or work assignment because staff was unvaccinated, S5 shook head and stated a long time ago unvaccinated staff was tested twice a week and vaccinated staff were tested once a week but there has been no covid testing right now. S5 stated that the last covid testing was done at the end of last year, maybe December. S5 further stated that N95 and face shield/goggles are used if resident was in isolation but this type of PPE was required of all staff, both vaccinated and unvaccinated. S5 stated that work assignment continues to be passing medications, performing treatments, blood sugar checks and providing direct resident care.

S2

Review of facility's response to Staff (S)2's request for non-medical exemption, dated 9/15/21, documented exemption was approved and showed "you may be required by your employer or other responsible party to take additional steps to protect you and others from contracting and spreading COVID-19."

During a face-to-face interview on 5/2/22 at 6:05 PM S2 stated they worked about 12 hours a week as a certified nursing aide at the facility and had never received any covid vaccine doses/boosters and had tested positive for covid twice with the most recent positive test around Christmas. S2 was wearing a surgical face mask. S2 was not wearing a N95 mask or eye protection such as face shield or goggles. When asked if there was any difference in PPE (personal protective equipment), frequency of testing or work assignment because staff was unvaccinated, S2 shook head and stated they did not need to wear N95 mask, face shield or do any extra covid testing. S2 stated that there was no change in work assignment and no one told me that I had to take any extra precautions. Maybe I didn't get the message but nothing that I know of.

S1

Review of facility's response to Staff (S)1's request for non-medical exemption, dated 9/16/21, documented exemption was approved and showed "you may be required by your employer or other responsible party to take additional steps to protect you and others from contracting and spreading COVID-19."

During a face-to-face interview on 5/2/22 at 6:10 PM S1 stated they worked full time as licensed nurse at the facility and had never received any covid vaccine doses/boosters and had tested positive for covid at the very beginning of January 2022. S1 was wearing a cloth and surgical face mask. S1 was not wearing a N95 mask or eye protection such as face shield or goggles. When asked if there was any difference in PPE (personal protective equipment), frequency of testing or work assignment because staff was unvaccinated, S1 shook head and stated all staff were the same and had to wear a mask, everyone wears a mask. S1 stated there was extra covid testing for awhile and as unvaccinated staff, they had to test twice a week but testing hasn't happened for awhile. S1 stated that N95 mask and face shield/goggles were worn if resident needed precautions because resident was positive or symptomatic with covid, but that was required of all staff and not just staff that was unvaccinated.

During a concurrent record review and interview on 5/3/22 at 11:09 AM Administrator stated that all staff, both vaccinated and unvaccinated staff (S1, S2, S3, S4, S5, S6), have not been covid tested since 2/24/22 per discussion with county, as stated earlier. Administrator stated that statement on facility's response to staff request for non-medical exemption that read "you may be required by your employer or other responsible party to take additional steps to protect you and others from contracting and spreading COVID-19" referred to unvaccinated staff being covid tested twice weekly and fully vaccinated staff being covid tested once weekly. Administrator stated that facility's Staff Vaccination Policy also noted additional testing for unvaccinated staff as referenced in sentence "Testing will be required as recommended by Marion County (county facility was located in)". However, Administrator stated that she learned today after reviewing with surveyor Centers for Medicare and Medicaid Services (CMS) QS)-20-38-NH memo, revised date 03/10/2022, the facility should have been conducting routine covid testing based on level of the county's covid-19 community transmission and following this CMS memo which was not in alignment with county's advice. Review of CDC community transmission showed Marion county was at high level and therefore frequency of testing was indicated for twice a week testing for staff who are not up-to-date with covid vaccinations. Administrator stated twice week testing for staff not up-to-date will begin immediately and since extra precautions were indicated for unvaccinated staff with exemptions, the facility would likely not implement more frequent testing otherwise it would be more than twice weekly testing and instead look at additional PPE or other measures. Administrator stated that when the facility's policy was written the facility was experiencing a covid outbreak with unvaccinated staff being covid tested twice weekly and vaccinated staff once weekly but when the county said no routine testing was needed except when resident/staff was symptomatic, all testing for both vaccinated and unvaccinated staff stopped. Administrator stated that the county said no one, staff or residents, regardless of vaccination status, had to do any testing but the facility will follow QSO memo and implement additional precautions for unvaccinated exempted staff.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident's call light was answered timely for assistance to the restroom for 1 of 1 sampled resident (#259) during a random observation. This placed residents at risk for accidents. Findings include:

A 3/21/22 Progress Note indicated Resident 259's daughter expressed a concern that the weekend staff did not answer Resident 259's call light in a timely manner. Resident 259's daughter was told by another family member that while visiting Resident 259 they waited 20 minutes before trying to find a CNA to help Resident 259 to the bathroom. The CNA had responded "[she/he's] not my resident".

The following observations were made on 3/23/22 of Resident 259:
*9:39 AM Resident 259's call light was observed as initiated. Staff 41 (Activities) went into Resident 259's room and asked what the resident needed. Staff 41 was overheard telling Resident 259 she was not certified to help the resident with "that."
*9:43 AM Resident 259 told the surveyor she/he was waiting to go to bathroom. Resident 259 could not recall how long her/his call light had been initiated but stated it had been "awhile" and she/he really needed "to go."
*10:02 AM Resident 259 was observed rocking back and forth while repeating letters from the crossword puzzle on her/his side table "G, O, I, N." Resident 259 stated she/he really needed to use the restroom, and no one had assisted her/him. Resident 259 stated "this happens sometimes" when asked if she/he had to wait a long time for her/his call light to be answered by staff. Resident 259 further stated getting staff to help her/him to the bathroom was "difficult." Resident 259 stated a family member had visited the day previously and had to go find a staff member to assist her/him to use the restroom because the call light was not answered. Resident 259 stated waiting so long for assistance to use the restroom made her/him feel "miserable."
*10:16 AM multiple staff were observed walking by Resident 259's room without stopping to check on the resident.
*10:26 AM Resident 259 was heard repeatedly saying "I really have to pee", while pressing the call light button.
*10:28 AM the surveyor observed no staff down Resident 259's hallway but observed multiple staff members at the nurses' station a few feet from the resident's room. While walking back to Resident 259's room the resident was observed to have her/his hands on her/his pelvis area, rocking back and forth in her/his wheelchair stating, "I really hope someone comes soon."
*10:30 AM the surveyor went to the nurses' station to inform Staff 7 (LPN) that Resident 259 was observed waiting 50 minutes to use the restroom.
*10:32 AM Staff 7 and another staff member were observed to enter Resident 259's room and close the door.

On 3/23/22 at 10:35 AM Staff 7 (LPN) confirmed Resident 259 needed to use the restroom and acknowledged the long call light wait time.

Based on observation, interview and record review it was determined the facility failed to ensure a resident was assessed for safety prior to discontinuing use of a power wheelchair for 1 of 2 sampled residents (#14) reviewed for accommodation of needs. This placed residents at risk for decreased quality of life. Findings include:

Resident 14 admitted to the facility in 11/2018 with diagnoses including a stroke resulting in hemiparesis (paralysis of half the body).

The 11/30/21 Annual MDS indicated Resident 14 was moderately cognitively impaired, was totally dependent on staff for transfers and locomotion on and off the unit, and utilized a wheelchair for mobility.

On 3/14/22 at 1:55 PM and on 3/17/22 at 1:35 PM Resident 14 stated she/he wanted her/his power wheelchair to get up out of bed. There was no power wheelchair observed in the resident's room. Resident 14 stated the facility "took away" her/his power wheelchair about 10 months prior as the resident was "unsafe" and did not see well out of one eye. Resident 14 stated the facility did not assess her/him prior to taking away the power chair and she/he had requested an assessment back in February 2022 and had not heard back. Resident 14 stated she/he did not want to utilize a manual wheelchair because it took away her/his independence and now she/he did not want to get out of bed, which made her/him feel "sad."

A 3/17/20 Motorized Wheelchair Safety Test indicated the assessment was initiated for "unsafe incidents", however Resident 14 had adjusted speed and was not permitted outdoors alone. The assessment indicated Resident 14 had passed the safety test assessment and did well at low speed.

A 5/11/20 Progress Note indicated Resident 14 refused to get out of bed despite encouragement and wanted to drive her/his "chair." Resident 14 agreed to get out of bed when she/he was approved to drive the powerchair with a staff member present.

A 5/28/20 Progress Note indicated Resident 14 was to use a Geri Chair (medical reclining chair) only and Resident 14's family was to take home the resident's power wheelchair due to behaviors and safety concerns.

A 2/22/22 Progress Note indicated a physical/occupational therapy evaluation for deconditioning and power wheelchair assessment was requested for Resident 14.

There was no evidence in the medical record a safety assessment had been completed after 3/17/20 for Resident 14's motorized wheelchair use.

On 3/21/22 at 11:53 AM Staff 2 (DNS) stated Resident 14 did not utilize her/his motorized wheelchair since the resident's eye was "sewn shut" and was unable to recall when the resident's eye procedure occurred. Staff 2 confirmed there was no safety assessment related to Resident 14's motorized wheelchair since the 3/17/20 evaluation. Staff 2 stated the expectation was for an assessment to be completed to ensure the resident could safely utilize her/his motorized chair.

Based on interview and record review it was determined the facility failed to notify the physician timely for a change of condition and notify family for non-pressure skin issues for 2 of 5 sampled residents (#s 58 and 109) reviewed for hospitalization and non-pressure skin. This placed residents at risk for untimely treatment. Findings include:

1. Resident 58 was admitted to the facility in 2019 with diagnoses including chronic obstructive pulmonary disease (COPD) and anxiety disorder.

The 1/18/22 physician order indicated to obtain oxygen saturation level and utilize PRN oxygen to maintain oxygen saturation between 88-92% every four hours.

Resident 58's progress notes, MARs and Vital Sign Records indicated the following:
-2/2/22 7:08 AM oxygen saturation was 84%.
-2/2/22 8:00 AM oxygen saturation was 81%.
-2/2/22 8:35 AM oxygen saturation was 86%.
-2/2/22 5:59 PM oxygen saturation was 87%.
-2/2/22 8:26 PM oxygen saturation was 86%.
-2/3/22 12:50 AM oxygen saturation was between 80-86% and increased to 98%.
-2/3/22 8:51 AM oxygen saturation was 71% and increased to 81%.
-2/3/22 10:52 AM oxygen saturation was 81%.
-2/3/22 11:15 AM oxygen saturation was 71% will contact on call provider and leave note in provider's box regarding the resident.
-2/3/22 12:18 PM the resident began coughing up a scant amount of bright red blood into tissues and her/his oxygen saturation was 69% a message was left for the on-call provider for a 20 minute call back.
-2/3/22 1:05 PM (a late entry note) a call back was received from the on-call provider and staff were instructed to send Resident 58 to the hospital. Emergency services were contacted and the resident went to the hospital at approximately 12:55 PM on 2/3/22.

There was no indication in the residents clinical record to indicate the physician was notified of Resident 58's oxygen saturations below 88% until 2/3/22 at 11:15 AM.

On 3/25/22 at 10:10 AM Witness 6 (Nurse Practitioner) reviewed the findings and stated Resident 58 had an order to maintain oxygen saturations between 88-92% and the expectation was for staff to call the provider if oxygen saturations dropped below 88%. Witness 6 further stated staff did not notify the provider timely of Resident 58's change in condition and the expectation was for staff to have notified the provider the morning of 2/2/22.

On 3/25/22 at 11:04 AM Staff 43 (RN) stated she worked day shift on 2/2/22 and 2/3/22. Staff 43 stated she should have notified the physician on the morning of 2/2/22 after Resident 58's oxygen saturations dropped below 88%.

On 3/23/22 at 2:14 PM and 3/28/22 at 8:46 AM Staff 2 (DNS) stated Resident 58's physician order indicated to keep oxygen saturations between 88-92 %. Staff 2 stated the expectation was for staff to notify the physician within 30 minutes after a change in condition and the physician should have been notified on 2/2/22 after the resident's oxygen saturations did not increase at 8:35 AM.

2. Resident 109 admitted to the facility in 10/2020 with diagnoses including heart failure.

The 12/29/21 progress note indicated an order was received to "swab sore on back of head" with povidone-iodine until resolved.

There were no skin assessments or measurements of the sore on the resident's head in the electronic health record and no indication as to what type of sore or wound Resident 109 had.

There was no indication in Resident 109's clinical record to indicate her/his responsible party was notified of the sore/wound.

On 3/14/22 at 12:19 PM Witness 1 (Responsible Party) stated she was not notified of the sore on Resident 109's head.

On 3/28/22 at 8:49 AM Staff 2 (DNS) acknowledged there were no wound and skin assessments on 12/29/21 or afterward to indicate what type of wound she/he had on the back of her/his head. Staff 2 acknowledged Witness 1 was Resident 109's responsible party and was not notified.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect.
The facility failed to ensure resident assessments were completed and implemented, care plans were revised and reviewed timely, failed to assess and monitor pressure ulcers, failed to ensure there was coordination of care with hospice, failed to ensure residents received restorative aide therapy to prevent a physical decline, failed to implement therapy orders, failed to notify the physician timely for a change of condition, failed to follow physician orders, address skin conditions and assess change of condition, failed to ensure interventions were implemented and assessed to prevent falls, failed to ensure residents at risk for aspiration were supervised while eating, failed to ensure residents with dementia did not elope from the facility and failed to develop person-centered care plans, failed to adhere to professional standards, and failed implement an antibiotic stewardship. The cumulative effect of these failures in providing care and services contributed to an environment of neglect to 18 of 64 sampled residents (#s 2, 3, 9, 12, 14, 17, 18, 19, 22, 23, 24, 27, 58, 108, 109, 108, 159 and 258 ) reviewed for care and services. This placed residents at risk for neglect of care. Findings include:

According to the Centers for Medicare & Medicaid Services (CMS), §483.5, "Neglect," means "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress."

ASPIRATION

Resident 158

Resident 158 admitted on 2/2022 with diagnoses including sepsis, dementia and acute kidney failure.

The 2/18/22 hospital discharge diet orders indicated Resident 158 required 1:1 supervision with feeding.

The 2/18/22 RN Admission Progress Note indicated the resident was on a regular/pureed thin liquids diet. The note did not indicate Resident 158 was to receive 1:1 supervision with meals.

The revised 2/23/22 Admission care plan revealed there was no indication of the resident's diet or whether the resident required supervision with meals.

The meal monitoring from 2/27/22 through 3/27/22 revealed the resident had setup help only for all meals and twice the resident had one person physical assist.

On 3/14/22 at 11:42 AM observed Resident 158 alone in her/his room. No aspiration signage noted in resident's room.

On 3/15/22 at 3:20 PM Staff 53 (CNA) stated so often residents were not supervised while eating as there were "so many" Personal Care Assistants (PCAs) and there were not enough staff to monitor residents. Staff 53 stated management had been told "over and over" and believed this was a form of neglect. Staff 53 further stated the facility needed a system for which residents received thickened liquids. Staff 53 stated new staff were not educated on who required supervision or thickened liquids and Staff 53 had seen residents not supervised during meals or provided thickened liquids.

On 3/15/22 at 5:31 PM Staff 13 (PCA) delivered Resident 158's dinner tray to her/his bedside table. Resident 158 was left unattended with the meal and staff closed the door.

On 3/15/22 at 5:35 PM Resident 158 was observed eating independently in the room with no staff present.

On 3/15/22 at 5:36 PM Staff 13 acknowledged Resident 158 eating in her/his room independently and stated she/he ate independently and was not an aspiration risk.

On 3/15/22 at 5:41 PM Staff 7 (LPN) reviewed Resident 158's physician orders which indicated the resident was to be 1:1 supervision for meals. Staff 7 confirmed staff were not providing 1:1 supervision during meals and 1:1 meal supervision is not indicated on the resident's Kardex or care plan.

On 3/15/22 a request was made for the meal supervision policy. Staff 2 (DNS) stated the facility did not have a policy for meal supervision.

On 3/15/22 at 9:47 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during meals.

Refer to F689

RESIDENT ELOPEMENT

Resident 17

Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions and anxiety. Resident 17 admitted from a memory care unit.

The 12/10/22 Admission MDS indicated the resident was moderately cognitively impaired. The MDS did not indicate Resident 17 had wandering behaviors.

The Care Plan, last updated 12/28/21, did not indicate Resident 17 was an elopement risk.

The 12/14/21 Wandering Risk Assessment was not completed in full and categorized Resident 17 as a "Low Risk for Wandering."

Record review from 1/2022 through 3/2022 indicated Resident had wandering and exiting-seeking behaviors with documentation of behaviors starting on 1/15/22. The records indicated:
*1/25/22 Resident 17 was opening the facility door to head outside and was stopped by staff. Later that evening staff heard the 300-hall door alarm sound, and it was Resident 17 and staff redirected the resident back into the building.
*2/15/22 Call made to Resident 17's daughter to reinforce the resident is not safe in the building due to it not being a locked building.
*2/15/22 Resident 17 out in the parking lot attempting to get into a staff's vehicle.

The 2/15/22 Incident Investigation indicated on 2/15/22 at 12:20 PM Resident 17 was reported to be outside the facility in the parking lot next to a staff's car with the door open. Resident 17 kept insisting she/he was going to leave. Staff attempted to redirect the resident multiple times and finally after getting Staff 2 (DNS) the resident agreed to return to the facility. The conclusion indicated: Resident 17 had diagnoses of legal blindness, dementia with behavioral disturbance and visual hallucinations. "Able to redirect resident's behaviors. Staff will continue to check [Resident 17] and reorient as [she/he] is noted with confusion." There were no witness statements.

There was no documented evidence the facility analyzed the hazards and risks related to Resident 7's elopement, updated the care plan, or implemented new interventions to reduce the hazards and risk associated with her/his elopement.

On 3/14/22 at 4:37 PM Witness 1 (Family Member) stated she was informed the night prior by Staff 15 (Unit Clerk) that Resident 17 had wandered outside the facility because the exit door down the 100 hall was unlocked. Witness 1 stated Resident 17 was an elopement risk and had attempted to leave the facility multiple times due to her/his diagnoses and previously made it outside the facility and refused to come back in.

On 3/14/22 at 5:13 PM Staff 7 (LPN) stated on 3/13/22 the door down the 100 hall was left unlocked, but he was not aware of Resident 17 getting out of the building.

On 3/14/22 at 5:17 PM Staff 15 stated she was informed a couple nights prior that Resident 17 got out of the emergency exit down the 100 hall and was informed by "morning staff." Staff 15 was unable to recall who specifically informed her of the incident, but believed the incident occurred over the past weekend. Staff 15 was unsure how long the resident was out of the facility, but management was aware of the incident.

On 3/14/22 at 5:23 PM Staff 39 (CNA) stated Resident 17 was "always" exit seeking and had previously gotten out of the back door that residents used to go smoke. Staff 39 stated on Thursday (3/10/22) the resident had gotten outside, but Staff 39 saw the resident right away and redirected the resident back inside. Staff 39 stated a few weeks prior she was coming onto her shift and found Resident 17 outside in the parking lot. Staff 39 stated staff did not have the ability to stop the resident as she/he was "so quick" and if staff were caring for another resident, Resident 17 would "leave."

On 3/15/22 at 8:50 AM Resident 19 stated before Resident 44 moved rooms the resident would come into Resident 19's room, and she/he would have to tell Resident 44 to leave. Resident 19 further stated the week prior staff were unable to locate Resident 17, so they went through all the rooms looking for Resident 44 and found the resident in another resident's bathroom.

On 3/15/22 at 4:13 PM Staff 19 (Admissions) stated he was not aware Resident 17 was outside the facility but was informed by Witness 1 on 3/13/22 that the resident attempted to leave the facility that day due to the door down the 100-hall being unlocked. Staff 19 stated he reported the incident to Staff 1 (Administrator).

On 3/15/22 at 4:18 PM Staff 1 (Administrator) stated she was aware Resident 17 had left the facility previously but was not aware of Resident 17 recently leaving the facility out the 100-hall door as the door was "always locked."

On 3/15/22 at 4:44 PM Staff 26 (LPN) had wandering behaviors and liked to wander into other residents' rooms and all hallways. Staff 26 reported there were times staff could not find the resident and had to look throughout the facility for her/him.

On 3/15/22 at 8:11 PM Staff 28 (CNA) stated Resident 17 had wandering behaviors, including going into other residents' rooms and had nearly gotten out of the exit door down the 300-hall. Staff 28 stated Resident 17 would often go past the nurses' station, so staff would shut the fire doors to prevent the resident from leaving.

There was no investigation for the alleged incident Resident 17 left the facility during the month of 3/2022, until 3/24/22. The care plan did not indicate wandering and elopement behaviors or interventions. There was no updated assessment of Resident 17's wandering and elopement behaviors.

On 3/15/22 at 9:47 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified Resident 17's elopement and attempted elopements constituted an immediate jeopardy situation.

Refer to F689

RESIDENT ASSESSMENTS, CARE PLAN REVISION AND REVIEW

Resident 108

Resident 108 admitted to the facility on 2/24/22 with diagnoses including depression, anxiety and assistance with personal care.

An Admission MDS was initiated on 3/3/22 with an assessment reference dated 3/9/22. The MDS was noted to be still in process, 17 days overdue as of 3/18/22.

On 3/18/22 at 10:19 AM Staff 2 (DNS) confirmed the Admission MDS for Resident 108 was not completed and overdue.

F636

Resident 158

Resident 158 was admitted to the facility on 2/18/22 with diagnoses including dementia and congestive heart failure.
An Admission MDS was initiated on 2/25/22 with an assessment reference date of 3/3/22. The MDS was noted to be still in process, 29 days overdue as of 3/18/22.

On 3/18/22 at 10:19 AM Staff 2 (DNS) confirmed the Admission MDS for Resident 158 was not completed and overdue.

Refer to F636

Resident 258

Resident 258 admitted to the facility on 2/8/22 with diagnoses including cerebral palsy and depression.

Review of Resident 258's clinical record on 3/17/22 did not indicate an Admission MDS was completed.
On 3/18/22 at 10:19 AM Staff 2 (DNS) confirmed Resident 258's Admission MDS was not completed for the required time frame.

Refer to F636

Resident 17

a. Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions, and anxiety.

A 2/27/22 Admission note indicated Resident 17 re-admitted to the facility on hospice on 2/27/22 following a hospitalization.

Review of Resident 17's record indicated a Significant Change MDS was due 3/11/22 related to the resident admitting to hospice and had not been completed.

On 3/17/22 at 10:56 AM staff 2 (DNS) acknowledged Resident 17 admitted to hospice on 2/27/22 and a Significant Change MDS had not been completed.

b. The 12/3/21 Wandering Risk Assessment was incomplete but indicated Resident 17 was a "low risk" for wandering.

The Resident's Care Plan, last updated 2/22/22, did not include wandering behaviors or any interventions related to prevent wandering or elopement.

On 3/14/22 04:37 PM Witness 1 (Family Member) stated she Resident 17 was an elopement risk and had attempted to leave the facility multiple times due to her/his diagnoses.

On 3/14/22 at 5:23 PM Staff 39 (CNA) stated Resident 17 was "always" exit seeking, wandered into other residents' rooms, and had previously gotten out of the back door of the facility.

On 3/15/22 at 4:44 PM Staff 26 (LPN) had wandering behaviors and liked to wander into other residents' rooms and all hallways. Staff 26 reported there were times staff could not find the resident and had to look throughout the facility for her/him.

On 3/18/22 at 10:19 AM Staff 2 (DNS) acknowledged Resident 17's care plan did not include wandering behaviors or interventions to prevent wandering. Staff 2 stated all care plans were "in progress" and not updated for residents.

Refer to F637 and F657

Resident 3

Resident 3 admitted to the facility in 21018 with diagnoses including congestive heart failure and dementia.

A progress note dated 3/7/22 indicate Resident 3's identified significant change was on 2/28/22.

A Significant Change MDS was initiated with an assessment reference dated of 2/28/22. The MDS was noted to be still in process, 18 days overdue as of 3/18/22.

On 3/18/22 at 10:19 AM Staff 2 (DNS) confirmed the Significant Change MDS for Resident 3 was not completed and overdue.

Refer to F637

Resident 27

Resident 27 admitted to the facility in 2018 with diagnoses including aphasia and stroke.

An Observation on 3/15/22 at 11:57 AM of Resident 27 was made of staff delivering a lunch tray to the resident. At 12:00 PM Resident 27 was observed feeding himself with no staff present. The resident stated she/he fed her/himself and received no assistance or supervision from staff.

Resident 27's care plan dated 9/24/19 indicated she/he needed supervision for meals.

Resident 27's Kardex (in room care plan) indicated she/he required supervision with meals.

Review of the medical record indicate a Refusal to Follow Prescribed Diet Release form was completed. The form indicated Resident 27 did not want to follow the prescribe diet, including supervision with meals. The form was signed by the resident on 2/7/20.

On 3/18/22 at 10:19 AM Staff 2 (DNS) Resident 27's care plan was not updated to reflect the current diet and meal assistance preference.

Refer to F657

Resident 14

Resident 14 admitted to the facility in 11/20218 with diagnoses including a stroke resulting in hemiparesis (paralysis of half the body) and a hip fracture.

A 3/1/22 Encounter Note indicated Resident 17 had a right hip fracture in August 2020 and was experiencing increased pain.

On 3/14/22 at 1:55 PM Resident 14 stated her/his pain medications were "always" late and she/he often had pain in her/his hip.

Resident 14's care plan was last updated in 2019 and did include the resident sustaining a hip fracture with increased pain or interventions to improve the resident's pain.

On 3/17/22 at 2:07 PM and 3/18/22 at 10:19 AM Staff 2 (DNS) acknowledged Resident 14's care plan had not been updated since 2019 to include her/his hip fracture, which resulted in increased pain and required pain interventions. Staff 2 stated all resident care plans were in progress and not updated.

Refer to F657

ASSESSMENT AND MONITORING OF PRESSURE ULCERS

Resident 18

Resident 18 was admitted to the facility in 1/2021 with diagnoses including Alzheimer's disease and failure to thrive.

The 2/4/22 skin assessment indicated there were no new skin issues noted and there were current orders in place for known skin issues, will continue to monitor and hospice will continue to evaluate. The note did not indicate Resident 18's wound type or measurements of wounds.

The 12/22/21 physician order indicated to cleanse the wound on the right lateral foot with wound cleanser, pat dry, apply iodosorb and calcium alginate to wound bed, apply skin prep to surrounding skin and cover with foam dressing. Change three times per week and PRN for soilage or accidental removal. Hospice nurse to change on Monday and Thursday, facility nurse to change on Saturday [and PRN].

The 2/22 and 3/22 TARs indicated dressing changes were completed as ordered.

On 3/16/22 at 1:47 PM Staff 11 (RN) and Staff 43 (RN) indicated they were the treatment nurses for the entire facility on 3/16/22 and both staff were unaware Resident 18 had a pressure ulcer.

The 3/23/21 care plan indicated Resident 18 had a Stage 4 pressure ulcer to the coccyx. The care plan did not include information about Resident 18's pressure ulcer on the foot.

On 3/23/22 10:05 AM Witness 11 (Hospice RN) was observed to complete a dressing change for Resident 18. Witness 11 stated Resident 18 had a healed pressure ulcer to the coccyx but was still placing a dressing on the area for preventative care and a pressure ulcer on her/his right foot. The area was observed to be open and red. Witness 11 stated the pressure ulcer to the foot was red and had less slough than the week prior and it was improving.

On 3/24/22 at 10:34 AM Staff 2 (DNS) acknowledged Resident 18 had an open pressure ulcer to the right foot and there was no indication of the stage of the pressure ulcer, no assessments, no measurements and no facility weekly skin assessments for Resident 18's the pressure ulcer on the right foot. Staff 2 further acknowledged there were no hospice notes indicating the condition of the pressure ulcer.

Refer to F686

Resident 14

Resident 14 admitted to the facility in 11/20218 with diagnoses including a stroke resulting in hemiparesis (paralysis of half the body) and a hip fracture.

The 11/30/21 Annual MDS indicated the resident was moderately cognitively impaired and was coded as having one Stage II pressure ulcer that was not present upon admission.

Physician orders indicated:
*1/1/22: Clean bilateral buttock and right posterior thigh with soap and water; pat dry. Apply Aquaphor (topical ointment) every evening shift every three days.
*2/28/22: Right gluteal fold: Clean with normal saline. Apply barrier cream and cover.

Review of the 3/2022 TAR indicated wound treatments were completed as ordered.

Weekly Skin Evaluations were reviewed for 1/2022 through 3/2022 and indicated:
*1/30/22: Buttocks wound with no description, measurements, or staging. Summary indicated the wound had "improved and "current treatment in place."
*2/2/22: Right buttock, left buttock, left gluteal fold, and right gluteal fold wounds. No measurements or staging. The only description of all four wounds was "redness." The summary indicated orders on TAR to complete weekly skin check to monitor improvement. Barrier cream being applied.
*2/20/22: Right gluteal fold wound, no description, measurements or staging. Summary indicated the provider had been notified and orders were entered in the TAR for monitoring of the wound.
*3/2/22: Form left blank.

A 3/17/22 Shower Skin Sheet indicated the resident had a "sore in [her/his] left bottom." There was no other description of the wound or an assessment.

On 3/15/22 at 11:52 AM Resident 14 stated she/he had a pressure sore on her/his bottom and was unsure if it was healing. Resident 14 stated staff attempted to reposition her/him, but she/he often refused and had the sore for "forever." Resident 14 declined to have the surveyor nurse observe the wound.

On 3/21/22 at 11:57 AM Staff 2 (DNS) and stated facility treatment nurses were not completing wound assessments and acknowledged the multiple dates Resident 14's skin assessments were not completed or completed in full.

On 3/22/22 at 10:14 AM Witness 6 (Nurse Practitioner) stated she was unsure the status of Resident 14's buttocks wound.

Refer to F686

HOSPICE COORDINATION

Resident 17

Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions and anxiety.

The 12/10/22 Admission MDS indicated the resident was moderately cognitively impaired.

Resident 17 admitted to hospice on 2/27/22.

Resident 17 had PRN orders for:
*Haloperidol (antipsychotic medication) tablet 0.5 G every two hours PRN
*Lorazepam (antianxiety medication) tablet 0.5 MG every two hours PRN

The 3/2022 MAR indicated Haloperidol was administered nine times out of the 13 days reviewed.

Progress Notes reviewed from 2/1/2022 through 3/14/22 indicated Resident 17 had multiple behaviors including wandering, calling out, hallucinations, aggression, agitation, and exit seeking.

On 3/8/22 the surveyor requested hospice notes for the past 30 days for Resident 17.

On 3/21/22 at 12:58 PM Staff 1 (Administrator) stated hospice notes were not available in the record for Resident 17 and she had to request them.

On 3/18/22 at 9:11 AM Witness 3 (Hospice LPN) stated she was seeing Resident 17 that day to increase scheduled psychotropic medications and use less PRN ones. Witness 3 stated she had "a lot" of concerns regarding communication with the facility. Witness 3 stated "at times" the facility did not notify hospice about Resident 17's behaviors, including elopement. Witness 3 further stated she had issues with medication orders being sent to the facility, but the facility not putting them into the system. Witness 3 stated she was doing "a lot of education" for PRN medication as staff were underutilizing the medication but now were now "overusing" them.

On 3/21/22 at 3:33 PM Witness 2 (Hospice RN) stated she had concerns about medication orders and having to keep calling the facility to ensure they received the order. Witness 2 stated orders were at times not implemented until the next day. Witness 2 stated facility staff were not utilizing PRN psychotropic medications for Resident 17 until a "crisis point", and by then it was difficult to get the resident back to baseline.

On 3/28/22 at 12:40 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the communication concerns with hospice.

Refer to F689 and F744

Resident 18

Resident 18 was admitted to the facility in 1/2021 with diagnoses including Alzheimer's disease and failure to thrive.

The 2/4/22 skin assessment indicated there were no new skin issues noted and there were current orders in place for known skin issues, will continue to monitor and hospice will continue to evaluate. The note did not indicate Resident 18's wound type or measurements of wounds.

The 12/22/21 physician order indicated to cleanse the wound on the right lateral foot with wound cleanser, pat dry, apply iodosorb and calcium alginate to wound bed, apply skin prep to surrounding skin and cover with foam dressing. Change three times per week and PRN for soilage or accidental removal. Hospice nurse to change on Monday and Thursday, facility nurse to change on Saturday [and PRN].

On 3/16/22 at 1:47 PM Staff 11 (RN) and Staff 43 (RN) indicated they were the treatment nurses for the entire facility on 3/16/22 and both staff were unaware Resident 18 had a pressure ulcer.

The 3/23/21 care plan indicated Resident 18 had a Stage 4 pressure ulcer to the coccyx. The care plan did not include information about Resident 18's pressure ulcer on the foot.

On 3/23/22 10:05 AM Witness 11 (Hospice RN) was observed to complete a dressing change for Resident 18. Witness 11 stated Resident 18 had a healed pressure ulcer to the coccyx but was still placing a dressing on the area for preventative care and a pressure ulcer on her/his right foot. The area was observed to be open and red. Witness 11 stated the pressure ulcer to the foot was red and had less slough than the week prior and it was improving. Witness 11 further stated if changes needed to be made immediately, she communicated with different facility staff depending on who was working. Witness 11 stated she hand delivered hospice notes to the facility once a month and there was no process in place to ensure the facility received hospice notes timely after she visited the resident.

On 3/24/22 at 10:34 AM Staff 2 (DNS) acknowledged Resident 18 had an open pressure ulcer to the right foot and there was no indication of the stage of the pressure ulcer, no assessments, no measurements, and no facility weekly skin assessments for Resident 18's the pressure ulcer on the right foot. Staff 2 further acknowledged there were no hospice notes indicating the condition of the pressure ulcer.

Refer to F686

RESTORATIVE AIDE AND THERAPY

Resident 258

Resident 258 admitted to the facility on 2/8/22 with diagnoses including cerebral palsy and depression.

The 2/8/22 Care Plan indicated Resident 258 had contractures of her/his bilateral upper extremities related to cerebral palsy. Staff were instructed to provide a cloth/palm pad as needed to keep clean and prevent skin breakdown.

The 3/25/22 Admission MDS indicated Resident 258 was cognitively intact and was totally dependent on staff for transfers, eating, dressing, and bed mobility. The resident received zero days of range of motion (both active and passive) in the look-back period.

a. A 2/22/22 Physician Order instructed staff to place appropriately sized piece of foam into Resident 258's left hand one time a day for contracture.

Observations of Resident 258 from 3/14/22 through 3/17/22 did not reveal the resident with a piece of foam for her/his left-hand contracture.

On 3/16/22 at 1:56 PM Resident 258 was asked about the foam for her/his left hand. Resident 258 stated the foam did not fit, it fell out of her/his hand and was not the right size, so staff did not use the foam.

On 3/17/22 at 9:13 AM Staff 35 (Restorative Services/CNA) stated Resident 258 had a" foam grip" in her/his bedroom drawer.

On 3/17/22 at 9:16 AM Staff 35 and surveyor entered Resident 258's room. Staff 35 acknowledged Resident 258 did not have the foam grip or other intervention for the resident's left contracture and the foam grip was on the bedside table. Resident 258 stated the foam grip was too big. Staff 35 stated she would order a smaller one and was unsure how often the foam grip was to be used for the resident.

On 3/17/22 at 10:48 AM Staff 2 (DNS) acknowledged Resident 258 was not utilizing the ordered foam intervention as the device was not the correct size. Staff 2 stated resident care managers were expected to complete assessments for residents like 258 to ensure the resident had the correct size foam, but the facility did not currently have any resident care managers.

b. On 3/14/22 at 10:24 AM Resident 258 stated she did not receive physical therapy or restorative aid and had requested them. Resident 258 stated staff did not assist the resident with ROM. Resident's bilateral upper extremities were observed to be contracted.

On 3/17/22 at 9:13 AM and 9:16 AM Staff 35 (Restorative Services/CNA) stated no residents in the facility received RA for a year, as she was getting pulled to be a CNA in the beginning and now there was no resident care managers to oversee the program. Staff 35 stated residents "want me back." Staff 35 further stated the facility did not have any in-house physical or occupational therapists.

On 3/17/22 at 10:48 AM Staff 2 (DNS) confirmed there was no RA program for the facility and no residents had received RA since 5/2021. Staff 2 confirmed Staff 35 was working the floor as a CNA and stated there were no resident care managers to oversee the RA program.

Refer to F688

Resident 12

Resident 12 admitted to the facility in 8/2018 with diagnoses including ulcerative colitis (inflammatory bowel disease) and diabetes.

The 2/25/22 MDS indicated the resident was cognitively intact and was totally dependent on staff for transfers and required extensive assistance for bed mobility. The resident did not receive therapy or a restorative program was not performed during the look-back period.

On 3/14/22 at 11:20 AM Resident 12 stated the facility ceased physical therapy in March 2021, and no one had offered to assist the resident with ROM. Resident 12 was observed to have a resistance band on her/his bed and stated that CNAs were unable to do RA with residents, including assisting the resident to use the band. Resident 12 stated management was aware she/he wanted therapy and RA, but stated she/he would have to "tell them again."

A 3/15/22 Physician Encounter note indicated the resident had a diagnoses of generalized weakness. Per the resident's report someone came to the facility to evaluate the resident for therapy, but the provider was also asked to put in a referral. The summary indicated a Physical/Occupational Therapy home health order for the resident was needed for home health services based on the resident's clinical condition.

On 3/17/22 at 9:13 AM and 9:16 AM Staff 35 (Restorative Services/CNA) stated no residents in the facility received RA for a year, as she was getting pulled to be a CNA and now there was no resident care managers to oversee the program. Staff 35 stated residents "want me back." Staff 35 further stated the facility did not have any in-house physical or occupational therapists.

On 3/17/22 at 10:48 AM Staff 2 (DNS) confirmed there was no RA program for the facility and no residents had received RA since 5/2021. Staff 2 confirmed Staff 35 was working the floor as a CNA and stated there were no resident care managers to oversee the RA program currently.

Refer to F688

Resident 14

Resident 14 admitted to the facility in 11/2018 with diagnoses including a stroke resulting in hemi-paresis (paralysis of half the body) and a right hip fracture.

The 11/30/21 Annual MDS indicated Resident 14 was moderately cognitively impaired, and was totally dependent on staff for transfers and bed mobility. The resident did not receive therapy or a restorative program during the look-back period.

On 3/14/22 at 1:55 PM Resident 14 stated she/he wanted to receive RA, but there was not enough staff to help her/him do exercises.

The 3/2022 RNA (Restorative Nursing Aid) Ambulating Task Sheet indicated staff were to document how much time the resident spent practicing ambulating. The sheet was blank for the past 20 days reviewed.

A 3/14/22 Physician Encounter indicated Resident 14 had limited ROM and right sided weakness and staff were to perform passive range of motion right lower extremity (RLE) daily.

On 3/17/22 at 9:13 AM and 9:16 AM Staff 35 (Restorative Services/CNA) stated no residents in the facility received RA for a year, as she was getting pulled to be a CNA and now there was no RCMs to oversee the program. Staff 35 stated residents "want me back." Staff 35 further stated the facility did not have any in-house physical or occupational therapists.

On 3/17/22 at 10:48 AM Staff 2 (DNS) confirmed there was no RA program for the facility and no residents had received RA since 5/2021. Staff 2 confirmed Staff 35 was working the floor as a CNA and stated there were no RCMs to oversee the RA program currently.
Refer to F688

Resident 19

Resident 19 was admitted to the facility on 12/15/21 with diagnoses including hypertension.

The 12/15/21 admission orders indicated Resident 19 had referrals for physical therapy and occupational therapy.

The 2/1/22 physician order indicated physical therapy and occupational therapy were to evaluate and treat Resident 19.

The 3/15/22 progress note indicated the resident reported she/he had not yet started therapy.

On 3/15/22 at 8:33 AM Resident 19 stated she/he had orders for therapy and was frustrated she/he had not yet received therapy services.

On 3/22/22 at 10:08 AM Witness 6 (Nurse Practitioner) stated Resident 19 had orders for therapy in 12/2021 and 2/2022 and she/he had not yet received therapy. Witness 6 further stated the facility promised residents therapy but it either gets delayed or does not happen.

On 3/22/22 at 1:10 PM Staff 2 (DNS) acknowledged the resident 12/15/21 and 2/15/21 she stated the expectation was for the facility to refer to physical therapy and occupational therapy within 72 hours of the facility receiving the order. Staff 2 further stated a referral was made on 3/2/22 and was pending but as of 3/22/22 Resident 19 had not received physical or occupational therapy

Refer to F825

Resident 2

Resident 2 was admitted to the facility in 1/21 with diagnoses including stroke.

The 2/6/22 progress note indicated Resident 2 stated she/he would like to try and drink thin liquids again and requested speech therapy for dietary change. A request was sent to the provider.

The 2/25/22 physician order indicated Resident 2 was to receive a speech therapy evaluation for a swallow evaluation and treatment for recommendations for her/his diet.

The 3/18/22 provider note indicated Resident 2 was curious about when she/he could get a speech evaluation done and she/he would like to see if an improvement could be made to her/his food consistency.

On 3/22/22 at 10:08 AM Witness 6 (Nurse Practitioner) stated the facility promised residents therapy but it either gets delayed or does not happen.

On 3/25/22 at 6:26 PM Staff 2 (DNS) stated Resident 2 received a pureed diet and thickened liquids. Staff 2 further stated there was a 2/25/22 physician order for speech therapy but the resident had not yet received it.

Refer to F825

FOLLOWING PHYSICIAN ORDERS, ADDRESSING SKIN CONDITIONS AND ASSESSING A CHANGE OF CONDITION

Resident 58

Resident 58 was admitted to the facility in 2019 with diagnoses including chronic obstructive pulmonary disease (COPD) and anxiety disorder.

The 1/18/22 physician orders indicated to obtain oxygen saturation level and utilize PRN oxygen to maintain oxygen saturation between 88-92% every four hours.

The 2/2/22 7:08 AM progress note indicated Resident 58's oxygen saturation was 84% and the resident was on oxygen 3 liters per minute. Staff instructed that resident may be bumped up to 4 liters per minute and to recheck oxygen in 30-45 minutes.

The 2/2/22 MAR indicated Resident 58's oxygen saturation was 81% at 8:00 AM.

The 2/2/22 Vital Sign records indicated at 8:35 AM indicated Resident 58's oxygen saturation was 86%.

There was no indication in the resident's clinical record to indicate the physician was notified of Resident 58's oxygen saturations below 88%.

The 2/3/22 12:50 AM progress note indicated Resident 58 had shortness of breath at the start of the shift with oxygen saturations ranging between 80%-86%. The nurse assisted the resident with breathing techniques to lower rapid breathing and deepen inhalation resulting in resident becoming more relaxed and oxygen increasing to over 90%. Oxygen saturation was 98%. No fever present. Resident has been compliant with cares and isolation status. Sleeping comfortably at this time. Vital signs stable and within normal limits. Will continue to monitor.

The 2/3/22 8:51 AM progress note indicated Resident 58 oxygen saturation dropped to 71% on 4 liters of oxygen per minute via mask. Staff instructed to put oxygen up to 5 liters per minute via mask and assist resident with breathing techniques to help deepen breathing and reduce anxiety. Resident's oxygen saturations went up to 81%. Continue with breathing techniques and to monitor oxygen.

The 2/3/22 11:15 AM progress note indicated Resident 58's oxygen saturation was at 71% on 5 liters per minute via mask. Assist resident with deep breathing exercises. Will contact on-call provider and leave a note in provider's box regarding resident.

The 2/3/22 12:18 PM progress note indicated Resident 58 began coughing up a scant amount of bright red blood into tissues and her/his oxygen saturations were 69%. A message was left for on-call provider for a 20-minute call back.

The 2/3/22 1:05 PM progress note indicated the facility received a call back from the on-call provider was instructed to send Resident 58 to the hospital. Emergency services were contacted. They arrived and collected resident and left for Salem Hospital at approximately 12:55 on 2/3/22.

On 3/25/22 at 10:10 AM Witness 6 (Nurse Practitioner) reviewed the findings and stated Resident 58 had an order to maintain oxygen saturations between 88-92% and the expectation was for staff to call the provider if oxygen saturations dropped below 88%. Witness 6 further stated staff did not notify the provider timely of Resident 58's change in condition and the expectation was for staff to have notified the provider the morning of 2/2/22.

On 3/25/22 at 11:04 AM Staff 43 (RN) stated she worked day shift on 2/2/22 and 2/3/22. Staff 43 stated she should have notified the physician on the morning of 2/2/22 after Resident 58's oxygen saturations dropped below 88%.

On 3/23/22 at 2:14 PM and 3/28/22 at 8:46 AM Staff 2 (DNS) stated Resident 58's physician order indicated to keep oxygen saturations between 88-92 %. Staff 2 stated the expectation was for staff to notify the physician within 30 minutes after a change in condition and the physician should have been notified on 2/2/22 after the resident's oxygen saturations did not increase at 8:35 AM.

Refer to F684

Resident 109

Resident 109 admitted to the facility in 10/2020 with diagnoses including heart failure.

The 12/29/21 progress note indicated an order was received to swab sore on back of head with povidone-iodine until resolved.

The 1/2022 TAR indicated the resident did not receive wound treatment on 1/1/22.

The 1/3/22 progress note indicated wound care was provided to the sore on the back of the head the sore was drying out and resident reported less pain.

The 1/5/22 progress note indicated wound to head with no drainage, no open area and slightly raised. Area swabbed with povidine and iodine per order.

There were no skin assessments or measurements of the sore on the resident's head in the electronic health record and no indication as to what type of sore or wound was.

On 3/28/22 at 8:49 AM Staff 2 (DNS) acknowledged there was no initial wound and skin assessment on 12/29/21 and no ongoing skin assessments indicating the type, measurements and characteristics of the wound on the back of Resident 109's head. Staff 2 further acknowledged the treatment for povidone-iodine was not completed on 1/1/22.

Refer to F684

Resident 159

Resident 159 was admitted to the facility on 2/23/22 with diagnoses including heart failure.

a. The 2/23/22 skin evaluation indicated the resident had a rash to the groin and left gluteal fold. There were no measurements of the areas.

A review of the clinical record indicated there was no follow up skin evaluations or skin assessments completed after 2/23/22.

The resident discharged on 3/12/22. No skin assessments were completed prior to her/his discharge.

On 3/18/22 at 2:00 PM Staff 2 (DNS) acknowledged Resident 159 had no measurements to the rash to the groin and left gluteal fold. She further acknowledged there were no additional skin assessments prior to her/his discharge.

b. The 2/7/17 Policy for documentation and monitoring of intake and output (I and O) indicated residents who may be at risk for an imbalance in fluids or electrolytes and a comparison total for I and O may be used as part of the comprehensive assessment in residents at risk for these imbalances.

The 2/23/22 physician order indicated Resident 159 was to receive torsemide (a diuretic medication used to treat heart failure) daily.

A review of the clinical record indicated no documentation of intake and output.

On 3/22/22 at 6:36 AM Staff 7 (LPN) stated CNA staff should have documented intake and output for Resident 159 especially since the resident had a Foley catheter.

On 3/22/22 at 8:28 AM Staff 11 (RN) stated she recalled Resident 159, but staff did not monitor intake and outputs for her/him.

On 3/23/22 at 8:28 AM Staff 2 (DNS) stated Resident 159 was receiving diuretic medication and the expectation was for staff to monitor intakes and outputs on any resident who is on a diuretic. Staff 2 acknowledged the facility did not monitor intakes and outputs for Resident 159.

Refer to F684

Resident 23

Resident 23 admitted to the facility in 2019 with diagnoses including heart failure and hypertension.

The 12/22/19 physician order indicated staff were to check blood pressure and pulse every morning related to hypertension.

The 3/22 MARs indicated staff did not check blood pressure or pulse on 3/7/22, 3/8/22, 3/9/22 and 3/10/22.

On 3/23/22 at 8:25 AM Staff 2 (DNS) stated an agency staff was working 3/7/22 through 3/10/22 and acknowledged Resident 23 did not received blood pressure or pulse checks as ordered by the physician.

Refer to F684

FALL INTERVENTIONS AND IMPLEMENTATION

Resident 40

Resident 40 admitted to the facility on 7/15/21 with diagnoses including dementia and anxiety.

The 10/21/21 Quarterly MDS indicated Resident 40 was significantly cognitively impaired and indicated the resident had "two or more" falls since admission with no injury.

The Fall Care Plan was last revised 2/23/22. There were no interventions updated to prevent falls post the 9/20/21 fall until 1/10/22 when the care plan indicated Resident 40 was to wear non-skid socks and staff were to remind the resident to use the call light with each meet and greet. The care plan had already included the interventions for non-skid socks and to remind the resident to use the call light on 7/15/21 and 7/18/21.

The care plan did not indicate signs were to be placed in the resident's room to remind the resident to ask for assistance before transferring.

The 9/20/21 Post Fall Assessment indicated Resident 40 was found in her/his room on the floor after self-ambulating barefoot. The investigation indicated the resident hit her/his head on the dresser and was bleeding at the base of her/his skull. The resident was sent out to the hospital. Preventive measure included: Signs placed in room and bathroom to remind the resident she/he needs assistance with transfers. Recommendations to prevent further falls indicated: frequent checks, lower bed, and "constant" reminding to use the call light because of her/his dementia and her/his tendency to overestimate her/his abilities. There were no witness statements documented or neurological assessments post fall. The Post Fall Assessment was completed on 9/30/21.

Resident 40 sustained over four falls since the 9/20/21 incident.

On 3/24/22 at 2:06 PM Resident 55's (Resident 40's roommate) call light was initiated. Resident 55 told Staff 49 (CNA) that Resident 40 had self-transferred to the restroom. Staff 49 was observed to enter the restroom with Resident 40. There were no signs in the resident's room or door of the restroom to remind Resident 40 to call for assistance prior to transferring.

On 3/24/22 at 2:09 PM Resident 55 stated she/he pressed her/his call light 10 minutes prior to alert staff Resident 40 had self-transferred to the restroom. Resident 55 stated the facility was "so shorthanded" and stated Resident 40 had four falls since Resident 55 had been the resident's roommate.

On 3/24/22 at 2:16 PM Staff 50 (CNA) stated Resident 40 experienced multiple falls and interventions included: a gait belt, non-skid socks and the resident used to have signs in the room to remind her/him to use the call light. Staff 50 confirmed there were no signs in Resident 40's room or restroom door to remind the resident to call for assistance.

On 3/24/22 at 2:23 PM Staff 2(DNS) acknowledged the fall investigation was not thorough for 9/20/22 incident, the investigation was completed 10 days after the incident, and confirmed there were no signs in the resident's room or bathroom per care planned interventions.

Refer to F689

Resident 22

Resident 22 was admitted to the facility on 12/2020 with diagnoses including cerebral vascular accident (CVA/Stroke) and morbid obesity.

The 12/2020 initial care plan indicated the resident required extensive assistance by two staff to turn and reposition in bed and required a mechanical lift with two staff assistance for transfers.

The revised 3/23/21 care plan identified the resident as a high risk for falls. Interventions included: Be sure bed is in lowest position when not providing care.

The 3/1/22 Post Fall Assessment stated Resident 22 had a witnessed fall in the room while being changed by a single staff member and was sent to the hospital to rule out knee fracture.

The 3/11/22 Physician Orders: Bed rails, both sides for mobility and fall mats on both sides of bed.

On 3/14/22 at 10:42 AM observations of Resident 22's room revealed bed at regular height, no fall mats, and no side rails. Resident 22 stated she/he had a recent fall on 3/1/22 and have been in misery ever since. Resident 22 stated she/he was leery about being dropped.

On 3/17/22 observed Staff 30 (CNA) in room with resident. Staff 30 acknowledged Resident 22's bed was not in the low position, there were no fall mats on either side of the bed and no side rails on the bed.

On 3/17/22 at 1:29 PM Staff 10 (LPN) confirmed Resident 22 did not have the bed in low position, no bed rails and no fall mats.

On 3/17/22 at 1:44 PM Staff 2 (DNS) observed Resident 22's room and confirmed the bed was not in low position, no bed rails on the bed and no fall mats. Staff 2 stated she expected orders to be implemented as soon as possible.

Refer to F689

PROFESSIONAL STANDARDS

Resident 58

Resident 58 was admitted to the facility in 2019 with diagnoses including chronic obstructive pulmonary disease (COPD) and anxiety disorder.

The 1/18/22 physician orders indicated to obtain oxygen saturation level and utilize PRN oxygen to maintain oxygen saturation between 88-92% every four hours.

The 2/2/22 at 7:08 AM progress note indicated Resident 58's oxygen saturation was 84% and the resident was on oxygen 3 liters per minute. The resident's oxygen could be increased to 4 liters per minute and the oxygen was to be rechecked in 30-45 minutes.

The 2/2/22 MAR indicated Resident 58's oxygen saturation was 81% at 8:00 AM.

The 2/2/22 Vital Sign records indicated at 8:35 AM indicated Resident 58's oxygen saturation was 86%.

There was no indication in the residents clinical record to indicate the physician was notified of Resident 58's oxygen saturations below 88%.

The 2/3/22 at 12:50 AM Progress Note indicated Resident 58 had shortness of breath at the start of the shift with oxygen saturations ranging between 80%-86%. The nurse assisted the resident with breathing techniques to lower rapid breathing and deepen inhalation resulting in resident becoming more relaxed and oxygen increasing to over 90%. Oxygen saturation was 98%.

The 2/3/22 at 8:51 AM Progress Note indicated Resident 58 oxygen saturation dropped to 71% on 4 liters of oxygen per minute via mask. Oxygen was instructed to be increased to 5 liters per minute via mask and the resident was assisted with breathing techniques to help deepen breathing and reduce anxiety. Resident's oxygen saturations went up to 81%.

The 2/3/22 at 11:15 AM Progress Note indicated Resident 58's oxygen saturation was at 71% on 5 liters per minute via mask. Assist resident with deep breathing exercises. Will contact on-call provider and leave a note in provider's box regarding resident.

The 2/3/22 at 12:18 PM Progress Note indicated Resident 58 began coughing up a scant amount of bright red blood into tissues and her/his oxygen saturations were 69%. A message was left for on-call provider for a 20-minute call back.

The 2/3/22 at 1:05 PM (late entry) Progress Note indicated the facility received a call back from the on-call provider was instructed to send Resident 58 to the hospital. Emergency services were contacted. They arrived and collected resident and left for Salem Hospital at approximately 12:55 PM on 2/3/22.

On 3/25/22 at 10:10 AM Witness 6 (Nurse Practitioner) reviewed the findings and stated Resident 58 had an order to maintain oxygen saturations between 88-92% and the expectation was for staff to call the provider if oxygen saturations dropped below 88%. Witness 6 further stated staff did not notify the provider timely of Resident 58's change in condition and the expectation was for staff to have notified the provider the morning of 2/2/22.

On 3/25/22 at 11:04 AM Staff 43 (RN) stated she worked day shift on 2/2/22 and 2/3/22. Staff 43 stated she should have notified the physician "in her professional opinion" on the morning of 2/2/22 after Resident 58's oxygen saturations dropped below 88%.

Resident 9

Resident 9 admitted 11/2021 with diagnoses including displaced bimalleolar fracture of right lower leg (ankle fracture).

On 3/17/22 at 11:32 AM Staff 34 (LPN) confirmed she did not put Resident 9's lidocaine patch on at 8:00 AM per the order but documented she did put the lidocaine patch on. She stated she meant to put it on Resident 9 but got distracted and forgot about Resident 9's lidocaine patch.

On 3/22/22 at 10:36 AM Staff 2 (DNS) stated she expected the nurses to sign off treatments and medication administration after completing the task not before.

Resident 49

Resident 49 admitted 1/2021 with diagnoses including dysphagia (swallowing disorder) and bronchiectasis (a condition in which the lungs' airways become damaged).

On 3/22/22 at 9:50 AM Staff 7 (LPN) stated he had administered Resident 49's tube feeding and marked on the MAR he had also assisted the resident with her/his I.S. (Incentive Spirometer, an apparatus used to expand the lungs) as per order. Resident 49's I.S. was not found in the room. Staff 7 stated he marked the assistance with the I.S. as completed and had not assisted the resident with the I.S. Staff 7 stated he was busy and should not have marked it as completed but he did.

On 3/22/22 at 10:36 AM Staff 2 (DNS) stated she expected the nurses to sign off treatments and medication administration after completing the task not before.

ANTIBIOTIC STEWARDSHIP

The CDC Core Elements of Antibiotic Stewardship https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html, dated 8/2021 indicated Antibiotics are among the most frequently prescribed medications in nursing homes. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridoides difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Core elements of a facility Antibiotic Stewardship Program should include analysis of infections and causative bacteria along with resistant data specific to both the facility and the type of infection (Antibiogram). This information should be given to the prescriber for appropriate antibiotic selection. Further retrospective infection surveillance utilizing McGeers Criteria should be conducted to ensure correct use of antibiotic therapy.

The facility Antibiotic Stewardship Policy updated 9/19/21 indicated the following:
-Train staff and use the McGeers Criteria Surveillance Checklist as a tool to prevent unnecessary antibiotic use. A laminated copy will be at the nurse's station.
-Follow up with MD about the choice of Antibiotics in relation to organisms found.

The policy did not include the use of a specific facility antibiogram or other mechanism to assess facility specific organism resistance patterns to antibiotic therapy for resident infections.

The infection log for October 2021 indicated there were 10 infections in the facility. Only two organisms were identified by Staff 48 (IP-infection preventionist). Both organisms were MRDO bacteria and included Extended Spectrum Beta Lactamases [(ESBL) (an enzyme produced by a bacteria to make it more resistant)] of unknown bacterial origin and ESBL- Methicillin Resistant Staphylococcus Aureus (MRSA)(a bacteria that is resistant to several antibiotics).

On 3/24/22 at 9:32 AM Staff 1 (DNS) stated she was not aware of a facility specific Antibiogram or other mechanism of assessing organism resistance patterns and there was no post infection surveillance being conducted to ensure correct treatment of infections and adherence to AUP.

On 3/24/22 at 10:09 am Staff 48 (IP-Infection Preventionist) confirmed the last infection tracking log was completed in 10/2021 approximately 5 months ago. She further stated the reason organisms were not logged was due to the fact when resident treatment was initiated in the hospital the facility did not intercede with care. She was not aware of a facility specific antibiogram or other mechanism of assessing organism antibiotic resistance and post infection surveillance was not being conducted via McGeers criteria.

On 3/25/22 at 10:22 AM Witness 6 ( Practitioner) confirmed she did not receive feedback from the facility regarding her antibiotic prescribing. She further stated she was unaware of a facility specific antibiogram or any similar mechanism of assessing organism antibiotic resistance patterns and any past surveillance of antibiotic use.

On 3/28/22 at approximately 1:00 PM Staff 1 (Administrator) confirmed the last data related to the facility ASP collected was in October 2021. She further stated no ASP data from 11/1/21 through 12/31/21 was included in the last facility QAPI meeting dated 1/20/22 and ASP data collected by the facility did not include feedback to facility prescribers, a facility specific antibiogram or other mechanism of assessing organism antibiotic resistance patterns or any post surveillance activity related to facility infections using McGeers criteria.

Refer to F881

Based on interview and record review it was determined the facility failed to ensure allegations of neglect were reported to the appropriate state agency for 2 of 6 sampled residents (#s 17 and 22) reviewed for accidents. This placed residents at risk for elopement and injury. Findings include:

The facility's revised 9/18/21 Incident Reports Policy stated: The DNS and NHA (Nursing Home Administrator) will review all incident reports to assure that the form is complete looking for root cause analysis and ruling out of abuse. If necessary, will fill out a FRI (Facility Incident Report) form and send it to the appropriate State Agency.

1. Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions.

A 2/15/22 a Progress Note indicated at 12:20 PM Resident 17 was found outside in the parking lot by staff attempting to get into a staff member's car and it took multiple attempts to redirect her/him back inside.

On 3/14/22 at 4:37 PM Witness 1 (Family Member) stated she was informed the night prior by Staff 15 (Unit Clerk) that Resident 17 had wandered outside the facility because the exit door down the 100 hall was unlocked. Witness 1 stated Resident 17 was an elopement risk and had attempted to leave the facility multiple times due to her/his diagnoses and previously made it outside the facility and refused to come back in. Witness 1 stated she reported the incident to Staff 19 (Admissions).

On 3/14/22 at 5:13 PM Staff 7 (LPN) stated on 3/13/22 the door down the 100 hall was left unlocked, but he was not aware of Resident 17 leaving the facility.

On 3/14/22 at 5:17 PM Staff 15 (Unit Clerk) stated she was informed a couple nights prior that Resident 17 left out of the emergency exit down the 100 hall and Staff 15 was informed by "morning staff" of the incident. Staff 15 was unable to recall who specifically informed her of the incident, but believed the incident occurred over the past weekend (3/12/22 through 3/13/22). Staff 15 was unsure how long the resident was out of the facility, but management was aware of the incident.

On 3/14/22 at 5:23 PM Staff 39 (CNA) stated Resident 17 was "always" exit seeking and had previously gotten out of the back door of the facility that residents used to go smoke. Staff 39 stated on Thursday (3/10/22) the resident had gotten outside, but Staff 39 saw the resident right away and redirected the resident back inside. Staff 39 stated a few weeks prior she was coming onto her shift and found Resident 17 outside in the parking lot.

On 3/15/22 at 4:13 PM Staff 19 (Admissions) stated he was not aware Resident 17 was outside the facility, but was informed by Witness 1 on 3/13/22 that the resident attempted to leave the facility that day due to the door down the 100 hall being unlocked. Staff 19 stated he reported the incident to Staff 1 (Administrator).

On 3/15/22 at 4:18 PM Staff 1 (Administrator) stated she was aware Resident 17 had left the facility previously, but was not aware of Resident 17 recently leaving the facility out the 100 hall door as the door was "always" locked.

There was no evidence in the record the alleged incident of Resident 17 leaving the facility was reported to the appropriate State Agency.

On 3/24/22 at 10:34 AM Staff 2 (DNS) confirmed the allegation reported by Witness 1 on 3/13/22 that Resident 17 eloped from the facility was not reported to the appropriate State Agency.

Refer to F610 and F689.
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2. Resident 22 was admitted to the facility in 12/2020 with diagnoses including Cerebral Vascular Accident (CVA/Stroke) and morbid obesity.

The 12/2020 initial Care Plan indicated the resident required extensive assistance by one to two staff to turn and reposition in bed and required a mechanical lift with two staff assistance for transfers.

The 12/2021 MDS indicated the resident had a BIMS score of 11, moderately impaired cognition.

On 3/1/22 at 9:48 PM the Post Fall Assessment stated Resident 22 had a witnessed fall in the room, while being changed by a single staff member and was sent to the hospital to rule out a knee fracture. Staff 52 (PCA) stated she had stepped away to get some wipes and the bed was left in a high position.

On 3/1/22 at 9:58 PM Progress Note indicated Resident 22 was assisted by Staff 52. Staff 51 (LPN) documented Staff 52 "stepped away" from Resident 22.

On 3/4/22 in a written statement by Staff 2 (DNS), Resident 22 told the staff she/he wanted to roll towards the window. Staff 52 was on the other side of the bed. Staff 52 stated she looked away, turned back toward Resident 22 and noted she/he falling and was unable to slow or stop the fall.

On 3/17/22 at 1:30 PM Staff 2 (DNS) stated the incident was not reported to the appropriate State Agency.

Based on interview and record review it was determined the facility failed to ensure an allegation of neglect was investigated for 1 of 3 sampled residents (#17) reviewed for accidents. This placed residents at risk for elopement and injury. Findings include:

Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions.

A 2/15/22 a Progress Note indicated at 12:20 PM Resident 17 was found outside in the parking lot by staff attempting to get into a staff member's car and it took multiple attempts to redirect her/him back inside.

On 3/14/22 04:37 PM Witness 1 (Family Member) stated she was informed the night prior by Staff 15 (Unit Clerk) that Resident 17 had wandered outside the facility because the exit door down the 100 hall was unlocked. Witness 1 stated Resident 17 was an elopement risk and had attempted to leave the facility multiple times due to her/his diagnoses and previously made it outside the facility and refused to come back in. Witness 1 stated she reported the incident to Staff 19 (Admissions).

On 3/14/22 at 5:13 PM Staff 7 (LPN) stated on 3/13/22 the door down the 100 hall was left unlocked, but he was not aware of Resident 17 getting out of the building.

On 3/14/22 at 5:17 PM Staff 15 (Unit Clerk) stated she was informed a couple nights prior that Resident 17 got out of the emergency exit down the 100 hall and was informed by "morning staff." Staff 15 was unable to recall who specifically informed her of the incident, but believed the incident occurred over the past weekend (3/12/22 through 3/13/22). Staff 15 was unsure how long the resident was out of the facility, but management was aware of the incident.

On 3/14/22 at 5:23 PM Staff 39 (CNA) stated Resident 17 was "always" exit seeking and had previously left the facility out of a back door that residents used to go smoke. Staff 39 stated on Thursday (3/10/22) the resident had gotten outside, but Staff 39 saw the resident right away and redirected the resident back inside. Staff 39 stated a few weeks prior she was coming onto her shift and found Resident 17 outside in the parking lot.

On 3/15/22 at 4:13 PM Staff 19 stated he was not aware Resident 17 was outside the facility but was informed by Witness 1 on 3/13/22 that the resident attempted to leave the facility that day due to the door down the 100-hall being unlocked. Staff 19 stated he reported the incident to Staff 1 (Administrator).

On 3/15/22 at 4:18 PM Staff 1 (Administrator) stated she was aware Resident 17 had left the facility previously but was not aware of Resident 17 leaving the facility out the 100-hall door as the door is always locked.

There was no evidence in the record the alleged incident of Resident 17 leaving the facility was investigated prior to 3/22/22.

On 3/24/22 at 10:34 AM Staff 2 (DNS) confirmed the allegation reported on 3/13/22 by Witness 1 that Resident 17 eloped from the facility was not investigated until 3/22/22, after it was brought to her attention by a State Surveyor.

Refer to F609 and F689.

Based on interview and record review it was determined the facility failed to timely and comprehensively assess residents' needs for 3 of 8 sampled residents (#s 108, 158 and 258) reviewed for resident assessments and limited range of motion. This placed residents at risk for unassessed needs. Findings include:

According to the RAI Manual 3.0 a resident must have an Admission MDS assessment completed within 14 days of admission to the facility.

1. Resident 108 admitted to the facility on 2/24/22 with diagnoses including depression, anxiety and assistance with personal care.

An Admission MDS was initiated on 3/3/22 with an assessment reference dated 3/9/22. The MDS was noted to be still in process, 17 days overdue as of 3/18/22.

On 3/18/22 at 10:19 AM Staff 2 (DNS) confirmed the Admission MDS for Resident 108 was not completed and overdue.

2. Resident 158 was admitted to the facility on 2/18/22 with diagnoses including dementia and congestive heart failure.

An Admission MDS was initiated on 2/25/22 with an assessment reference date of 3/3/22. The MDS was noted to be still in process, 29 days over due as of 3/18/22.

On 3/18/22 at 10:19 AM Staff 2 (DNS) confirmed the Admission MDS for Resident 158 was not completed and overdue.
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3. Resident 258 admitted to the facility on 2/8/22 with diagnoses including cerebral palsy and depression.

Review of Resident 258's clinical record on 3/17/22 did not indicate an Admission MDS was completed.

On 3/18/22 at 10:19 AM Staff 2 (DNS) confirmed Resident 258's Admission MDS was not completed for the required time frame.

2. Resident 3 admitted to the facility in 2018 with diagnoses including congestive heart failure and dementia.

A Progress Note dated 3/7/22 indicated Resident 3's identified significant change was on 2/28/22.

A Significant Change MDS was initiated with an assessment reference dated of 2/28/22. The MDS was noted to be in process, 18 days overdue as of 3/18/22.

On 3/18/22 at 10:19 AM Staff 2 (DNS) confirmed the Significant Change MDS for Resident 3 was not completed and was overdue.



, Based on interview and record review it was determined the facility failed to conduct a Significant Change MDS assessment for 2 of 8 sampled residents (#s 3 and 17) reviewed for accidents and resident assessments. This placed residents at risk for unassessed care needs. Findings include:

According to the RAI Manual 3.0 a Significant Change MDS must be completed within 14 days of the determination of when a change occurred.

1. Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions.

A 2/27/22 Admission note indicated Resident 17 re-admitted to the facility on hospice on 2/27/22 following a hospitalization.

Review of Resident 17's record indicated a Signifcant Change MDS was due 3/11/22 related to the resident admitting to hospice and had not been completed as of 3/17/22.

On 3/17/22 at 10:56 AM Staff 2 (DNS) acknowledged Resident 17 admitted to hospice on 2/27/22 and a Significant Change MDS had not been completed.

Based on interview and record review it was determined the facility failed to implement a person-centered care plan for 1 of 2 sampled residents (#19) reviewed for rehabilitation. This placed residents at risk for unmet care needs. Findings include:

Resident 19 was admitted to the facility on 12/15/21 with diagnoses including difficulty walking and hip pain.

Resident 19's 12/17/21 Care Plan indicated the following:
-The resident had limited physical mobility
-"The resident is able to: (specify)"
-"The resident is totally dependent on (x) staff for walking"
-"The resident requires (specify: assistance) by (x) staff to walk (specify frequency) and as necessary"
-"The resident uses (specify assistive device) for walking. Clean (specify frequency)"
-"The resident is able to: (specify)"
-Invite the resident to activity programs that encourage physical activity, physical mobility, such as exercise group, walking activities to promote mobility

The 12/22/21 ADL CAA indicated Resident 19 was able to ambulate before admitting to the facility, was at risk for falls and needed assistance with transfers.

On 3/22/22 at 11:42 AM Staff 2 (DNS) reviewed the care plan and acknowledged it was not comprehensive, was not resident specific and did not include information about the resident's status and her/his ambulation, walking ability, assistive devices or staff assistance required for transfers.

Based on interview and record review it was determined the facility failed to review and revise care planned interventions for 3 of 7 sampled residents (#s 14, 17 and 27) reviewed for accidents, pain, and hospice. This placed residents at risk for unassessed needs. Findings include:

1. Resident 27 admitted to the facility in 2018 with diagnoses including aphasia (inability to comprehend formulate language) and stroke.

An observation on 3/15/22 at 11:57 AM was made of staff delivering a lunch tray to Resident 27. At 12:00 PM Resident 27 was observed feeding her/himself with no staff present. The resident stated she/he fed her/himself and received no assistance or supervision from staff.

Resident 27's Care Plan dated 9/24/19 indicated she/he needed to be supervised for meals.

Resident 27's Kardex (in room care plan) indicated she/he required supervision with meals.

Review of the medical record indicated a Refusal to Follow Prescribed Diet Release form was completed by Resident 27. The form indicated Resident 27 did not want to follow the prescribed diet, including supervision with meals. The form was signed by the resident on 2/7/20.

On 3/18/22 at 10:19 AM Staff 2 (DNS) stated Resident 27's care plan was not updated to reflect the current diet and meal assistance preference.

, 2. Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions.

The 12/3/21 Wandering Risk Assessment was incomplete, but indicated Resident 17 was a "low risk" for wandering.

The resident's Care Plan, last updated 2/22/22, did not include wandering behaviors or any interventions related to prevent wandering or elopement.

On 3/14/22 at 4:37 PM Witness 1 (Family Member) stated Resident 17 was an elopement risk and had attempted to leave the facility multiple times due to her/his diagnoses.

On 3/14/22 at 5:23 PM Staff 39 (CNA) stated Resident 17 was "always" exit seeking, wandered into other residents' rooms, and had previously gotten out of the back door of the facility.

On 3/15/22 at 4:44 PM Staff 26 (LPN) had wandering behaviors and liked to wander into other residents' rooms and all hallways. Staff 26 reported there were times staff could not find the resident and had to look throughout the facility for her/him.

On 3/15/22 at 8:11 PM Staff 28 (CNA) stated Resident 17 had wandering behaviors, including going into other residents' rooms and had nearly gotten out of the exit door down the 300-hall. Staff 28 stated Resident 17 would often go past the nurses station, so staff would shut the fire doors to prevent the resident from leaving.

On 3/21/22 at 3:39 PM Staff 33 (LPN) stated the resident had wandering behaviors and one time was found in the back parking lot. Staff 33 stated Resident 17 was "always trying to leave", wandered into other residents' rooms and staff had to close the fire doors at night to prevent the resident from wandering out. Staff 33 stated interventions to prevent the resident from wandering included: hot chocolate, sandwiches, and since the resident used to be a nurse Staff 33 let Resident 17 pretend to take her vitals.

On 3/18/22 at 10:19 AM Staff 2 (DNS) acknowledged Resident 17's care plan did not include wandering behaviors or interventions to prevent wandering. Staff 2 stated all care plans were "in progress" and not updated for residents.

Refer to F689.

3. Resident 14 admitted to the facility in 11/2018 with diagnoses including a stroke resulting in hemiparesis (paralysis of half the body) and a hip fracture.

A 3/1/22 Encounter Note indicated Resident 17 had a right hip fracture in August, 2020 and was experiencing increased pain.

On 3/14/22 at 1:55 PM Resident 14 stated her/his pain medications were "always" late and she/he often had pain in her/his hip.

Resident 14's Care Plan was last updated in 2019 and did include the resident sustaining a hip fracture with increased pain or interventions to improve the resident's pain.

On 3/17/22 at 2:07 PM and 3/18/22 at 10:19 AM Staff 2 (DNS) acknowledged Resident 14's care plan had not been updated since 2019 to include her/his hip fracture, which resulted in increased pain and required pain interventions. Staff 2 stated all resident care plans were "in progress" and not updated.

Refer to F697.

Based on observation, interview and record review it was determined the facility failed to ensure Staff 43 (RN), Staff 7 (LPN) and Staff 34 (LPN) adhered to professional standards related to a change of condition and documentation. This failure resulted in Resident 58 experiencing a noted decline in condition without appropriate intervention prior to the resident's hospitalization. This placed residents at risk for unmet care needs and increased pain. Findings include:

OAR 851-045-0040 Scope of Practice Standards for All Licensed Nurses:
(1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse:
(b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering.

OAR 851-045-0070 Conduct Derogatory to the Standards of Nursing Defined:
Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following:
(1) Conduct related to the client's safety and integrity:
(b) Failing to take action to preserve or promote the client's safety based on nursing
assessment and judgment.
(2) Conduct related to other federal or state statute/rule violations:
(b) Neglecting a client. The definition of neglect includes, but is not limited to, carelessly allowing a client to be in physical discomfort or be injured.
(3) Conduct related to communication:
(h) Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse coworker) in an ongoing and timely manner; and
(i) Failing to communicate information regarding the client's status to other individuals who need to know; for example, family, and facility administrator.
(4) Conduct related to communication:
(c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or agency records. This includes but is not limited to:
(A) Documenting nursing practice implementation that did not occur;

1. Resident 58 was admitted to the facility in 2019 with diagnoses including chronic obstructive pulmonary disease (COPD) and anxiety disorder.

The 1/18/22 physician orders indicated to obtain oxygen saturation level and utilize PRN oxygen to maintain oxygen saturation between 88-92% every four hours.

The 1/25/22 progress note indicated Resident 58 tested positive for COVID that day and was moved to the isolation unit.

The 2/2/22 at 7:08 AM Progress Note by Staff 43 indicated Resident 58's oxygen saturation was 84% and the resident was on oxygen 3 liters per minute. The resident's oxygen could be increased to 4 liters per minute and the oxygen was to be rechecked in 30-45 minutes.

The 2/2/22 MAR indicated Resident 58's oxygen saturation was 81% at 8:00 AM.

The 2/2/22 Vital Sign records indicated at 8:35 AM indicated Resident 58's oxygen saturation was 86%.

There was no indication in the residents clinical record to indicate the physician was notified of Resident 58's oxygen saturations below 88%.

The 2/2/22 Vital Sign records indicated at 11:43 PM Resident 58's temperature was 97.5 F. This was the last temperature documented in the clinical record.

The 2/3/22 at 12:50 AM Progress Note indicated Resident 58 had shortness of breath at the start of the shift with oxygen saturations ranging between 80%-86%. The nurse assisted the resident with breathing techniques to lower rapid breathing and deepen inhalation resulting in resident becoming more relaxed and oxygen increasing to over 90%. Oxygen saturation was 98%. No fever present. Resident has been compliant with cares and isolation status. Sleeping comfortably at this time. Vital signs stable and within normal limits. Will continue to monitor.

The 2/3/22 at 8:51 AM Progress Note by Staff 43 indicated Resident 58 oxygen saturation dropped to 71% on 4 liters of oxygen per minute via mask. Oxygen was instructed to be increased to 5 liters per minute via mask and the resident was to be assisted with breathing techniques to help deepen breathing and reduce anxiety. Resident's oxygen saturations went up to 81%. Continue with breathing techniques and to monitor oxygen.

The 2/3/22 at 11:15 AM Progress Note by Staff 43 indicated Resident 58's oxygen saturation was at 71% on 5 liters per minute via mask. Assist resident with deep breathing exercises. Will contact on-call provider and leave a note in provider's box regarding resident.

The 2/3/22 at 12:18 PM Progress Note by Staff 43 indicated Resident 58 began coughing up a scant amount of bright red blood into tissues and her/his oxygen saturations were 69%. A message was left for on-call provider for a 20-minute call back.

The 2/3/22 at 1:05 PM [late entry] Progress Note by Staff 43 indicated the facility received a call back from the on-call provider was instructed to send Resident 58 to the hospital. Emergency services were contacted. They arrived and "collected" the resident and left for Salem Hospital at approximately 12:55 PM on 2/3/22.

The 2/3/22 hospital records indicated the following:
-Resident 58 came from the care facility to the emergency department for worsening shortness of breath and recently tested positive for COVID one week ago and had been having difficulty breathing. Staff at the care facility were having a difficult time maintaining her/his oxygen saturations today and called paramedics. While at the facility, she/he had saturations of 67% while on oxygen. She/he was placed on non-rebreather by paramedics, which brought her/his oxygen saturations up to 79%. Patient arrived on CPAP with oxygen saturations at 88%. Paramedics reported a fever with temperature of 103 F.

The 2/4/22 progress note indicated Resident 58 was admitted to the hospital with admitting diagnoses of COPD exacerbation, pneumonia due to COVID and respiratory failure.

The 2/7/22 at 1:11 PM progress note indicated the hospital called to confirm that Resident 58 passed away at 8:04 AM on 2/5/22.

On 3/25/22 at 10:10 AM Witness 6 (Nurse Practitioner) reviewed the findings and stated Resident 58 had an order to maintain oxygen saturations between 88-92% and the expectation was for staff to call the provider if oxygen saturations dropped below 88%. Witness 6 further stated staff did not notify the provider timely of Resident 58's change in condition and the expectation was for staff to have notified the provider the morning of 2/2/22.

On 3/25/22 at 11:04 AM Staff 43 (RN) stated she worked day shift on 2/2/22 and 2/3/22. Staff 43 stated she should have notified the physician "in my professional opinion" on the morning of 2/2/22 after Resident 58's oxygen saturations dropped below 88%.

On 3/23/22 at 2:14 PM and 3/28/22 at 8:46 AM Staff 2 (DNS) stated Resident 58's physician order indicated to keep oxygen saturations between 88-92 %. Staff 2 stated the expectation was for staff to notify the physician within 30 minutes after a change in condition and the physician should have been notified on 2/2/22 after the resident's oxygen saturations did not increase at 8:35 AM.
, 2. Resident 9 admitted the facility 11/2021 with diagnoses including an ankle fracture.

On 3/17/22 at 11:32 AM Staff 34 (LPN) confirmed she did not put Resident 9's lidocaine patch on at 8:00 AM per the order but documented she did put the lidocaine patch on. She stated she "meant to" put it on Resident 9 but got distracted and forgot about Resident 9's lidocaine patch.

On 3/22/22 at 10:36 AM Staff 2 (DNS) stated she expected the nurses to sign off treatments and medication administration after completing the task not before.

3. Resident 49 admitted 1/2021 with diagnoses including dysphagia (swallowing disorder) and bronchiectasis (a condition in which the lungs' airways become damaged).

On 3/22/22 at 9:50 AM Staff 7 (LPN) stated he had administered Resident 49's tube feeding and marked on the MAR he had also assisted the resident with her/his I.S. (Incentive Spirometer, an apparatus used to expand the lungs) as per order. Resident 49's I.S. was not observed in the room. Staff 7 stated he marked the assistance with the I.S. as completed and had not assisted the resident with the I.S. Staff 7 stated he was "busy" and should not have marked it as completed.

On 3/22/22 at 10:36 AM Staff 2 (DNS) stated she expected the nurses to sign off treatments and medication administration after completing the task not before.

Based on interview and record review it was determined the facility failed to address a change of condition, follow physician orders and address skin conditions for 4 of 8 sampled residents (#s 23, 58, 109, and 159) reviewed for medication, non-pressure skin, and hospitalization. This failure resulted in Resident 58 experiencing a noted decline in condition without appropriate intervention prior to the resident's hospitalization. This placed residents at risk for adverse side effects of medications, worsening conditions, and death. Findings include:

1. Resident 58 was admitted to the facility in 2019 with diagnoses including chronic obstructive pulmonary disease (COPD) and anxiety disorder.

The 1/18/22 physician orders indicated to obtain oxygen saturation level and utilize PRN oxygen to maintain oxygen saturation between 88-92% every four hours.

The 1/25/22 progress note indicated Resident 58 tested positive for COVID that day and was moved to the isolation unit.

The 2/2/22 at 7:08 AM progress note indicated Resident 58's oxygen saturation was 84% and the resident was on oxygen 3 liters per minute. The resident's oxygen could be increased to 4 liters per minute and the oxygen was to be rechecked in 30-45 minutes.

The 2/2/22 MAR indicated Resident 58's oxygen saturation was 81% at 8:00 AM.

The 2/2/22 Vital Sign records indicated at 8:35 AM indicated Resident 58's oxygen saturation was 86%.

There was no indication in the residents clinical record to indicate the physician was notified of Resident 58's oxygen saturations below 88%.

The 2/2/22 Vital Sign records indicated at 11:43 PM Resident 58's temperature was 97.5 F. This was the last temperature documented in the clinical record.

The 2/3/22 at 12:50 AM Progress Note indicated Resident 58 had shortness of breath at the start of the shift with oxygen saturations ranging between 80%-86%. The nurse assisted the resident with breathing techniques to lower rapid breathing and deepen inhalation resulting in resident becoming more relaxed and oxygen increasing to over 90%. Oxygen saturation was 98%. No fever present. Resident has been compliant with cares and isolation status. Sleeping comfortably at this time. Vital signs stable and within normal limits. Will continue to monitor.

The 2/3/22 at 8:51 AM Progress Note indicated Resident 58 oxygen saturation dropped to 71% on 4 liters of oxygen per minute via mask. Oxygen was instructed to be increased to 5 liters per minute via mask and the resident was assisted with breathing techniques to help deepen breathing and reduce anxiety. Resident's oxygen saturations went up to 81%. Continue with breathing techniques and to monitor oxygen.

The 2/3/22 at 11:15 AM Progress Note indicated Resident 58's oxygen saturation was at 71% on 5 liters per minute via mask. Assist resident with deep breathing exercises. Will contact on-call provider and leave a note in provider's box regarding resident.

The 2/3/22 at 12:18 PM Progress Note indicated Resident 58 began coughing up a scant amount of bright red blood into tissues and her/his oxygen saturations were 69%. A message was left for on-call provider for a 20-minute call back.

The 2/3/22 at 1:05 PM [late entry] Progress Note indicated the facility received a call back from the on-call provider was instructed to send Resident 58 to the hospital. Emergency services were contacted. They arrived and collected resident and left for Salem Hospital at approximately 12:55 PM on 2/3/22.

The 2/3/22 hospital records indicated the following:
-Resident 58 came from the care facility to the emergency department for worsening shortness of breath and recently tested positive for COVID one week ago and had been having difficulty breathing. Staff at the care facility were having a difficult time maintaining her/his oxygen saturations today and called paramedics. While at the facility, she/he had saturations of 67% while on oxygen. She/he was placed on non-rebreather by paramedics, which brought her/his oxygen saturations up to 79%. Patient arrived on CPAP with oxygen saturations at 88%. Paramedics reported a fever with temperature of 103 F.

The 2/4/22 progress note indicated Resident 58 was admitted to the hospital with admitting diagnoses of COPD exacerbadtion, pneumonia due to COVID and respiratory failure.

The 2/7/22 at 1:11 PM progress note indicated the hospital called to confirm that Resident 58 passed away at 8:04 AM on 2/5/22.

On 3/25/22 at 10:10 AM Witness 6 (Nurse Practitioner) reviewed the findings and stated Resident 58 had an order to maintain oxygen saturations between 88-92% and the expectation was for staff to call the provider if oxygen saturations dropped below 88%. Witness 6 further stated staff did not notify the provider timely of Resident 58's change in condition and the expectation was for staff to have notified the provider the morning of 2/2/22.

On 3/25/22 at 11:04 AM Staff 43 (RN) stated she worked day shift on 2/2/22 and 2/3/22. Staff 43 stated she should have notified the physician "in my professional opinion" on the morning of 2/2/22 after Resident 58's oxygen saturations dropped below 88%.

On 3/23/22 at 2:14 PM and 3/28/22 at 8:46 AM Staff 2 (DNS) stated Resident 58's physician order indicated to keep oxygen saturations between 88-92 %. Staff 2 stated the expectation was for staff to notify the physician within 30 minutes after a change in condition and the physician should have been notified on 2/2/22 after the resident's oxygen saturations did not increase at 8:35 AM.

2. Resident 109 admitted to the facility in 10/2020 with diagnoses including heart failure.

The 12/29/21 Progress Note indicated an order was received to "swab sore on back of head" with povidone-iodine until resolved.

The 1/2022 TAR indicated the resident did not receive wound treatment on 1/1/22.

The 1/3/22 Progress Note indicated wound care was provided to the sore on the back of the head the sore was drying out and resident reported less pain.

The 1/5/22 Progress Note indicated head wound had no drainage, no open area and was slightly raised. The area was swabbed with povidine-iodine per order.

There were no skin assessments or measurements of the sore on the resident's head in the electronic health record and no indication as to what type of sore or wound it was.

On 3/28/22 at 8:49 AM Staff 2 (DNS) acknowledged there was no initial skin and wound assessment on 12/29/21 and no ongoing skin assessments indicating the type, measurements and characteristics of the head wound. Staff 2 further acknowledged the treatment for povidone-iodine was not completed on 1/1/22.

3. Resident 159 was admitted to the facility on 2/23/22 with diagnoses including heart failure.

a. The 2/23/22 skin evaluation indicated the resident had a rash to the groin and left gluteal fold. There were no measurements of the identified areas.

A review of the clinical record indicated there was no follow up skin evaluations or skin assessments completed after 2/23/22.

The resident discharged on 3/12/22. No skin assessments were completed prior to her/his discharge.

On 3/18/22 at 2:00 PM Staff 2 (DNS) acknowledged Resident 159 had no measurements of the rash to the groin and left gluteal fold. She further acknowledged there were no additional skin assessments prior to her/his discharge.

b. The 2/7/17 Intake and Output (I and O) Policy for documentation and monitoring of I and O indicated residents who may be at risk for an imbalance in fluids or electrolytes and a comparison total for I and O may be used as part of the comprehensive assessment in residents at risk for these imbalances.

The 2/23/22 physician order indicated Resident 159 was to receive torsemide (a diuretic medication used to treat heart failure) daily.

A review of the clinical record indicated no documentation of intake and output.

On 3/22/22 at 6:36 AM Staff 7 (LPN) stated CNA staff "should have" documented I and O for Resident 159 especially since the resident had a Foley catheter.

On 3/22/22 at 8:28 AM Staff 11 (RN) stated she recalled Resident 159 but staff did not monitor I's and O's for her/him.

On 3/23/22 at 8:28 AM Staff 2 (DNS) stated Resident 159 was receiving diuretic medication and the expectation was for staff to monitor I's and O's on any resident received a diuretic. Staff 2 acknowledged the facility did not monitor I's and O's for Resident 159.

4. Resident 23 admitted to the facility in 2019 with diagnoses including heart failure and hypertension.

The 12/22/19 Physician Order indicated staff were to check blood pressure and pulse every morning related to hypertension.

The 3/22 MARs indicated staff did not check blood pressure or pulse on the following dates:
-3/7/22
-3/8/22
-3/9/22
-3/10/22

On 3/23/22 at 8:25 AM Staff 2 (DNS) stated an agency staff was working 3/7/22 through 3/10/22 and acknowledged Resident 23 did not received blood pressure or pulse checks as ordered by the physician.

Based on interview and record review it was determined the facility failed to have a system in place to monitor pressure ulcers for residents and failed to assess and monitor pressure ulcers for 2 of 2 sampled resident (#s 14 and 18) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:

Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present.

Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple
discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage.

The 9/2021 Pressure Ulcer Policy indicated the following:
-A skin event was to be filled out for Stage 2 or greater pressure ulcers.
-Treatment nurse starts treatment to protect skin until orders were received from the physician.
-Treatment nurse notified Resident Care Managers (RCM) and faxes or calls the physician for treatment orders.
-If a skin event was generated in the electronic health record, the RCM reviewed, reported and evaluated skin and the care plan was updated if needed.
-If the pressure ulcer was a Stage 2 or greater the RCM would evaluate each week, which included weekly notes, measurements, description, if the wound worsened or improved, and the plan to continue or change treatment.
-The treatment nurse would monitor other skin issues on the TAR until resolved. If the issue did not resolve within two weeks, the physician needed to be notified to request new treatment.

On 3/16/22 at 1:47 PM Staff 11 (RN) and Staff 43 (RN) indicated they were the treatment nurses' for the entire facility on 3/16/22 and both staff stated they were not aware of any residents who currently had pressure ulcers

On 3/16/22 at 2:23 PM Staff 2 (DNS) provided a list of eight residents who had pressure ulcers, but did not identify the stages of the pressure ulcers.

On 3/22/22 at 10:14 AM Witness 6 (Nurse Practitioner) stated the facility had "so many wounds" and was concerned facility staff were not completing assessments.

On 3/25/22 at 4:14 PM Staff 10 (LPN) stated she was the treatment nurse and was unaware of any residents in the facility with pressure ulcers.

1. Resident 18 admitted to the facility in 1/2021 with diagnoses including Alzheimer's disease and failure to thrive.

The 2/4/22 Skin Assessment indicated there were no new skin issues noted and there were current orders in place for "known" skin issues, will continue to monitor and hospice will continue to evaluate. The note did not indicate Resident 18's wound type, location, or measurements of wounds.

The 12/22/21 Physician Order indicated to cleanse the wound on the right lateral foot with wound cleanser, pat dry, apply iodosorb and calcium alginate to wound bed, apply skin prep to surrounding skin and cover with foam dressing. Change three times per week and PRN for soilage or accidental removal. Hospice nurse to change on Monday and Thursday, facility nurse to change on Saturday [and PRN].

The 2/2022 and 3/2022 TARs indicated dressing changes were completed as ordered.

On 3/16/22 at 1:47 PM Staff 11 (RN) and Staff 43 (RN) indicated they were the treatment nurses' for the entire facility on 3/16/22 and both staff were unaware Resident 18 had a pressure ulcer.

The 3/23/21 Care Plan indicated Resident 18 had a Stage 4 pressure ulcer to the coccyx. The care plan did not include information about Resident 18's pressure ulcer on the foot.

On 3/21/22 at 11:57 AM Staff 2 (DNS) stated facility treatment nurses were not completing wound assessments.

On 3/23/22 at 10:05 AM Witness 11 (Hospice RN) was observed to complete a dressing change for Resident 18. Witness 11 stated Resident 18 had a healed pressure ulcer to the coccyx but was still placing a dressing on the area for preventative care and had a pressure ulcer on her/his right foot. The resident refused to allow for a preventative dressing to her/his coccyx wound but allowed staff to complete a dressing change on her/his right foot. The area was observed to be open and red. Witness 11 stated the pressure ulcer to the foot was red and had less slough than the week prior and it was improving. Witness 11 further stated if changes needed to be made immediately she communicated with different facility staff depending on who was working. Witness 11 stated she "hand delivered" hospice notes to the facility once a month and there was no process in place to ensure the facility received hospice notes timely after she visited the resident.

On 3/24/22 at 10:34 AM Staff 2 (DNS) acknowledged Resident 18 had an open pressure ulcer to the right foot and there was no indication of the stage of the pressure ulcer, no assessments, no measurements and no facility weekly skin assessments for Resident 18's pressure ulcer on the right foot. Staff 2 further acknowledged there were no hospice notes indicating the condition of the pressure ulcer until she requested the documentation from hospice on 3/23/22.

On 3/25/21 at 9:51 AM Witness 11 stated the pressure ulcer to Resident 18's foot originally presented on 5/6/21 as a suspected deep tissue injury. She stated the area was closed and dark purple in color. She stated she did not change the staging of the pressure ulcer once it opened because she was not able to see the wound bed.
,
2. Resident 14 admitted to the facility in 11/2018 with diagnoses including a stroke resulting in hemiparesis (paralysis of half the body) and a hip fracture.

The 11/30/21 Annual MDS indicated the resident was moderately cognitively impaired and was coded as having one Stage 2 pressure ulcer that was not present upon admission.

Physician orders indicated:
*1/1/22: Clean bilateral buttock and right posterior thigh with soap and water; pat dry. Apply Aquaphor (topical ointment) every evening shift every three days.
*2/28/22: Right gluteal fold: Clean with normal saline (NS). Apply barrier cream and cover.

Review of the 3/2022 TAR indicated wound treatments were completed as ordered.

Weekly Skin Evaluations were reviewed for 1/2022 through 3/2022 and indicated:
*1/30/22: Buttocks wound with no description, measurements, or staging. Summary indicated the wound had "improved and "current treatment in place."
*2/2/22: Right buttock, left buttock, left gluteal fold, and right gluteal fold wounds. No measurements or staging. The only description of all four wounds was "redness." The summary indicated orders on TAR to complete weekly skin check to monitor improvement. Barrier cream being applied.
*2/20/22: Right gluteal fold wound, no description, measurements or staging. Summary indicated the provider had been notified and orders were entered in the TAR for monitoring of the wound.
*3/2/22: Form left blank.

A 3/17/22 Shower Skin Sheet indicated the resident had a "sore in [her/his] left bottom." There was no other description of the wound or an assessment.

On 3/15/22 at 11:52 AM Resident 14 stated she/he had a pressure sore on her/his bottom and was unsure if it was healing. Resident 14 stated staff attempted to reposition her/him, but she/he often refused and had the sore for "forever." Resident 14 declined to have the surveyor nurse observe the wound.

On 3/21/22 at 11:57 AM Staff 2 (DNS) stated facility treatment nurses were not completing wound assessments and acknowledged the multiple dates Resident 14's skin assessments were not completed or completed in full.

On 3/22/22 at 10:14 AM Witness 6 (Nurse Practitioner) stated she was unsure the status of Resident 14's buttocks wound.

Based on observation, interview and record review it was determined the facility failed to ensure residents received restorative services and appropriate orthotic devices for 4 of 4 sampled residents (#s 12, 14, 36, and 258) reviewed for ROM and mobility. This placed residents at risk for decreased mobility and independence. Findings include:

1. Resident 258 admitted to the facility on 2/8/22 with diagnoses including cerebral palsy and depression.

The 2/8/22 Care Plan indicated Resident 258 had contractures of her/his bilateral upper extremities related to cerebral palsy. Staff were instructed to provide a cloth/palm pad as needed to keep clean and prevent skin breakdown.

The 3/25/22 Admission MDS indicated Resident 258 was cognitively intact and was totally dependent on staff for transfers, eating, dressing, and bed mobility. The resident received zero days of ROM (both active and passive) in the look-back period.

a. A 2/22/22 Physician Order instructed staff to place an appropriate sized piece of foam into Resident 258's left hand one time a day for contracture.

Observations of Resident 258 from 3/14/22 through 3/17/22 did not reveal the resident with a piece of foam for her/his left hand contracture.

On 3/16/22 at 1:56 PM Resident 258 was asked about the foam for her/his left hand. Resident 258 stated the foam did not fit, it fell out of her/his hand and was not the right size, so staff did not use the foam.

On 3/17/22 at 9:13 AM Staff 35 (Restorative Services/CNA) stated Resident 258 had a" foam grip" in her/his bedroom drawer.

On 3/17/22 at 9:16 AM Staff 35 and surveyor entered Resident 258's room. Staff 35 acknowledged Resident 258 did not have the foam grip or other intervention for the resident's left hand and the foam grip was on the bedside table. Resident 258 stated the foam grip was too big. Staff 35 stated she would order a smaller one and was unsure how often the foam grip was to be used for the resident.

On 3/17/22 at 10:48 AM Staff 2 (DNS) acknowledged Resident 258 was not utilizing the ordered foam intervention as the device was not the correct size. Staff 2 stated resident care managers (RCMs) were expected to complete assessments for residents ensure the resident had the correct size foam, but the facility did not currently have any RCMs.

b. On 3/14/22 at 10:24 AM Resident 258 stated she did not receive physical therapy or restorative aid and had requested them. Resident 258 stated staff did not assist the resident with ROM. Resident's bilateral upper extremities were observed to be contracted.

On 3/17/22 at 9:13 AM and 9:16 AM Staff 35 (Restorative Services/CNA) stated no residents in the facility received RA for a year, as she was getting pulled to be a CNA and now there was no resident care managers (RCMs) to oversee the program. Staff 35 stated residents "want me back." Staff 35 further stated the facility did not have any in-house physical or occupational therapists.

On 3/17/22 at 10:48 AM Staff 2 (DNS) confirmed there was no RA program for the facility and no residents had received RA since 5/2021. Staff 2 confirmed Staff 35 was working the floor as a CNA and stated there were no RCMs to oversee the RA program.

2. Resident 12 admitted to the facility in 8/2018 with diagnoses including ulcerative colitis (inflammatory bowel disease) and diabetes.

The 2/25/22 MDS indicated the resident was cognitively intact and was totally dependent on staff for transfers and required extensive assistance for bed mobility. The resident did not receive therapy or a restorative program was not performed during the look-back period.

On 3/14/22 at 11:20 AM Resident 12 stated the facility ceased physical therapy in March 2021, and no one had offered to assist the resident with ROM. Resident 12 was observed to have a resistance band on her/his bed and stated that CNAs were unable to do RA with residents, including assisting the resident to use the band. Resident 12 stated management was aware she/he wanted therapy and RA, but stated she/he would have to "tell them again."

A 3/15/22 Physician Encounter note indicated the resident had a diagnoses of generalized weakness. Per the resident's report someone came to the facility to evaluate the resident for therapy, but the provider was also asked to put in a referral. The summary indicated a Physical/Occupational Therapy home health order for the resident was needed for home health services based on the resident's clinical condition.

On 3/17/22 at 9:13 AM and 9:16 AM Staff 35 (Restorative Services/CNA) stated no residents in the facility received RA for a year, as she was getting pulled to be a CNA and now there was no resident care managers to oversee the program. Staff 35 stated residents "want me back." Staff 35 further stated the facility did not have any in-house physical or occupational therapists.

On 3/17/22 at 10:48 AM Staff 2 (DNS) confirmed there was no RA program for the facility and no residents had received RA since 5/2021. Staff 2 confirmed Staff 35 was working the floor as a CNA and stated there were no resident care managers to oversee the RA program currently.

3. Resident 14 admitted to the facility in 11/2018 with diagnoses including a stroke resulting in hemi-paresis (paralysis of half the body) and a right hip fracture.

The 11/30/21 Annual MDS indicated Resident 14 was moderately cognitively impaired, and was totally dependent on staff for transfers and bed mobility. The resident did not receive therapy or a restorative program during the look-back period.

On 3/14/22 at 1:55 PM Resident 14 stated she/he wanted to receive RA, but there was not enough staff to help her/him do exercises.

The 3/2022 RNA (Restorative Nursing Aid) Ambulating Task Sheet indicated staff were to document how much time the resident spent practicing ambulating. The sheet was blank for the past 20 days reviewed.

A 3/14/22 Physician Encounter indicated Resident 14 had limited ROM and right sided weakness and staff were to perform passive range of motion right lower extremity (RLE) daily.

On 3/17/22 at 9:13 AM and 9:16 AM Staff 35 (Restorative Services/CNA) stated no residents in the facility received RA for a year, as she was getting pulled to be a CNA and now there was no RCMs to oversee the program. Staff 35 stated residents "want me back." Staff 35 further stated the facility did not have any in-house physical or occupational therapists.

On 3/17/22 at 10:48 AM Staff 2 (DNS) confirmed there was no RA program for the facility and no residents had received RA since 5/2021. Staff 2 confirmed Staff 35 was working the floor as a CNA and stated there were no RCMs to oversee the RA program currently.

4. Resident 36 was admitted to the facility on 7/2/18 with diagnoses including stroke, high blood pressure and dementia.

Resident 36's Admission MDS date indicated she/he was cognitively impaired.

Resident 36's care plan revised on 4/8/2021, indicated she/he was to receive restorative aid (RA) for right hand /wrist range of motion three times a week and bilateral leg extensions while seated in wheelchair as needed for leg contractures.

On 3/25/22 at 3:07 PM and on 3/28/22 Staff 2 (DNS) confirmed Resident 36 did not receive RA as ordered because the facility did not have an RA program since April 2021 due to staffing shortages.

B. Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions. Resident 17 admitted from a memory care unit.

The 12/10/22 Admission MDS indicated the resident was moderately cognitively impaired. The MDS did not indicate Resident 17 had wandering behaviors.

The Care Plan, last updated 12/28/21, did not indicate Resident 17 was an elopement risk.

The 12/14/21 Wandering Risk Assessment was not completed in full with the Behavior/Mood section, the Mobility section, and History of Wandering section left blank. The assessment categorized Resident 17 as a "Low Risk for Wandering."

Record review from 1/2022 through 3/2022 indicated Resident 17 had wandering and exiting-seeking behaviors with documentation of behaviors starting on 1/15/22. The records indicated:
*1/15/22 at 12:57 AM Resident wandering in hallways per wheelchair locomotion, accepting of staff redirection when attempts to go behind nurses desk or into wrong room.
*1/16/22 at 9:32 AM Resident was wheeling her/himself down the hall and yelling in other residents' rooms that she/he was going to put them on the "law suit." Resident if difficult to re-direct and she/he was resistive to cares.
*A 1/21/22 Physician Encounter Note completed by Witness 6 (Nurse Practitioner) indicated staff discussed Resident 17 going into other residents' rooms.
*1/24/22 at 12:25 AM Resident continued to have delusions and behaviors, such as going into other residents' rooms.
*1/25/22 6:35 PM Resident 17 was opening the facility door to head outside and was stopped by staff informing the resident it was cold outside. Later that evening staff heard the 300-hall door alarm sound and it was Resident 17 and staff redirected the resident back into the building.
*1/27/22 at 9:20 PM Resident had been increasingly exit seeking. The resident had some 1:1 time for redirection. It worked temporarily and redirection was needed again. Will continue to keep a close eye on resident.
*1/29/22 at 2:29 AM Resident currently now wandering throughout the facility via wheelchair.
*1/31/22 at 6:45 AM It was reported the resident was wandering and the staff could not find the resident for "a while." The resident was in another resident's room. Resident needs constant reorientation and reassurance and was unaware of her/his situation
*1/31/22 at 2:47 PM Resident continued to have delusions and was wandering and going into other residents' rooms.
*2/1/22 at 4:48 
PM Social Services spoke with Resident 17's daughter regarding Resident 17's behaviors today of agitation, exit seeking, hallucinations, and unable to re-direct behaviors. Daughter stated she was looking into Memory Care for the resident.
*2/2/22 at 10:34 PM Resident was caught wandering into other residents rooms, mostly male rooms. The resident was found at the back door by kitchen trying to get out of the facility.
*2/4/22 at 2:23 
PM Resident experiencing a lot of hallucinations and confusion on this shift. Resident was unable to be redirected and was barging into multiple other resident rooms. While attempting to remove resident from a resident's room Resident 17 yelled profanity at the nurse and hit the nurse twice.
*2/4/22 at 11:51 AM Resident went into room 102 and was asked to leave room after being reminded that it was against facility rules to enter rooms without permission. Resident was asked to leave, but refused. Resident was asked again to leave, but refused to do so. Resident was removed from room by staff.
*A 2/4/22 Physician Encounter Note completed by Witness 6 (Nurse Practitioner) indicated this week the resident had been exit-seeking and that day the resident was difficult to redirect and tried going to multiple residents' rooms.
*2/12/22 at 2:48 AM Exit seeking behavior noted, redirected with good effect.
*2/14/22 at 12:34 PM Resident was wrapping catheter around door handle last night and she/he was wandering throughout the facility.
*2/15/22 2:46 AM Call made to Resident 17's daughter to reinforce the resident is not safe in the building due to it not being a locked building.
*2/15/22 12:34 PM Resident 17 out in the parking lot attempting to get into a staff's vehicle and required multiple redirection to come back into the facility after explaining the resident would be warmer as it was cold outside.
*2/15/22 Provider Note completed by Witness 6 (Nurse Practitioner) indicated that day the resident had been exit seeking and hyper focused and going to other residents' rooms. That afternoon the resident got out into the parking lot and it took the resident's daughter coming in and redirecting the resident back inside.
*2/16/22 at 12:08 PM Resident asking where her/his mother was this AM. Staff able to redirect the resident when she/he was exit seeking.
*3/12/22 at 5:29 AM Resident having hallucinations, heightened restlessness, agitation and having difficulty staying asleep. The Resident had been wandering into other residents rooms.

The 2/15/22 Incident Investigation indicated on 2/15/22 at 12:20 PM Resident 17 was reported to be outside the facility in the parking lot next to a staff member's car with the door open. Resident 17 kept insisting she/he was going to leave. Staff attempted to redirect the resident multiple times and finally after getting Staff 2 (DNS) the resident agreed to return to the facility. The conclusion indicated: Resident 17 had diagnoses of legal blindness, dementia with behavioral disturbance and visual hallucinations. "Able to redirect resident's behaviors. Staff will continue to check [Resident 17] and reorient as [she/he] is noted with confusion." There were no witness statements.

There was no documented evidence the facility analyzed the hazards and risks related to Resident 7's elopement, updated the care plan, or implemented new interventions to reduce the hazards and risk associated with her/his elopement.

On 3/14/22 at 4:37 PM Witness 1 (Family Member) stated she was Resident 17's responsible party and was informed the night prior by Staff 15 (Unit Clerk) that Resident 17 had wandered outside the facility because the exit door down the 100-hall was unlocked. Witness 1 stated Resident 17 was an elopement risk and had attempted to leave the facility multiple times due to her/his diagnoses, but Witness 1 was only informed once when the resident would not come back inside the facility.

On 3/14/22 at 5:13 PM Staff 7 (LPN) stated on 3/13/22 the door down the 100-hall was left unlocked as the morgue had a collected a resident previously that day, but he was not aware of Resident 17 leaving the building.

On 3/14/22 at 5:17 PM Staff 15 (Unit Clerk) stated Resident 17 was an "escape artist" and she was informed a couple nights prior that Resident 17 got out of the emergency exit down the 100-hall and was informed by "morning staff." Staff 15 was unable to recall who specifically informed her of the incident, but believed the incident occurred over the past weekend (3/12/22 through 3/13/22). Staff 15 was unsure how long the resident was out of the facility, but management was aware of the incident.

On 3/14/22 at 5:23 PM Staff 39 (CNA) stated Resident 17 was "always" exit seeking and had previously gotten out of the back door that residents used to go smoke. Staff 39 stated on Thursday (3/10/22) the resident had gotten outside, but Staff 39 saw the resident right away and redirected the resident back inside. Staff 39 stated a few weeks prior she was coming onto her shift and found Resident 17 outside in the parking lot. Staff 39 stated staff did not have the ability to stop the resident as she/he was "so quick" and if staff were caring for another resident Resident 17 would "leave."

On 3/15/22 at 8:50 AM Resident 19 stated before Resident 17 moved rooms the resident would come into Resident 19's room and she/he would have to tell Resident 17 to leave. Resident 19 further stated the week prior staff were unable to locate Resident 17, so they went through all the rooms looking for Resident 17 and found the resident in another resident's bathroom.

On 3/15/22 at 4:13 PM Staff 19 (Admissions) stated he was not aware Resident 17 was outside the facility but was informed by Witness 1 on 3/13/22 that the resident attempted to leave the facility that day due to the door down the 100-hall being unlocked. Staff 19 stated he reported the incident to Staff 1 (Administrator).

On 3/15/22 at 4:18 PM Staff 1 (Administrator) stated she was aware Resident 17 had left the facility previously, but was not aware of Resident 17 recently leaving the facility out the 100-hall door as the door was "always locked."

On 3/15/22 at 4:44 PM Staff 26 (LPN) stated Resident 17 had wandering behaviors and liked to wander into other residents' rooms and all hallways. Staff 26 reported there were times staff could not find the resident and had to look throughout the facility for her/him.

On 3/15/22 at 8:11 PM Staff 28 (CNA) stated Resident 17 had wandering behaviors, including going into other residents' rooms and had nearly gotten out of the exit door down the 300-hall. Staff 28 stated Resident 17 would often go past the nurses' station, so staff would shut the fire doors to prevent the resident from leaving.

There was no investigation for the alleged incident Resident 17 left the facility during the month of 3/2022, until 3/24/22. The care plan did not indicate wandering and elopement behaviors or interventions. There was no updated assessment of Resident 17's wandering and elopement behaviors. There was no policy in place for wandering or elopement prior to 3/16/22.

On 3/15/22 at 9:47 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified Resident 17's elopement and attempted elopements constituted an immediate jeopardy situation.

A plan to abate the immediate jeopardy situation was submitted by the facility and accepted on 3/16/22 at 12:59 AM. The plan included:
*Resident 17 would be assessed for wandering/elopement March 16, 2022. The care plan would be updated to reflect the resident's risk of elopement and interventions by March 16, 2022.
*No other residents wander, therefore would not be at risk of elopement. However, if staff observe elopement/exit seeking/wandering behavior, an assessment would be completed.
*Visual observations of Resident 17's location would be done every 30 minutes for two weeks to establish a potential pattern. Observations would be adjusted accordingly if a pattern was identified.
*Visual observations would be documented on a spreadsheet, that identified the time, location, and staff member.
*Licensed nurses would be in-serviced on how to assess for wandering and elopement and an assessment would be implemented for all new admission residents by March 18, 2022. All staff would receive dementia training related to wandering and elopement by March 18, 2022.
*Random monthly audits of new admission orders would be completed by Staff 2 (DNS) or designee to assure residents who were assessed to be at risk of elopement were care planned for three months and then quarterly thereafter.

On 3/24/22 at 3:12 PM Staff 1 and Staff 2 were notified the immediacy was removed based on observations, staff interviews, and record review that the IJ immediacy removal plan was fully implemented.

2. Based on observation, interview, and record review it was determined the facility failed to ensure interventions were implemented and interventions were assessed and updated to prevent falls for 2 of 4 residents (#s 22 and 40) reviewed for falls. This placed residents at risk for repeated falls and injury. Findings include:

A. Resident 40 admitted to the facility on 7/15/21 with diagnoses including dementia and anxiety.

The 10/21/21 Quarterly MDS indicated Resident 40 was significantly cognitively impaired and indicated the resident had "two or more" falls since admission with no injury.

The Fall Care Plan was last revised 2/23/22. There were no interventions updated to prevent falls post the 9/20/21 fall until 1/10/22 when the care plan indicated Resident 40 was to wear non-skid socks and staff were to remind the resident to use the call light with each "meet and greet." The care plan had already included the interventions for non-skid socks and to remind the resident to use the call light on 7/15/21 and 7/18/21. The care plan did not indicate signs were to be placed in the resident's room to remind the resident to ask for assistance before transferring.

The 9/20/21 Post Fall Assessment indicated Resident 40 was found in her/his room on the floor after self-ambulating barefoot. The investigation indicated the resident hit her/his head on the dresser and was bleeding at the base of her/his skull. The resident was sent out to the hospital. Preventive measure included: Signs placed in room and bathroom to remind the resident she/he needs assistance with transfers. Recommendations to prevent further falls indicated: frequent checks, lower bed, and "constant" reminding to use the call light because of her/his dementia and her/his tendency to overestimate her/his abilities. There were no witness statements documented or neurological assessments post fall. The Post Fall Assessment was completed on 9/30/21.

Resident 40 sustained multiple falls since the 9/20/21 incident.

On 3/24/22 at 2:06 PM Resident 55's (Resident 40's roommate) call light was initiated. Resident 55 told Staff 49 (CNA) that Resident 40 had self-transferred to the restroom. Staff 49 was observed to enter the restroom with Resident 40. There were no signs in the resident's room or door of the restroom to remind Resident 40 to call for assistance prior to transferring.

On 3/24/22 at 2:09 PM Resident 55 stated she/he pressed her/his call light 10 minutes prior to alert staff that Resident 40 had self-transferred to the restroom. Resident 55 stated the facility was "so short handed" and stated Resident 40 had four falls since Resident 55 had been the resident's roommate.

On 3/24/22 at 2:16 PM Staff 50 (CNA) stated Resident 40 experienced multiple falls and interventions included: a gait belt, non-skid socks and the resident used to have signs in the room to remind her/him to use the call light. Staff 50 confirmed there were no signs in Resident 40's room or restroom door to remind the resident to call for assistance.

On 3/24/22 at 2:23 PM Staff 2 (DNS) acknowledged the fall investigation was not thorough for the 9/20/22 incident, the investigation was completed 10 days after the incident, and confirmed there were no signs in the resident's room or bathroom per care planned interventions.

B. Resident 22 was admitted to the facility on 12/2020 with diagnoses including cerebral vascular accident (CVA/Stroke) and morbid obesity.

The 12/2020 initial care plan indicated the resident required extensive assistance by two staff to turn and reposition in bed and required a mechanical lift with two staff assistance for transfers.

The 12/2021 MDS indicated the resident had a BIMS score of 11, moderately impaired cognition.

The revised 3/23/21 care plan identified the resident as a high risk for falls. Interventions included: Be sure bed is in lowest position when not providing care.

The 3/1/22 Post Fall Assessment stated Resident 22 had a witnessed fall in the room while being changed by a single staff member and was sent to the hospital to rule out a knee fracture.

The 3/11/22 Physician Orders: Bed rails, both sides for mobility and fall mats on both sides of bed.

On 3/14/22 at 10:42 AM observations of Resident 22's room revealed bed at regular height, no fall mats, and no side rails. Resident 22 stated she/he had a recent fall on 3/1/22 and had been "in misery ever since." Resident 22 stated she/he was leery about being dropped.

On 3/17/22 at 1:22 PM observed Staff 30 (Personal Care Assistance/PCA) in room with resident. Staff 30 acknowledged Resident 22's bed was not in the low position, there were no fall mats on either side of the bed and no side rails on the bed.

On 3/17/22 at 1:29 PM Staff 10 (LPN) confirmed Resident 22 did not have the bed in low position, no bed rails and no fall mats.

On 3/17/22 at 1:44 PM Staff 2 (DNS) observed Resident 22's room and confirmed the bed was not in low position, no bed rails on the bed and no fall mats. Staff 2 stated she expected orders to be implemented as soon as possible and she did not do it because she did not have time.


























, 1. Based on observation, interview, and record review it was determined the facility failed to ensure residents with dementia did not elope from the facility and the facility failed to ensure residents who were at risk for aspiration were supervised while eating for 4 of 14 sampled residents (#s 2, 17, 18 and 158) reviewed for elopement and aspiration precautions. These failures resulted in immediate jeopardy situations and placed other residents at risk for accidents. Findings include:

A. Resident 158 admitted on 2/2022 with diagnoses including sepsis, dementia and acute kidney failure.

The 2/18/22 hospital discharge diet orders indicated Resident 158 required 1:1 supervision with feeding.

The 2/18/22 RN Admission Progress Note indicated the resident was on a regular/pureed thin liquids diet. The note did not indicate Resident 158 was to receive 1:1 supervision with meals.

The revised 2/23/22 Admission care plan revealed there was no indication of the resident's diet or whether the resident required supervision with meals.

The 2/25/22 Admission MDS indicated the resident had severely impaired cognition.

A 2/25/22 narrative note entered by Witness 13 (hospice RN) on the Hospice Client Coordination Note Report, stated Resident 158 was 'up to WC (wheelchair) with the assist of one, ambulated in hall with assist of one, fed self after set up.'

The meal monitoring sheets from 2/27/22 through 3/27/22 revealed the resident had setup help only for all meals and twice the resident had one person physical assist.

On 3/14/22 at 11:42 AM Resident 158 was observed alone in her/his room. No aspiration signage noted in resident's room.

On 3/15/22 at 3:20 PM Staff 53 (CNA) stated so often residents were not supervised while eating as there were "so many" Personal Care Assistants (PCAs) and there were not enough staff to monitor residents. Staff 53 stated management had been told "over and over" and believed this was a form of neglect. Staff 53 further stated the facility needed a system for which residents received thickened liquids. Staff 53 stated new staff were not educated on who required supervision or thickened liquids and Staff 53 had seen residents not supervised during meals or provided thickened liquids.

On 3/15/22 at 5:31 PM Staff 13 (Personal Care Assistant) delivered Resident 158's dinner tray to her/his bedside table. Resident 158 was left unattended with the meal and staff closed the door.

On 3/15/22 at 5:35 PM Resident 158 was observed eating independently in the room with no staff present.

On 3/15/22 at 5:36 PM Staff 13 acknowledged Resident 158 was eating in her/his room independently and stated she/he ate independently and was not an aspiration risk.

On 3/15/22 at 5:41 PM Staff 7 (LPN) reviewed Resident 158's physician orders which indicated the resident was to be 1:1 supervision for meals. Staff 7 confirmed staff were not providing 1:1 supervision during meals and 1:1 meal supervision was not indicated on the resident's Kardex or care plan.

On 3/15/22 a request was made for the meal supervision policy. Staff 2 (DNS) stated the facility did not have a policy for meal supervision.

On 3/15/22 at 7:33 PM hospice physician's orders indicated to discontinue 1:1 feeding and the resident was able to self feed after set-up. There was no indication Resident 158 was assessed prior to the order change.

On 3/15/22 at 9:47 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during meals.

On 3/16/22 at 3:00 PM Witness 12 (Hospice RN) performed a swallow evaluation recommending a dysphagia level three (mechanical soft/minced/moist) diet with thin liquids and the resident no longer needed 1:1 assist with meals, set-up only.

On 3/16/22 at 4:12 PM hospice physician orders: 'DC previous diet order. New diet order: dysphagia level three, mechanical soft, thin liquids, set up assistance only.'

A plan to abate the immediate jeopardy situation was submitted by the facility and accepted on 3/16/22 at 12:59 AM.

An immediate plan of correction (POC) was requested.

The IJ Removal Plan included:

-The facility will follow the order for 1:1 supervision starting at breakfast on 3/16/22 by encouraging Resident 158 to go to the dining room and if unwilling facility will have the resident eat in the hall so the resident can be visualized by staff for meals.

-Resident 158 will be assessed by hospice for need of this supervision and orders will be obtained depending on the outcome of the assessment.

-Resident 158's care plan will be updated according to the assessment by 3/18/22.

-Orders for all residents will be reviewed to assure they are accurate and that all precautions are in place and assessed for appropriate meal supervision by 3/17/22.

-The facility will develop a policy and procedure for meal supervision by 3/18/22.

-Licensed nurses will be in-serviced on the process of entering admission orders and identifying precautions that need to be included in the orders.

-All nursing staff will be trained on what is required when a resident needs meal supervision from the policy that we develop 3/18/22.

-There will be a binder for agency staff to read our expectations regarding meal supervision and the staff who orient agency and new employees to the floor will include this policy and procedure.

-Random monthly audits of all new admit orders will be done by the DNS or designee to assure that precautions are in place for three months and then quarterly thereafter.

2. Resident 18 admitted to the facility in 2021 with diagnoses including dysphagia (difficulty swallowing) and Alzheimer's disease.

The 1/6/21 and 3/22/21 Care Plans indicated the following:
-Resident 18 had a swallowing problem;
-Resident 18 was to eat only with 1:1 supervision;
-Instruct the resident to eat in an upright position as close to 90 degrees as possible, body in midline position, upright 15 minutes after eating or drinking;
-Eat small bites slowly and to chew each bite thoroughly;
-Monitor, document and report PRN any signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and "appear concerned during meals."

a. On 3/17/22 at 8:26 AM and 8:29 AM Resident 18 was observed to be in bed with her/his bedside table in reach with a bowl of blueberries and strawberries. The resident was observed to be laying on her/his right side facing the bedside table with the head of bed slightly elevated. No staff were present in the room. Resident 18 took a bite of a strawberry and the Surveyor immediately exited the room to alert nursing staff.

On 3/17/22 at 8:31 AM Staff 11 (RN) entered Resident 18's room and acknowledged Resident 18 had blueberries and strawberries within reach. Staff 11 was informed of the observation of the resident eating independently and Staff 11 removed the food items.

On 3/17/22 at 8:40 AM Staff 54 (CNA) stated she was Resident 18's primary CNA today [3/17/22] and assisted the resident at breakfast earlier that morning. Staff 54 stated she left the strawberries and blueberries in a bowl on her/his bedside table that was "pushed away from [her/him]" and left the room. Staff 54 stated the resident was not to be left alone with food in the room and the resident "must have grabbed" the table and pulled it toward her/him. Staff 54 stated the resident was more alert and hungrier this morning than usual and grabbed the French toast off the fork at breakfast when she was assisting the resident which she/he usually did not do.

On 3/17/22 at approximately 9:00 AM Staff 1 (Administrator) was informed of the observation of Resident 18 having strawberries and blueberries in her/his room and was observed eating without staff present and was care planned to be 1:1 supervision with meals.

b. On 3/18/22 at 8:59 AM Resident 18 was observed in bed laying on her/his side facing the bedside table. There was a cup of grapes on the table and it was within the resident's reach.

On 3/18/22 at 9:01 AM Staff 55 (CMA) entered the room to pass medication to Resident 18's roommate. Staff 55 was asked by the Surveyor to observe Resident 18. Staff 55 acknowledged Resident 18 had a cup of grapes on her/his bedside table within reach. Staff 55 stated the resident was not to be left unattended with food in her/his room and removed the grapes from the room.

On 3/18/22 at 9:08 AM Staff 1 (Administrator) was informed of the observation of Resident 18 being unattended with grapes on her/his bedside table and she/he was care planned to be 1:1 supervision with meals.

3. Resident 2 admitted to the facility in 2021 with diagnoses including stroke.

The 2/9/21 physician order indicated Resident 2 was to receive a dysphagia mechanical soft diet with nectar thick consistency.

The 2/9/21 Care Plan indicated Resident 2 had swallowing problems related to a history of a stroke and required nectar thick liquids.

On 3/25/22 at 6:26 PM Resident 2 was observed in her/his room with the head of bed slightly elevated and had a water cup on the bedside table with a straw in it. The water was regular consistency and was not thickened. Resident 2 stated she/he had a swallow study completed and it was determined "stuff was going into my lungs." Resident 2 stated she/he preferred to have thickened liquids "to be safe" but had drank some thin water that was on her/his bedside table on 3/25/21.

On 3/25/22 at 6:33 PM Staff 33 (LPN) acknowledged Resident 2 had regular water in her/his cup on the bedside table within reach and acknowledged the resident was care planned to have thickened liquids. Staff 33 removed the water from the room.

On 3/25/22 at 6:47 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the observation of Resident 2 having thin liquids at the bedside within reach and acknowledged she/he was care planned for thickened liquids.

On 3/28/22 at 12:59 PM Staff 1 and Staff 2 that immediacy has been removed for the aspiration portion of F689 regulation.

Based on observation, interview, and record review it was determined the facility failed to ensure the administration of enteral nutrition was consistent with and followed the practitioner's order for 1 of 1 sampled resident (#49) reviewed for enteral tube feeding. This placed residents at risk for malnutrition and increased blood sugars. Findings include:

Resident 49 readmitted to the facility 3/2022 with diagnoses including dysphagia (difficulty in swallowing) and diabetes mellitus.

The 3/12/22 Physician Orders for enteral feeding: four times a day Jevity 1.5 237 ml (or house equivalent [Glucerna]). Bolus feed, hold if >150ml residuals. Give 130 ml water before and after each feed.

On 3/15/22 at 10:34 AM Staff 37 (Registered Dietician) made a recommendation in the progress note to change the resident's tube feeding from Jevity 1.5 237 ml four times a day to Glucerna 1.5 237 ml five times per day and change water flush to 150ml after each bolus.

On 3/21/22 at 4:14 PM Resident 49 was observed to receive two doses of 237 mls of Glucerna instead of the ordered one dose.

On 3/23/22 at 1:14 PM Staff 36 (LPN RCM) stated she found an email on 3/23/22 from the DNS written and sent on 3/16/22, asking her to follow up with the provider regarding Staff 37's tube feeding recommendations. Staff 36 stated she had not followed up with the order and confirmed it is her responsibility to get Staff 37's recommendations to the physician.

On 3/23/22 at 3:31 PM Staff 2 (DNS) stated Staff 37 recommendations were emailed to Staff 36 the former dietary manager. Staff 2 acknowledged she had sent an email to Staff 36 to follow up on Staff 37's recommendation and was not aware the order was not completed and expected it to be completed.

Based on interview and record review it was determined the facility failed to ensure a resident received PRN pain medication as ordered and was care planned for pain management to prevent an increase in pain for 1 of 1 sampled resident (#14) reviewed for pain management. This placed residents at risk for uncontrolled pain. Findings include:

Resident 14 admitted to the facility in 11/2018 with diagnoses including a stroke resulting in hemi-paresis (paralysis of half the body) and a hip fracture.

Resident 14 had the following pain medication orders:
*Acetaminophen Liquid (pain medication) 160 MG/5ML. Give 30 ml every eight hours for pain and not to exceed 4gm for all sources in 24 hours.
*Acetaminophen Liquid 160 MG/5ML. Give 20 ml every six hours as needed for pain and not to exceed 4gm in 24 hours from any source.

A 3/1/22 Encounter Note indicated Resident 17 had a right hip fracture in August 2020 and was experiencing increased pain.

On 3/14/22 at 1:55 PM Resident 14 stated her/his pain medications were "always" late and she/he often had pain in her/his hip.

On 3/17/22 at 1:33 PM Resident 14 stated she/he asked for pain medication "a long time ago" and had not received the medication. The resident did not express significant pain.

On 3/17/22 at 1:47 PM Staff 21 (CNA) stated Resident 14 requested pain medication and she informed Staff 14 (Agency RN) about the resident's request around 1:15 PM.

On 3/17/22 at 1:48 PM Staff 11 (Agency RN) and Staff 10 (LPN) stated the resident was not due for pain medications but would be able to receive them in an hour.

Review of the 3/17/22 MAR indicated Resident 14 had not received PRN acetaminophen.

On 3/17/22 at 2:05 PM Staff 10 (LPN) confirmed Resident 14 had both scheduled and PRN acetaminophen orders, but Point Click Care (healthcare software) would flag the medication as unable to administer for the timeframe, which was observed by the surveyor.

On 3/17/22 at 2:07 PM Staff 2 (DNS) stated Resident 14 was expected to receive both the PRN and scheduled acetaminophen as ordered when requested by the resident. Staff 2 stated there may have been a "glitch" in the software and staff needed to clarify the pain medication orders.

Refer to F657.

Based on observation, interview, and record review it was determined the facility failed to consistently monitor the resident post-dialysis and enter/obtain weights for 1 of 2 sampled residents (#24) reviewed for dialysis. This placed residents at increased risk for complications associated with dialysis treatment. Findings include:

Resident 24 admitted to the facility in 9/2018 with diagnoses including end stage renal disease.

The Care Plan, last updated 3/29/21, indicated Resident 24 received dialysis on Mondays, Wednesdays, and Fridays and staff were to monitor for changes in mental status or hypervolemia (condition of having too much water in the body). The care plan noted the resident had a history of needing to be hospitalized related to critical labs and had been sent from dialysis to the hospital.

A 5/13/20 Order indicated Resident 14's weights were to be recorded post dialysis on Monday, Wednesday, and Friday and to record as dry weight as the resident was not to be weighed at the facility (the resident was weighed at dialysis).

Review of the 3/2022 MAR and TAR did not indicate any orders for entering weights.

Review of the Weight Summary indicated the last weight entered for Resident 14 was on 3/9/22.

Review of the Pre/Post Dialysis Communication sheets for 2/2022 and 3/2022 indicated the forms were sent with the resident to every dialysis appointment. The post-dialysis section of the communication forms were not completed or were partially completed for 4 of the last 12 appointments (2/16/22, 3/4/22, 3/7/22, and 3/14/22) and 6 of the last 12 appointments (2/16/22, 2/21/22, 2/23/22, 3/2/22, 3/4/22, and 3/11/22) did not have the Dialysis Clinic information of pre and post dialysis weights and vitals completed in full. There was no 2/18/22 Dialysis Communication sheet in the resident's dialysis book.

A 3/14/22 Dialysis Note indicated the Dialysis Form and book were not sent to dialysis with the resident.

On 3/15/22 at 11:29 AM Resident 14 stated staff did not consistently check her/his dialysis site and vitals after dialysis. Resident 14 stated she/he was "supposed to" take the binder to dialysis, but it had not always gone with the resident.

On 3/17/22 at 12:36 PM Resident 14's Dialysis Book was observed to be at the nurses' station. Staff 10 (LPN) confirmed Resident 14 was at an additional dialysis appointment that week and staff did not provide the book for the resident to take to the dialysis appointment.

A 3/17/22 Dialysis Note indicated the dialysis form and book were sent with Resident 14 and a dry weight was entered for Resident 14. The note was completed by Staff 33 (LPN).

On 3/21/22 at 12:22 PM Staff 2 (DNS) acknowledged Resident 14's Dialysis Communication sheets were not completed for the identified dates, the binder was not consistently sent with the resident, and Resident 14's weights had not been obtained/entered for the resident in the medical record since 3/9/22.

Based on interview and record review it was determined the facility failed to comprehensively assess, create a person-centered care plan, and provide care and services to maintain the highest practicable level of well-being for residents with dementia for 1 of 2 sampled residents (#17) reviewed for dementia. This placed residents at risk for unmet needs. Findings include:

Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions.

The 12/10/22 Admission MDS indicated the resident was moderately cognitively impaired and had behaviors including rejection of cares during the lookback period.

The 3/13/22 Dementia CAA indicated the resident was diagnosed with unspecified dementia with behavioral disturbances, visual hallucinations, legally blind, and anxiety. The CAA further indicated the resident "may describe seeing water running down a wall, or people or bugs." The resident was on antipsychotic medications for behaviors.

There were no care planned interventions for Resident 17's behaviors related to dementia in the medical record prior to 3/17/22.

Resident 17's Care Plan, last updated 12/16/21 indicated the resident had a behavior problem related to "occasional hallucinations due to medical condition." Interventions included:
*Administer medications as ordered. Monitor/document for side effects and
effectiveness.
*Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. Resident could be quite frightened during these and does best with gently showing her/him (such as by touch) that the wall is not wet. Resident 17 could sometimes see water on the walls, animals or people when hallucinating.
*Caregivers to provided opportunity for positive interaction, attention. Stop and talk with "him/her as passing by."
*Explain all procedures to the resident before starting and allow the resident to adjust to changes.
*If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is
inappropriate and/or unacceptable to the resident.
*When the resident experienced hallucinations gently direct her/him to shut her/his eyes and look away from the image; switch on the room lights or if in a brightly lit area, move somewhere darker; distract her with an activity or conversation, simply get up and do something else. Hallucinations may disappear, however they often continue.

A 2/15/22 Provider Note completed by Witness 6 (Nurse Pracitioner) indicated she spoke with the resident's daughter and discussed different tactics that could be helpful with the resident;s behaviors. Resident 17's daughter indicated the resident was a very spiritual person and maybe if staff talked to the resident about that it would help calm the resident down. The note further indicated this intervention was discussed with staff and should be added to the care plan.

There was no indication this intervention was implemented or added to the care plan.

On 3/14/22 at 4:37 PM Witness 1 (Family Member) stated she was informed the night prior by Staff 15 (Unit Clerk) that Resident 17 had wandered outside the facility because the exit door down the 100 hall was unlocked. Witness 1 stated Resident 17 was an elopement risk and had attempted to leave the facility multiple times due to her/his diagnoses and previously made it outside the facility and refused to come back in.

On 3/14/22 at 5:23 PM Staff 39 (CNA) stated Resident 17 was "always" exit seeking and had previously left the facility. Staff 39 stated staff did not have the ability to stop the resident as she/he was "so quick" and if staff were caring for another resident Resident 17 would "leave."

On 3/15/22 at 8:50 AM Resident 19 stated before Resident 17 moved rooms the resident would come into Resident 19's room and she/he would have to tell Resident 17 to leave. Resident 19 further stated the week prior staff went through all the rooms looking for Resident 17 and found the resident in another resident's bathroom.

On 3/15/22 at 4:44 PM Staff 26 (LPN) stated Resident 17 wandered into other res rooms, all halls of the building and at times staff had to check all resident rooms to find the resident.

On 3/17/22 11:28 AM Staff 27 (CNA) stated Resident 17 had wandering behaviors and would go up to facility exits and try to open the doors. Staff 27 stated Resident 17 wandered into other resident's rooms and had to be redirected. Staff 27 was unaware of what Resident 17's interventions were to prevent wandering.

On 3/21/22 at 3:39 PM Staff 33 (LPN) stated Resident 17 was "always trying to leave" and wandered into other residents' rooms. Staff 33 further stated staff had to close the fire doors at night to prevent Resident 17 from wandering. Staff 33 stated interventions to help with Resident 17's behaviors included: hot chocolate, sandwiches, letting the resident pretend to take vitals as the resident worked as a nurse prior.

Progress Notes reviewed from 1/1/22 through 3/15/22 indicated Resident 17 had wandering behaviors including wandering into other resident rooms and exit-seeking.

There was no indication in the medical record that Resident 17 had wandering behaviors or interventions were careplanned to prevent wandering.

On 3/15/22 at 4:25 PM Staff 2 (DNS) acknowledged the resident was not care planned and interventions were not in place for wandering and agitation behaviors related to dementia.

Refer to F689 and F849.

Based on interview and record review it was determined the facility failed to follow pharmacy recommendations for 1 of 6 sampled residents (#23) reviewed for unnecessary medications. This placed residents at risk for medication side effects. Findings include:

Resident 23 admitted to the facility in 2019 with diagnoses including heart failure and hypertension.

The 2/17/22 pharmacy recommendation indicated the following:
-Resident 23 had the following elevated blood pressures and to evaluate if an addition to the hypertension therapy would be appropriate:
-2/13/22: 188/92
-2/14/22: 154/88
-2/15/22: 171/85
-2/16/22: 174/86
-2/17/22: 168/90

On 3/18/22 at 3:26 PM Witness 4 (Physician) indicated she was Resident 23's primary care physician and she received the 2/17/22 recommendation for the elevated blood pressures. Witness 4 further stated she followed up with the facility and indicated to forward the pharmacy review to the Resident 23's cardiologist since they were responsible for prescribing blood pressure medication.

There was no indication in the resident's clinical record that the cardiologist was notified.

On 3/17/22 at 2:27 PM Staff 2 (DNS) stated Resident Care Managers (RCM) were responsible for sending pharmacy reviews and the last time the facility had an RCM was approximately the end of January 2022. Staff 2 acknowledged there was no process for the facility to review pharmacy recommendations and follow up with residents' physicians.

On 3/17/22 at 4:45 Witness 10 (Pharmacist) indicated in 2/22 she noted elevated blood pressures and requested the provider evaluate the blood pressures and determine if an intensification or current therapy or the addition of new therapy would be appropriate and had not received a response for this request.

On 3/22/22 at 1:46 PM Witness 5 (Medical Records at Cardiologist Office) stated the facility did not notify the cardiologist of the 2/17/22 pharmacy recommendation for elevated blood pressure and to evaluate if additional hypertension therapy would be appropriate.

On 3/23/22 at 8:25 AM Staff 2 (DNS) acknowledged the Resident 23's pharmacy recommendation was not sent to Resident 23's cardiologist.

Based on interview and record review the facility failed to ensure residents were free from unnecessary medications for 1 of 6 sampled residents (#159) reviewed for unnecessary medications. This placed residents at risk for significant drug to drug, drug to disease interactions and adverse drug events. Findings include:

Resident 159 was admitted to the facility on 2/23/22 with diagnoses including congestive heart failure (CHF) (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) and atrial fibrillation (irregular heartbeat).

Resident 159's Hospital discharge orders dated 2/23/22 revealed:
-Demadex 5 mg once daily (used to treat fluid build- up in heart failure).
-DDVAP 0.2 mg at bedtime (used to decrease urine production and prevent bleeding).
-Eliquis 5 mg twice daily (a blood thinner used to lower the chance of stroke due to blood clots in residents with irregular heart- beats).

Resident 159's Hospital 2/23/22 Discharge Summary and Electronic Health Record did not include any labs assessing Creatinine Clearance or Glomerular Filtration Rate (GFR) (kidney function).

The Nursing Admission Assessment dated 2/23/22 e-signed by Witness 9 (Former Resident Care Manager) indicated "Medication regimen appears to be appropriate at this time with no known adverse effects."

A Progress Note dated 2/24/22 and signed by Witness 6 (Nurse Practitioner) indicated Resident 159 was to continue on Demadex 5 mg, DDVAP 0.2 mg and Eliquis 5 mg as previously ordered by the hospital physician.

Resident 159's 2/24/2022 through 3/12/2022 MARs revealed Resident 159 received all three drugs each day.

Resident 159's care plan dated 2/23/22 did not indicate any monitoring of fluid input and output, edema (accumulation of extra fluid in the body) or signs and symptoms of blood clots.

The Lexicomp Adult Drug information Handbook 30th Edition, 2021-2022 indicated the following:
-DDVAP was contraindicated in residents with heart failure.
-DDVAP was contraindicated in residents using loop diuretics (Demadex).
-DDVAP should have been used cautiously in residents with decreased renal (kidney) function.
-DDVAP should have been used cautiously in residents on anticoagulant therapy (Eliquis).
-For all indications fluid intake, urine volume, and signs and symptoms of hyponatremia (low sodium in the blood) should be monitored, especially in those residents with heart failure.

On 3/24/22 at 9:54 AM via telephone Witness 9 (Former Resident Care Manager) refused to speak with this surveyor about the resident's medication regimen investigation.

On 3/25/22 at 10:22 AM Witness 6 (Nurse Practitioner) stated she was familiar with Resident 159 and had seen her/him twice in the facility since admission from the hospital. She further stated when Resident 159 was admitted she only had the hospital discharge orders to go on because she did not have comprehensive access to the resident's clinical record which usually contained renal function labs. Witness 6 remembered questioning the incoming medication regimen but did not document it and continued the orders. Witness 6 stated she would "take the hit and the heat" for the medication error and further confirmed DDVAP was contraindicated in residents with heart failure, loop diuretic use and was to be used cautiously in residents on anticoagulants.

On 3/28/22 at 9:44 AM Staff 2 (DNS) confirmed when Resident 159 was admitted to the facility, Witness 9 evaluated the medication regimen and did not indicate based on other medication use and disease states including CHF or Atrial fibrillation DDVAP was contraindicated or was to be used with caution. She further confirmed Resident 159's Care Plan did not indicate monitoring of fluid input and output, edema or signs and symptoms of blood clots.

Based on observation, interview and record review it was determined the facility failed to provide palatable and appealing food for 5 of 5 sampled residents (#s 12, 19, 48, 55, and 109) reviewed for food. This placed at residents at risk for weight loss. Findings include:

Interviews with residents revealed the following regarding the food provided:

- On 3/14/22 at 11:10 AM Resident 12 stated she/he did not like the food and was given items she/he did not like.

-On 3/14/22 at 11:35 AM Resident 55 stated she/he did not care for the food and often was given items she/he did not want.

- On 3/14/22 at 1:48 PM Resident 48 stated the facility's food was not good and had no variety.

- On 3/15/22 at 8:37 AM Resident 19 stated the food was "so bad" and was often served "undistinguishable" meat.

- On 1/11/22 it was reported by Resident 109 the food provided was cold.

Review of the 2/24/22 Resident Council notes indicated several concerns regarding the food including:
- The chicken noodles and beef vegtables were no longer good.
- The breading on the chicken was soggy.
- The eggs were ice cold and when new eggs were requested, they were also cold.
- The soup was always cold.

On 3/18/22 at 12:15 a lunch test tray was sampled. The meal consisted of roasted potatoes that were dry and cold, mushy shrimp, lukewarm vegetables and a salad containing stale and soggy croutons.

On 3/18/22 at 12:20 PM Staff 1 (Administrator) was asked to sampled the test tray. Staff 1 confirmed the potato's were dry and cold, the crouton was stale and soggy and the shrimp was "the warmest item" on the plate. Staff 1 acknowledged improvements could be done to the food quality.

Based on observation, interview, and record review it was determined the facility failed to ensure dishwashing temperature logs were completed, staff personal items were not near resident food, and staff utilized face masks properly for 1 of 1 kitchen reviewed for kitchen. This placed residents at risk for cross contamination, illness and unsanitized kitchen items. Findings include:

1. On 3/14/22 and 3/18/22 the following observations were made in the kitchen:

-Staff 45 (Kitchen Prep Clerk) and Staff 46 (Dishwasher) were observed to have surgical masks below their noses.

-Staff 24 (Cook) was observed cooking at the stove with the surgical mask below his nose.

On 3/14/22 at 9:45 AM Staff 45 and Staff 46 acknowledged the surgical masks were below their noses.

On 3/14/22 at 9:46 AM Staff 47 (Dietary Manager) confirmed the surgical masks were not properly worn by Staff 45 and Staff 46.

On 3/18/22 at 1:25 PM Staff 24 confirmed the surgical mask was below his nose and did not fit properly.

2. On 3/18/22 at 1:26 PM two personal staff drinks were observed on the prep kitchen counter near resident food. Staff 23 (Dietary Aide) confirmed the drinks were for personal use and did not belong on the counter near resident food.

3. Review of Dish Machine Logs revealed the following:

- The February 2022 Log revealed 62 out of the 84 opportunities to document dishwasher temperatures were not documented. Of the 22 instances that were documented, 6 temperatures were below 150 degrees.

- The March 2022 Log revealed 30 out of 42 opportunities to document dish washer temperatures were not documented.

On 3/14/22 at 9:53 AM Staff 47 (Dietary Manager) confirmed the dishwasher logs were not completed as required for February 2022 and March 2022.

Based on interview and record review it was determined the facility failed to implement therapy orders in a timely manner for 2 of 2 sampled residents (#s 2 and 19) reviewed for therapy services. This placed residents at risk for a decline in mobility and lack of quality of life. Findings include:

1. Resident 19 was admitted to the facility on 12/15/21 with diagnoses including hypertension.

The 12/21/21 BIMS indicated Resident 19 was cognitively intact.

The 12/15/21 admission orders indicated Resident 19 had referrals for physical therapy and occupational therapy.

The 2/1/22 Physician Order indicated physical therapy and occupational therapy were to evaluate and treat Resident 19.

The 3/15/22 Progress Note indicated the resident reported she/he had not yet started therapy.

On 3/15/22 at 8:33 AM Resident 19 stated she/he had orders for therapy and was frustrated she/he had not yet received therapy services.

On 3/22/22 at 10:08 AM Witness 6 (Nurse Practitioner) stated Resident 19 had orders for therapy in 12/2021 and 2/2022 and she/he had not yet received therapy. Witness 6 futher stated the facility promised residents therapy but it either was delayed or did not happen.

On 3/22/22 at 1:10 PM Staff 2 (DNS) acknowledged the resident's orders for 12/15/21 and 2/1/22 were not implemented and stated the expectation was for the facility to refer to physical therapy and occupational therapy within 72 hours of the facility receiving the order. Staff 2 further stated a referral was made on 3/2/22 and was pending but as of 3/22/22 Resident 19 had not received physical or occupational therapy.

2. Resident 2 was admitted to the facility in 1/2021 with diagnoses including stroke.

The 2/3/22 BIMS indicated Resident 2 was cognitively intact.

The 2/6/22 Progress Note indicated Resident 2 stated she/he would like to try and drink thin liquids again and requested speech therapy for a dietary change. A request was sent to the provider.

The 2/25/22 Physician Order indicated Resident 2 was to receive a speech therapy assessment for a swallow evaluation and treatment for recommendations for her/his diet.

The 3/18/22 Provider Note indicated Resident 2 was "curious" about when she/he could get a speech evaluation done and she/he would like to see if an improvement could be made to her/his food consistency.

On 3/22/22 at 10:08 AM Witness 6 (Nurse Practitioner) stated the facility promised residents therapy but it either was delayed or did not happen.

On 3/25/22 at 6:26 PM Staff 2 (DNS) stated Resident 2 received a pureed diet and thickened liquids. Staff 2 further stated there was a 2/25/22 Physician Order for speech therapy but the resident had not yet received it.

2. Resident 18 was admitted to the facility in 1/2021 with diagnoses including Alzheimer's disease and failure to thrive.

The 2/4/22 skin assessment indicated there were no new skin issues noted and there were current orders in place for known skin issues, will continue to monitor and hospice will continue to evaluate. The note did not indicate Resident 18's wound type or measurements of wounds.

The 12/22/21 physician order indicated to cleanse the wound on the right lateral foot with wound cleanser, pat dry, apply iodosorb and calcium alginate to wound bed, apply skin prep to surrounding skin and cover with foam dressing. Change three times per week and PRN for soilage or accidental removal. Hospice nurse to change on Monday and Thursday, facility nurse to change on Saturday [and PRN].

On 3/16/22 at 1:47 PM Staff 11 (RN) and Staff 43 (RN) indicated they were the treatment nurses' for the entire facility on 3/16/22 and both staff were unaware Resident 18 had a pressure ulcer.

The 3/23/21 Care Plan indicated Resident 18 had a Stage 4 pressure ulcer to the coccyx. The care plan did not include information about Resident 18's pressure ulcer on the foot.

On 3/23/22 at 10:05 AM Witness 11 (Hospice RN) was observed to complete a dressing change for Resident 18. Witness 11 stated Resident 18 had a healed pressure ulcer to the coccyx but was still placing a dressing on the area for preventative care and a pressure ulcer on her/his right foot. The resident refused to allow for a preventative dressing to her/his coccyx wound but allowed staff to complete a dressing change on her/his right foot. The area was observed to be open and red. Witness 11 stated the pressure ulcer to the foot was red and had less slough than the week prior and it was improving. Witness 11 further stated if changes needed to be made immediately she communicated with different facility staff depending on who was working. Witness 11 stated she hand delivered hospice notes to the facility once a month and there was no process in place to ensure the facility received hospice notes timely after she visited the resident.

On 3/24/22 at 10:34 AM Staff 2 (DNS) acknowledged Resident 18 had an open pressure ulcer to the right foot and there was no indication of the stage of the pressure ulcer, no assessments, no measurements and no facility weekly skin assessments for Resident 18's pressure ulcer on the right foot. Staff 2 further acknowledged there were no hospice notes indicating the condition of the pressure ulcer until she requested the documentation from hospice yesterday (3/23/22).



, Based on interview and record review it was determined the facility failed to ensure a resident received coordination for end-of-life care for 2 of 3 sampled residents (#s 17 and 18) reviewed for hospice. This placed residents at risk for a lack of coordination of care. Findings include:

1. Resident 17 admitted to the facility in 12/2021 with diagnoses including dementia with behaviors and delusions.

The 12/10/22 Admission MDS indicated the resident was moderately cognitively impaired.

Resident 17 admitted to hospice on 2/27/22.

Resident 17 had PRN orders for:
*Haloperidol (antipsychotic medication) tablet 0.5 MG every two hours PRN.
*Lorazepam (antianxiety medication) tablet 0.5 MG every two hours PRN.

The 3/2022 MAR indicated Haloperidol was administered nine times out of the 13 days reviewed.

Progress Notes reviewed from 2/1/2022 through 3/14/22 indicated Resident 17 had multiple behaviors including wandering, calling out, hallucinations, aggression, agitation, and exit seeking.

On 3/18/22 the surveyor requested hospice notes for the past 30 days for Resident 17.

On 3/21/22 at 12:58 PM Staff 1 (Administrator) stated hospice notes were not available in the record for Resident 17 and she had to request them.

Hospice notes on 3/10/22 (provided on 3/21/22) indicated Resident 17 had increased behaviors and education was provided on giving both Haloperidol PRN and Lorazepam PRN for agitation as the facility was only giving Lorazepam PRN and not the Haloperidol PRN. A patient alert note indicated if the resident's daughter called reporting the resident was uncomfortable, "please call the facility and instruct them which medications to give. PRN dosing has been very inconsistent."

On 3/18/22 at 9:11 AM Witness 3 (Hospice LPN) stated she was seeing Resident 17 that day to increase scheduled psychotropic medications and use less PRN ones. Witness 3 stated she had "a lot" of concerns regarding communication with the facility. Witness 3 stated "at times" the facility did not notify hospice about Resident 17's behaviors, including elopement. Witness 3 further stated she had issues with medication orders being sent to the facility, but the facility not putting them into the system. Witness 3 stated she was doing "a lot of education" for PRN medication as staff were underutilizing the medication but were now "over using" them. Witness 3 further stated she did not have a specific facility contact to relay information to, just whichever charge nurse was on duty at the facility.

On 3/21/22 at 3:33 PM Witness 2 (Hospice RN) stated she had concerns about medication orders and having to keep calling the facility to ensure they received the order. Witness 2 stated orders were at times not implemented until the next day. Witness 2 stated facility staff were not utilizing PRN psychotropics for Resident 17 until a "crisis point", and by then it was difficult to get the resident back to baseline. Witness 2 stated she "used to" work closely with a resident care manager, but they were no longer at the facility. Witness 2 stated there was no specific contact who she relayed information to just whichever charge nurse was on duty.

On 3/28/22 at 12:40 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the communication concerns with hospice and stated if hospice had concerns they previously relayed them to resident care managers, but since the facility did not currently have resident care managers, hospice could contact Staff 1 or Staff 2 , but when asked if hospice was aware of who they could contact, Staff 1 stated "probably not."

Refer to F689 and F744.

Based on observations, interview, and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to systematically identify and correct deficiencies in the areas of comprehensive assessments, treatments and services to prevent pressure ulcers, accidents, antibiotic stewardship, care planning timing and revision, hospice coordination of care, pharmacy reviews, physician orders, restorative aid, and therapy orders. This placed residents at risk for multiple unmet care needs. Findings include:

1. The facility failed to ensure those who were at risk for aspiration were supervised while eating and failed to ensure residents with dementia did not elope from the facility for 3 of 14 residents reviewed, which resulted in an immediate jeopardy situation.

2. The facility failed to assess and monitor pressure ulcers for 2 of 2 residents reviewed.

3. The facility failed to ensure coordination of care with hospice for 2 of 3 residents reviewed.

4. The facility failed to develop and implement an antibiotic stewardship program.

5. The facility failed to ensure residents received restorative aide therapy to prevent a physical decline and implement therapy orders for 5 of 6 residents reviewed.

6. The facility failed to notify the physician timely for a change of condition and notify family for non-pressure skin for 2 of 5 residents reviewed.

7. The facility failed to follow physician orders, address skin conditions, and assess change of condition for 6 of 8 residents reviewed.

8. The facility failed to ensure interventions were implemented and residents were assessed to prevent falls for 3 of 4 residents reviewed.

9. The facility failed complete comprehensive assessments and implement, review, and revise resident care plans timely for 10 out of 25 residents reviewed.

On 3/28/22 at 12:40 PM Staff 1 (Administrator) and Staff 2 (DNS) stated the last QAA meeting was held on 1/20/22 on Zoom (video meeting). Staff 1 and Staff 2 stated the Nurse Practitioner did not come to the facility as often as previously. Staff 1 and Staff 2 stated the facility did not have resident care managers to complete weekly skin assessments. Staff 1 and Staff 2 stated due to staffing shortages restorative aide was not being completed. Staff 1 and Staff 2 stated they were not aware of any issues with hospice until it was brought up in survey. Staff 1 and Staff 2 further stated they were not aware of any issues with aspiration concerns and the elopement incident only occurred once to their knowledge. Staff 1 and Staff 2 stated the biggest reason the identified issues had not been addressed was due to the facility not having resident care managers.

Based on interview and record review it was determined the facility failed to develop and implement an antibiotic stewardship program (ASP) that included feedback to prescribing providers on their antibiotic use, review of antibiotic resistance patterns based on laboratory data (Antibiogram) specific for facility infections and follow-up surveillance to ensure treated infections met antibiotic use protocols (AUP) and represented the treatment of true infections versus colonization. These failures increased residents' risk for multidrug-resistant organisms (MRDO), Clostridioides Difficile (a bacterium that causes severe diarrhea) and adverse drug events for 1 of 1 facility. Findings include:

The CDC Core Elements of Antibiotic Stewardship https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html, dated 8/2021 indicated Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridoides difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Core elements of a facility Antibiotic Stewardship Program should include analysis of infections and causative bacteria along with resistant data specific to both the facility and the type of infection (Antibiogram). This information should be given to the prescriber for appropriate antibiotic selection. Further retrospective infection surveillance utilizing McGeers Criteria should be conducted to ensure correct use of antibiotic therapy adherence to facility antibiotic use protocols (AUP) and the treatment of true infections versus colonization.

The facility Antibiotic Stewardship Policy updated 9/19/21 indicated the following:
-Train staff and use the McGeers Criteria Surveillance Checklist as a tool to prevent unnecessary antibiotic use. A laminated copy will be at the nurses station.
-Follow up with MD about the choice of Antibiotics in relation to organisms found.

The policy did not include the use of a specific facility antibiogram or other mechanism to assess facility specific organism resistance patterns to antibiotic therapy for resident infections.

The infection log for October 2021 indicated there were 10 infections in the facility. Only two organisms were identified by Staff 48 (Infection Preventionist). Both were MRDO bacteria and included Extended Spectrum Beta Lactamases [(ESBL)(an enzyme produced by a bacteria to make it more resistant)] of unknown bacterial origin and ESBL- Methicillin Resistant Staphylococcus Aureus (MRSA)(a bacteria that is resistant to several antibiotics).

On 3/24/22 at 9:32 AM Staff 2 (DNS) stated she was not aware of a facility specific Antibiogram or other mechanism of assessing organism resistance patterns and there was no post infection surveillance being conducted to ensure correct treatment of infections and adherence to AUP. She further stated when a resident displayed signs and symptoms of an infection empiric (broad spectrum) antibiotic therapy was always utilized and then converted to more targeted antibiotic therapy once a culture and sensitivity report was received.

On 3/24/22 at 10:09 AM Staff 48 (Infection Preventionist) confirmed the last infection tracking log was completed in 10/2021 approximately 5 months ago. She further stated the reason organisms were not logged was due to the fact when resident treatment was initiated in the hospital the facility did not intercede with care. She was not aware of a facility specific antibiogram or other mechanism of assessing organism antibiotic resistance and post infection surveillance was not being conducted via McGeers criteria.

On 3/25/22 at 10:22 AM Witness 6 (Nurse Practitioner) confirmed she did not receive feedback from the facility regarding her antibiotic prescribing. She further stated she was unaware of a facility specific antibiogram or any similar mechanism of assessing organism antibiotic resistance patterns and any past surveillance of antibiotic use.

On 3/28/22 at approximately 1:00 PM Staff 1 (Administrator) confirmed the last data related to the facility ASP collected was in October 2021. She further stated no ASP data from 11/1/21 through 12/31/21 was included in the last facility QAPI meeting dated 1/20/22 and ASP data collected by the facility did not include feedback to facility prescribers, a facility specific antibiogram or other mechanism of assessing organism antibiotic resistance patterns or any post surveillance activity related to facility infections using Mcgeers criteria.

Based on observation, interview and record review it was determined the facility failed to ensure call lights were functioning for 2 of 3 halls (100 and 200 halls) reviewed for call lights. This placed resident at risk for delayed assistance and unmet needs. Findings include:

1. Resident 258 admitted to the facility on 2/8/22 with diagnoses including cerebral palsy and depression.

The 3/25/22 Admission MDS indicated Resident 258 was cognitively intact and was totally dependent on staff for transfers and bed mobility.

On 3/14/22 at 10:47 AM Resident 258's call light cord was observed to fall out from the wall when the resident attempted to initiate the call light button.

On 3/14/22 at 10:48 AM Staff 14 (Personal Care Assistant) confirmed Resident 258's call light cord came out of the wall and stated call lights had been coming out of the wall since she started working at the facility in mid-February. Staff 14 stated she was unsure if management was aware of the call lights coming out of the wall, but stated it was definitely an issue.

Review of the 2/2022 and 3/2022 Maintenance Logs indicated no call light concerns.

On 3/24/22 at 9:35 AM Staff 44 (Maintenance Director) stated he was aware call lights became loose and were coming out of the wall for certain resident rooms and started putting in longer cords. Staff 44 stated he was unaware of Resident 258's call light concerns. Staff 44 stated there had been issues getting nursing staff to put in work orders for maintenance issues.

2. Resident 14 admitted to the facility in 11/2018 with diagnoses including a stroke resulting in hemiparesis (paralysis of half the body).

The 11/30/21 Annual MDS indicated Resident 14 was moderately cognitively impaired and was totally dependent on staff for bed mobility and transfers.

On 3/15/22 at 11:44 AM Resident 14's call light cord was observed pulled out from the wall, unable to be utilized by the resident. Resident 14 stated the call light falling out of the wall occurred often.

On 3/15/22 at 11:45 AM Staff 9 (CNA) confirmed Resident 14's call light cord was pulled out of the wall and stated this occurred often as the cords were really short.

Review of the 2/2022 and 3/2022 Maintenance Logs indicated no call light concerns.

On 3/24/22 at 9:35 AM Staff 44 (Maintenance Director) stated he was aware call lights became loose and were coming out of the wall for certain resident rooms and started putting in longer cords. Staff 44 stated he was unaware of Resident 14's call light concerns. Staff 44 stated there had been issues getting nursing staff to put in work orders for maintenance issues.

3. Resident 12 admitted to the facility in 8/2018 with diagnoses including diabetes and unspecified intellectual disabilities.

The 2/25/22 Quarterly MDS indicated the resident was cognitively intact and was totally dependent on staff for transfers.

On 3/14/22 at 11:26 AM Resident 12 reported there were issues with her/his call light cord coming out of the wall.

Review of the 2/2022 and 3/2022 Maintenance Logs indicated no call light concerns.

On 3/24/22 at 9:35 AM Staff 44 (Maintenance Director) stated he was aware call lights became loose and were coming out of the wall for certain resident rooms and started putting in longer cords. Staff 44 stated he was unaware of Resident 12's call light concerns. Staff 44 stated there had been issues getting nursing staff to put in work orders for maintenance issues.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 6 days in December 2021, 14 days in January 2022 and 7 days from 2/12/22 through 3/14/22. reviewed for minimum CNA staffing. This placed residents at risk for delayed care. Findings include:

Due to Oregon's current statewide hospital capacity crisis, the Oregon Department of Human Services, Safety, Oversight and Quality Unit temporarily revised the Oregon Administrative Rules (OARs) related to certified nursing assistant staffing, effective immediately. The Department temporarily amended the minimum certified nursing assistant ratios as follows:

Current OARs for Certified Nursing Assistants (411-086-0100(C)):
o DAY SHIFT: 1 certified nursing assistant per 7 residents.
o EVENING SHIFT: 1 certified nursing assistant per 9.5 residents.
o NIGHT SHIFT: 1 certified nursing assistant per 17 residents.

Effective August 24th, 2021, Temporary OARs for Certified Nursing Assistants (411-086-0100(C)):
o DAY SHIFT: 1 certified nursing assistant per 8.5 residents.
o EVENING SHIFT: 1 certified nursing assistant per 12 residents.
o NIGHT SHIFT: 1 certified nursing assistant per 18 residents.

The Department also temporarily expanded definitions of who can be counted towards the minimum certified nursing assistant ratios. Effective immediately, nursing facilities may temporarily utilize the services of nursing assistants, personal care assistants, physical therapists and occupational therapists to account for up to 25% of the required minimum staff required on each shift.

The revised staffing ratios and use of staff other than certified nursing assistants to meet the minimum CNA staffing ratio is a temporary measure and will only be allowed during this statewide emergency.

411-086-0100 Nursing Services: Staffing -This updated filing suspends the temporary rule that was filed on August 24, 2021. The language that was in place prior to August 24, 2021 will become effective January 3, 2022. As announced in Provider Alert NF-21-067 dated November 19, 2021, the staffing ratios will return to the following:

Day Shift: 1 certified nursing assistant per 7 residents.
Evening Shift: 1 certified nursing assistant per 9.5 residents.
Night Shift: 1 certified nursing assistant per 17 residents.

OAR 411-070-0087 Bariatric Criteria and Services: (2) If an individual meets the criteria listed in section (1) of this rule, and the Department has authorized the bariatric rate, the facility must provide one (1) additional Certified Nursing Assistant, above the licensing staffing standard in OAR 411-086-0100(5), for every five (5) individuals receiving the bariatric rate.

The facility identified eight residents who received the bariatric rate.

Review of Direct Care Staff Daily Reports revealed the following dates CNA were below the minimum ratio required:
-12/18/21
-12/19/21
-12/24/21
-12/27/21
-12/30/21
-12/31/21
-1/1/22
-1/2/22
-1/3/22
-1/4/22
-1/6/22
-1/9/22
-1/10/22
-1/13/22
-1/14/22
-1/15/22
-1/16/22
-1/18/22
-1/20/22
-1/27/22
-2/12/22
-2/19/22
-2/21/22
-3/4/22
-3/8/22
-3/10/22
-3/13/22

On 3/18/22 at 10:19 AM and on 3/25/22 at 4:16 PM Staff 2 (DNS) confirmed the identified dates CNAs were below the required ratios.

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OAR 411-085-0310 Residents' Rights"Generally

Refer to F550
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OAR 411-086-0360 Resident Furnishings, Equiptment

Refer to F558
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OAR 411-086-0130 Nursing Services: Notification

Refer to F580
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OAR 411-085-0360 Abuse

Refer to F600, F609 and F610
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OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F636, F637, F656 and F657
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F658, F684, F693, F697, F698, F744 and F760
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventative Care

Refer to F686, F689
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OAR 411-086-0150 Nursing Services: Restorative Care

Refer to F688
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OAR 411-086-0310 Employee Orientation and In-Service Training

Refer to F730
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OAR 411-086-0260 Pharmaceutical Services

Refer to F756
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OAR 411-086-0250 Dietary Services

Refer to F804 and F812
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OAR 411-086-0220 Rehabilitative Services

Refer F825
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OAR 411-086-0010 Administrator

Refer to F849
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OAR 411-085-0220 Quality Asssurance

Refer to F867
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411-086-0330 Infection Control and Universal Precautions

Refer to F881 and F888
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411-087-0440 Electrical Systems: Alarm and Nurse Call Systems

Refer to F919
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