Stanley Post Acute

Resident 2 admitted to the facility in 2015 with diagnoses of diabetes and urinary incontinence. Resident 2's 1/9/26 MDS assessment indicated Resident 2 was dependent on staff for ADLs including bed mobility and toileting. Resident 2's Care Plan documented Resident 2 required two-person assistance and was dependent on staff for ADLs including toileting and bed mobility.-á Resident 2's Progress Notes documented: -At 7:40 PM on 2/7/26, Staff 3 (LPN) charted Resident was transferred to the hospital after a witnessed fall at 4:40 PM. -At 10:30 AM on 2/8/26, Staff 7 (RN) charted that a hospital social worker called to report Resident 2 required surgery on her/his legs. A 2/7/26 Fall Report initiated by Staff 3 on 2/7/26 at 6:50 PM documented: -Staff 5 (CNA) left the resident's room to request barrier cream from Staff 3, leaving Staff 4 (CNA) with Resident 2. -Resident 2 was left on her/his side. -While outside Resident 2's room, Staff 5 heard Staff 4 yell, ""Help! Help!"" -Staff 5 and Staff 3 found Resident 2 on the floor. -Staff 4 stated she had gotten a washcloth from Resident 2's drawer and wet it in the sink. Resident 2 suddenly yelled that she/he was rolling. -Staff 4 yelled for help and Staff 5 and Staff 3 came into the room. -On 2/9/26, the fall report was updated to reflect Resident 2 sustained bilateral femur fractures. In a written statement signed on 2/7/26, Staff 4 stated she was the only person in the room when Resident 2 fell. On 2/18/26 at 11:51 AM, Staff 3 stated Resident 2 required assistance of two staff for all ADL care including bed mobility and incontinence care for the duration of cares. She stated that on 2/7/26 around 6:30 PM, Staff 4 and Staff 5 were assisting Resident 2 with incontinence care. Staff 5 exited the room to request barrier cream from Staff 3, leaving Staff 4 alone with Resident 2. Staff 3 stated another CNA notified her of the fall. Staff 3 stated Resident 2 looked injured and she called 911. She stated Resident 2 sustained femur fractures as a result of the fall. On 2/19/26 at 2:22 PM, Staff 5 stated Resident 2 was unable to perform any bed mobility for her/himself. Staff stated Resident 2 was on her/his side when Staff 4 left the room to get barrier cream. Staff 5 stated she was ringing out a washcloth while Resident 2 remained on her/his side when she heard the resident say, ""Oh, I'm falling."" On 2/19/26 at 2:38 PM, Staff 4 stated she and Staff 5 were in the middle of changing Resident 2's brief and Resident 2 was on her/his side when Staff 4 left the room to get barrier cream. Staff explained Resident 2 required assistance of two people for bed mobility and incontinence care and that Resident 2 was dependent and unable to roll her/himself in bed independently. Staff 4 stated Resident 2 should have been rolled onto her/his back before she left the room.-á On 2/20/26 at 7:37 AM, Staff 8 (CNA) stated Resident 2 required assistance from two staff for bed mobility including rolling and for incontinence care. Staff 8 stated two staff were required to remain with Resident 2 for the duration of care or the resident should be rolled onto her/his back before staff left the room. On 2/20/26 at 7:42 AM, Staff 7 (RN) stated two-person dependent meant two staff must assist at all times during bed mobility and when changing Resident 2's brief. On 2/20/26 at 7:49 AM, Staff 18 (CNA) stated two-person dependent required two staff to assist Resident 2 for the duration of incontinence care and bed mobility, with one staff supporting Resident 2 on her/his side while the second staff completed care. On 2/20/26 at 9:01 AM, Staff 21 (LPN/Care Manager) stated Resident 2 was fully dependent on staff for all cares and required two-person assistance for bed mobility and toileting. She stated if a care plan documented two-person dependent, then two staff must remain with the resident throughout the care and should not leave the resident on her/his side unattended to prevent falling.-á On 2/20/26 at 9:13 AM, Staff 2 (DNS) stated for a two-person dependent resident, both staff must remain through the care and reposition the resident onto her/his back before leaving. -á -á

This Plan of Correction constitutes the facility’s written allegation of compliance for the deficiency cited in CMS 2567.  However, the submission of this plan is not an admission that a deficiency exists.  The Plan of Correction is prepared and executed solely because it is required by federal and state law. This response and Plan of Correction does not constitute an admission or agreement by the provider of the facts alleged or set forth in the statement of deficiencies. Resident 2 was sent to the hospital for evaluation. The Director of Nursing Services (DNS) or Designee conducted an audit of all resident falls in the last 14 days to verify the care plan was followed.  Any adverse findings were addressed immediately. The DNS or Designee educated direct-care staff regarding resident care plans and avoiding resident accidents.  Education was provided to all direct-care staff at the beginning of their shifts for the following 5 days.  To ensure ongoing compliance, education was also sent out to all direct care staff electronically. The DNS or Designee will conduct random audits of resident incidents for 4 weeks, and monthly for 2 months.  The Administrator or Designee will report the result of this audit at the monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Resident 37 admitted to the facility in 2025 with diagnoses including insomnia and depression.-á A 6/11/25 physician order indicated 25mg quetiapine fumarate (antipsychotic) related to insomnia for Resident 37. An updated 7/10/25 physician order indicated an increase of the quetiapine fumarate to 50mg related to depression.-á Review of Resident 37's medical record revealed no indication the resident was informed of the risks and benefits of the use of quetiapine fumarate. On 9/4/25 at 2:00 PM Staff 2 (DNS) acknowledged there was no evidence in Resident 37's medical record a risk and benefits of the quetiapine fumarate was completed.-á -á

This Plan of Correction constitutes the facility’s written allegation of compliance for the deficiency cited in CMS 2567.  However, the submission of this plan is not an admission that a deficiency exists.  The Plan of Correction is prepared and executed solely because it is required by federal and state law. This response and Plan of Correction does not constitute an admission or agreement by the provider of the facts alleged or set forth in the statement of deficiencies. Resident 37 was educated of the risks versus benefits of all psychotropic medications that they are prescribed. The Director of Nursing Services (DNS) or Designee did an audit of all residents that have been prescribed psychotropic medications.  Any adverse findings were addressed immediately. The DNS or Designee educated Licensed Nurses (LNs) on informing residents of the risks versus benefits of receiving psychotropic medications. The Social Services Director or Designee will conduct random audits of residents with psychotropic medications for 4 weeks, and monthly for 2 months. The Social Services Director or Designee will report the result of this audit at the monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

The facility's 9/2024 Advance Directive policy indicated residents were to be asked about, and provided with information about, advance directives upon admission and quarterly thereafter. 1.Resident 46 admitted to the facility in 2021 with diagnoses including diabetes. A 12/2023 POLST (Physician Order for Life Sustaining Treatment) indicated Resident 46's family member was the medical power of attorney. Resident 46's care plan, revised on 8/14/25, indicated the resident had an advance directive. The resident's advance directive was to be honored and kept in the medical record at all times. A review of Resident 46's medical record revealed neither the medical power of attorney form nor the advance directive were on file. On 9/3/25 at 12:36 PM Resident 46 stated she/he completed an advance directive with her/his family. On 9/3/25 at 1:42 PM Staff 12 (Social Services) was asked about Resident 46's advance directive and indicated a POLST (Physician Orders for Life Sustaining Treatment) was on file. Staff 12 indicated she was not familiar with the difference between a POLST and an advance directive and used the terms interchangeably. Staff 12 acknowledged Resident 46's advance directive was not in the resident's clinical record. 2. Resident 96 readmitted to the facility in 4/2025 with diagnoses including multiple sclerosis.-á The resident's care plan, updated 6/3/25, indicated Resident 96 had an advance directive. The advance directive was to be honored. A review of the resident's clinical record revealed the advance directive was not on file.-á On 9/3/25 at 12:31 PM Resident 96 indicated she/he completed an advance directive while residing in the facility.-á On 9/3/25 at 1:42 PM Staff 12 (Social Services) was asked about Resident 96's advance directive and indicated a POLST (Physician Orders for Life Sustaining Treatment) was on file. Staff 12 indicated she was not familiar with the difference between a POLST and an advance directive and used the terms interchangeably. Staff 12 acknowledged Resident 96's advance directive was not in the resident's clinical record. -á -á -á -á -á

The advanced directives for Residents 46 & 96 were obtained and made available to honor end of life preferences. The Medical Records Director or Designee conducted a 100% audit of resident records to ensure that advanced directives were available, if applicable.  Any adverse findings were addressed immediately. The Administrator or Designee educated the Interdisciplinary Team (IDT) on the importance of making advanced directives available. The Medical Records Director or Designee will conduct random audits of residents advanced directives for 4 weeks and then monthly for 2 months. The Medical Records Director or Designee will report the result of these audits at the monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Resident 96 was admitted to the facility in 8/2022 with a diagnosis of multiple sclerosis. -á A 3/18/2025 Restorative Nursing Referral revealed Resident 96 was to receive passive ROM exercises for her/his right and left lower extremities. -á Resident 96GÇÖs 7/31/25 Annual MDS revealed she/he was cognitively intact, had ROM impairment on both sides of her/his lower extremities and received no passive ROM during the seven-day look back period. -á Resident 96GÇÖs Comprehensive Care Plan last revised on 8/18/25 included a restorative nursing program to address her/his risk for decreased range of motion which included bilateral knee and right hip passive ROM exercises. -á A review of Resident 96GÇÖs ROM Program Task tracking form from 8/5/25 through 9/3/25 and a restorative nursing services binder revealed no documentation of restorative services were provided for Resident 96. The restorative nursing binder indicated Resident 96 was to receive ROM to her/his lower extremities. -á On 9/3/25 at 2:35 PM Resident 96 stated staff no longer provided ROM exercises for her/his legs. -á On 9/4/25 at 11:47 AM Staff 6 (CNA) stated the restorative nursing services binder indicated to staff which residents were supposed to be offered exercises but was unaware if Resident 96 received restorative services. -á On 9/4/25 at 1:30 PM Staff 7 (CNA) stated she did not provide passive ROM exercises to Resident 96's lower extremities when she worked with her/him. -á On 9/5/25 at 11:43 AM and 11:46 AM Staff 5 (LPN Resident Care Manager) stated Resident 96 had a restorative program to address her/his risk for contractures. Staff 5 stated the facility previously had a designated restorative aide, but CNAs were currently responsible to provide restorative services to residents. Staff 5 stated she expected staff to provide Resident 96 passive ROM exercises for her/his lower extremities as indicated in her/his care plan.

The restorative program was updated and communicated to direct care staff for Resident 96. Resident Care Managers (RCMs) or Designee audited 100% of residents with restorative programs.  Any adverse findings were addressed immediately. The DNS or Designee re-educated All Nursing Staff on the importance of restorative programs for increased range of motion. The DNS or Designee will conduct random audits of residents with restorative programs weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

On 9/4/25 at 7:00 PM Staff 3 (LPN) was observed to prepare insulin glargine for Resident 44, there was no open date on the insulin vial. The manufacturerGÇÖs instructions indicated the medication was to be discarded 28 days after opening. On 9/4/25 at 7:00 PM Staff 3 acknowledged the insulin glargine vial was open with no open date.

The indicated insulin vial was discarded. The DNS or Designee conducted a 100% audit of biologicals for proper labeling.  Any adverse findings were addressed immediately. The DNS or Designee re-educated LNs and Certified Medication Aides (CMAs) on the importance of labeling biologicals. The RCMs or Designee will conduct random audits of biologicals weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Resident 3 admitted to the facility in 1/2025 with diagnoses including blindness. -á A 2/1/25 Admission MDS indicated Resident 3 had no dental concerns. -á A 7/8/25 progress note indicated a physician ordered new bottom dentures for Resident 3. -á A 7/8/25 physician order indicated a new bottom denture was to be fabricated. -á No further information related to the new lower denture was found in the resident's clinical record. -á On 9/2/25 Resident 3 stated she/he had a dental appointment two months ago and was supposed to receive a new lower denture, but she/he did not receive anything and was unsure why. -á On 9/3/25 at 1:42 PM Staff 12 (Social Services) stated she was typically involved with assisting residents acquiring dentures but she was unaware of Resident 3's new order for a new lower denture.-á -á On 9/3/25 at 3:16 PM Staff 5 (LPN Resident Care Manager) indicated she was unaware of the resident's order for a new lower denture. Staff 5 acknowledged no follow-up was completed regarding the order since the appointment two months ago.

Resident 3 was assisted to obtain dentures and informed of potential delays in completing that process due to current insurance coverage. The Social Services Director or Designee conducted audits of residents needing dental care, addressing concerns as identified. The DNS or Designee educated All Staff on the importance of resident dental care. The DNS or Designee will conduct random audits of resident dental care needs weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

3. During 9/2/25 lunch meal service, the following was observed on the Northwest unit hallway: -On 9/2/25 at 12:00 PM Staff 8 (NA) carried a tray with partially eaten food out of Room 19 and then delivered a tray to Room 20 without completing hand hygiene. -On 9/2/25 at 12:03 PM Staff 8 left Room 20 and delivered a tray to Room 22 without completing hand hygiene. -On 9/2/25 at 12:04 PM Staff 8 left Room 22 and passed a drink to a family member of a resident in Room 18 without completing hand hygiene. -á On 9/2/25 at 12:10 Staff 8 stated they did not perform hand hygiene after leaving resident rooms during meal service. -á On 9/5/25 at 12:19 PM Staff 5 (LPN Resident Care Manager) stated staff were expected to perform hand hygiene after leaving a resident room during meal service. , 2. The blood glucose monitoring system manufacturer instructions indicated to disinfect the meter with EPA-registered wipes. The 8/1/24 facility policy and procedure indicated to clean glucometers according to manufacturerGÇÖs recommendation using EPA approved disinfectants to protect residents from cross contamination of blood-borne pathogens. On 9/4/25 at 7:00 PM Staff 3 (LPN) was observed to check Resident 44GÇÖs CBG using a community use glucometer. Staff 3 exited the room and set the glucometer on the cart without cleaning it. At 7:23 PM Staff 3 proceeded to enter Resident 40GÇÖs room using the same glucometer. The State Surveyor intervened, and Staff 3 went back to the treatment cart and used and EPA approved wipe to clean the glucometer. Staff 3 acknowledged she did not clean the community use glucometer between resident use and stated she usually cleans the glucometer but GÇ£it slipped my mind."" On 9/4/25 at 8:11 PM Staff 2 (DNS) stated staff were expected to clean community use glucometers using EPA approved wipes and ensure the two-minute dwell time was reached in between resident use. -á , The facility policy ""Guidelines for Cleaning and Disinfection of Non-Critical Resident Care Items"" dated 9/1/24 indicated: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 1.On 9/4/25 at 6:59 AM, Staff 4 (CNA) was observed exiting room 28 with a rolling vitals cart which contained reusable vitals equipment without cleaning the reusable vitals equipment. Staff 4 walked across the hall to room 29 and began to enter the room with the vitals cart without cleaning the vital equipment. Staff 4 stated she did not clean the vitals equipment because Room 28 did not have wipes, so she was going to clean the vitals equipment at the next resident's bedside with their wipes. Staff 4 walked across the hall to a precautions cart which had a package of FitRight Wet Wipes (personal care wipes) and used the personal care wipes to clean the vitals equipment. Staff 4 stated she was to use the purple alcohol wipes (Super Sani-Cloth wipes), but CNAs no longer had access to them, so she used the resident personal care wipes to clean the reusable vitals equipment. Staff 4 stated the personal care wipes were used to clean the residents, so it was okay to clean the vitals equipment.-á On 9/4/25 at 8:19 AM, Staff 2 (DNS) stated the facility staff were to clean the reusable vitals equipment between each resident with the Super Sani-Cloth wipes and stated the personal care wet wipes were not acceptable because it did not have the appropriate germicide. -á -á

Direct care staff were instructed to disinfect reusable medical equipment.  LNs were instructed to clean and sanitize CBG glucometers per manufacturers recommendations.  Direct care staff were instructed to perform hand hygiene in between passing trays during meals. To ensure ongoing compliance, the DNS or Designee audited direct care staff utilizing reusable medical equipment or CBG glucometers.  The DNS or Designee also audited hand hygiene during tray pass.  Any adverse findings were addressed immediately. The DNS or Designee educated All Staff on infection control practices, including cleaning or sanitizing equipment and hand hygiene. The DNS or Designee will conduct random audits direct care staff utilizing reusable medical equipment or CBG glucometers, and hand hygiene during tray pass, weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Resident 7 was admitted to the facility in 9/2015 with diagnoses including multiple sclerosis and overactive bladder. The 5/15/25 Quarterly MDS revealed Resident 7 had a BIMS score of 15, which indicated the resident was cognitively intact, and dependent for toilet hygiene. A review of the 9/14/24 Care Plan revealed Resident 7 required two-person assistance for toileting. A 2/4/25 facility investigation revealed Resident 7 fell out of bed when Staff 5 (Agency CNA) was providing toileting care and did not have a second person assisting. On 8/25/25 at 12:12 PM Resident 7 stated the staff member rolled her/him off the bed while providing care because the CNA stated she could provide the care herself and did not need another person to assist. On 8/28/25 at 1:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 7GÇÖs care was not followed when the fall occurred.

This Plan of Correction constitutes the facility’s written allegation of compliance for the deficiency cited in CMS 2567.  However, the submission of this plan is not an admission that a deficiency exists.  The Plan of Correction is prepared and executed solely because it is required by federal and state law. This response and Plan of Correction does not constitute an admission or agreement by the provider of the facts alleged or set forth in the statement of deficiencies. Direct care staff were educated on Resident 7’s need for two-person assistance for toilet hygiene. The Resident Care Managers (RCMs) or Designee(s) did an audit of all residents that required assistance for toilet hygiene.  Any adverse findings were addressed immediately. The DNS or Designee educated All Staff on accidents and resident who require assistance from more than one person. The DNS or Designee will conduct random audits of residents that need assistance during toilet hygiene 4 weeks, and monthly for 2 months. The DNS or Designee will report the results of this audit at the monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on record review and interview it was determined the facility failed to complete a discharge summary which included a recapitulation of stay and a final summary of the resident's status for 1 of 3 sampled residents (#1) reviewed for a discharge summary. This placed residents at risk for unmet needs post discharge. Findings include: Resident 1 admitted to the facility in 4/2024, with diagnoses including hip fracture and congestive heart failure. On 7/1/24, the State Agency received a public complaint which alleged Resident 1 was discharged home and the facility did not refer Resident 1 to her/his long standing home health agency. Witness 1 (Complainant) stated she made multiple phone calls to the facility in order to ensure Resident 1 received continuity of care with her/his home health agency upon her/his discharge. Witness 1 stated the facility referred Resident 1 to a different home health agency and the other home health agency never made a home visit. Review of the Discharge Summary dated 6/25/24 revealed that Resident 1 was discharged home. The Discharge Summary did not include a nursing or physician recapitulation of Resident 1's diagnosis, course of illness or treatment at the facility, pertinent home health agency or contact information, prognosis or condition on discharge. On 2/12/25 at 11:02 AM, Staff 3 (Social Services Director) stated it was an expectation that a resident discharge summary contain information about resident diagnoses, course of illness or treatment at the facility, prognosis or condition on discharge and home health agency and contact information. She further stated the facility typically referred discharged residents to their previous home health agency unless the agency was unable to resume services.

This Plan of Correction constitutes the facility’s written allegation of compliance for the deficiency cited in CMS 2567. However, the submission of this plan is not an admission that a deficiency exists. The Plan of Correction is prepared and executed solely because it is required by federal and state law. This response and Plan of Correction does not constitute an admission or agreement by the provider of the facts alleged or set forth in the statement of deficiencies. The discharge summary was completed for Resident 1. The DNS or Designee audited all discharges in the last 30 days to ensure discharge summaries were in place. Any adverse findings were addressed immediately. The Administrator or Designee educated the Inter-Disciplinary Team (IDT) on discharges summaries and the risks of unmet needs. The DNS or Designee will conduct random audits of discharged residents for 4 weeks, and monthly for 2 months. The DNS or Designee will report the results of this audit at the monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#4) reviewed for medication administration. This placed residents at risk for unmet medication needs. Findings include: Resident 4 admitted to the facility in 8/2024, with diagnoses including End Stage Renal Disease (ESRD) and clavicle fracture. Resident 4's initial care plan dated 8/24/24 revealed she/he received medications for pain and End Stage Renal Disease and attended dialysis two times per week. Physician orders dated 8/24/24 revealed Resident 4 was to receive Gabapentin (a medication for nerve pain), 100 mg capsule TID, and Sodium Zirconium Cyclosilicate, 1 packet QD for hyperkalemia (a condition where the potassium level in the blood is too high) on the resident's non dialysis days. Review of Resident 4's 9/2024 MAR revealed she/he was not administered Sodium Zirconium Cyclosilicate on 9/12/24 and 9/14/24 and was not administered Gabapentin on 9/24/24, 9/25/24 and 9/26/24. Progress notes reviewed from 9/12/24 through 9/26/24 did not provide an explanation as to why the medication was not administered. On 2/14/25 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings regarding missed medications and provided no additional information.

Resident 57 discharged from the facility The DNS or Designee audited medication administration records for all residents with a diagnosis of ESRD. Any adverse findings were addressed immediately. The DNS or Designee educated Licensed Nurses (LNs) on the importance of physician orders and the risk of unmet medication needs. The DNS or Designee will conduct random audits of resident’s medication administration records for 4 weeks and then monthly for 2 months. The DNS or Designee will report the results of these audits at the monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

****************************************** OAR 411-086-0160: Nursing Services: Discharge Summary Refer to F661 ******************************************* OAR 411-086-0110: Nursing Services: Resident Care Refer to F684 *******************************************

Based on interview and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 4 sampled residents (#114) reviewed for dignity. This placed residents at risk for lessened quality of life. Findings include: Resident 114 was admitted to the facility on 2/2024 with diagnoses including end stage renal disease and depression. A 3/20/24 Mistreatment Investigation revealed the following: * Staff 2 (DNS) was informed on 2/27/24 Resident 114 had a concern regarding her/his care. Staff 2 spoke with Resident 114, who indicated the incident occurred "roughly" one week prior. During the night shift, a female staff member entered the resident's room because she/he had a bowel movement in bed. The staff person stated, "Oh, you shit the bed." Resident 114 did not feel abused, but stated the staff person was rude. Resident 114 stated other staff assisted with cleaning her/him up. *Staff 2 determined Staff 26 (Former RN) worked with Resident 114 on 2/19/24 during the night of the incident. *Staff 26 recalled the incident and stated Resident 114 had a bowel movement, and "poop" was everywhere. Staff 26 denied making a derogatory comment towards Resident 114. Staff 26 stated she had a CNA and another nurse provide ADL care and clean the bed/bedding. Resident 114 was assisted back to bed. *Staff 21 (LPN) reported Staff 26 worked the night shift on 2/19/24. While the CNA assigned to Resident 114 was on break, Resident 114's roommate peaked her/his head out and indicated they needed help in the room. Staff 26 went into the room and immediately came back to the nurses' station and stated, "[She/He] shit everywhere, [she/he's] wiping it everywhere." Staff 26 asked Staff 21 to assist in cleaning Resident 114 up. The bedding was changed, and Resident 114 received a shower before being situated back in bed. *Conclusion: Mistreatment was ruled out. Staff 26 provided all necessary cares at the time of the incident and denied speaking to Resident 114 in the alleged manner. No other resident concerns were reported. Staff 26 received education regarding customer service in the workplace. On 5/13/24 at 2:07 PM Witness 1 (Complainant) stated Resident 114 reported a bowel incident which occurred roughly in the middle of 2/2024. Witness 1 stated during the night, Resident 114 had a bowel movement, and a staff person entered the resident's room, saying, "You shit all over yourself and the bed." Witness 1 stated Resident 114 was embarrassed and did not want to talk about the incident. Witness 1 stated the facility investigated the incident but Witness 1 was unsure of the outcome. On 5/14/24 at 10:57 AM Resident 114 stated she/he recalled the incident, which happened during night shift. Resident 114 stated she/he had an "accident" (bowel movement) in bed. Staff 26 entered her/his room and stated, "You shit all over the place." Resident 114 stated Staff 26 "berated" her/him and the incident was "embarrassing." Resident 114 stated two other staff members assisted in cleaning her/him up. Attempts were made on 5/15/24 and 5/16/24 to reach Staff 26, but were unsuccessful. On 5/16/24 at 2:25 PM Staff 21 (LPN) stated she recalled the incident on 2/19/24 with Resident 114. Staff 26 approached the nurses' station and reported the resident, "had shit everywhere." Staff 21 stated she and another CNA, along with Staff 26, cleaned up the resident and her/his bedding. On 5/17/24 at 2:50 PM Staff 2 (DNS) stated she initiated and completed the investigation. Staff 26 denied she made derogatory comments towards Resident 114 and assisted in cleaning her/him. Staff 2 stated education was provided to Staff 26, and she did not return to the building after the 2/19/24 incident. On 3/3/24, the Past Noncompliance was corrected when the facility completed the following: 1. Performed a thorough investigation of the incident and submitted a FRI on 2/27/24. 2. Interviewed Resident 114 and other residents in the facility and asked about care concerns. 3. Interviewed staff involved in the incident. 4. Educated Staff 26 and she did not return or work for the facility after 2/19/24 incident.

Based on observation, interview and record review it was determined the facility failed to assess self-administration of a medication for 2 of 3 sampled residents (#s 8 and 26) reviewed for self-administration of medication. This placed residents at risk for unsafe medication administration. Findings include: The facility's Self-Administration Medication policy last revised on 3/2020, specified the following: -Upon admission the resident's desire to self-administer is ascertained. -During the 14-day admission assessment period the RCM (Resident Care Manager) evaluates the resident's ability to self-administer medications. -If the resident has the cognitive, physical, and emotional ability to self-administer their own medications in a safe and prudent manner a plan for self-administration is established with the resident. -A physician order is obtained indicating the specific medications that the resident is able to self-administer. -The self-administration is on the resident's care plan to include location of drugs, documentation procedure, place of administration and specific medications. -The resident is reevaluated for continued ability to self-administer their medications annually and with significant change in condition. 1. Resident 8 was admitted to the facility in 4/2024 with diagnoses including a stroke and heart disease. A Physician Order dated 4/29/24 revealed Resident 8 was to receive Artificial Tears ophthalmic solution and to instill one drop in both eyes as needed for dry eyes daily. A 4/30/24 Admission MDS indicated Resident 8 had a BIMS score of 14 and she/he was cognitively intact. A review of Resident 8's clinical record revealed no evidence that a self-administration of medication assessment was completed. Random observations from 5/13/24 through 5/16/24 revealed Resident 8 was in bed, and a small green bottle labeled "Artificial Tears" was on her/his bedside table. On 5/14/24 at 10:40 AM Resident 8 stated the eye drops were for her/his eyes and she/he self-administered the eye drops. On 5/16/24 at 11:42 AM Staff 6 (CNA) stated Resident 8 was confused at baseline. Staff 6 stated she did not notice the eyedrops on the resident's bedside table, but Resident 8 required assistance from a nurse in administering the eye drops. On 5/16/24 at 2:39 PM and 3:20 PM Staff 12 (LPN-Resident Care Manager) stated she was unaware Resident 8 had eye drops accessible at her/his bedside table and thought maybe a family member brought the eye drops in. Staff 12 removed the eye drops from the resident's bedside table. Staff 12 stated the resident was not to self-administer eye drops unless a self-medication assessment was completed. , 2. Resident 26 was admitted to the facility in 1/2024 with diagnoses including paraplegia. The 1/15/24 Admission MDS revealed Resident 26 was cognitively intact. On 5/17/24 at 10:42 AM Resident 26 stated she/he kept a prescription medication, ipratropium bromide nasal spray (used for rhinitis), at her/his bedside in a locked box. Resident 26's comprehensive care plan, last revised on 3/25/24, revealed the resident self-administered certain prescription medications including ipratropium bromide nasal spray. A review of Resident 26's health record indicated a self-administration of medication evaluation was completed on 2/23/24, however, Resident 26 was not assessed to self-administer ipratropium bromide nasal spray. On 5/17/24 at 11:14 AM Staff 36 (Agency RN) stated Resident 26 had self-administered ipratropium bromide nasal spray and reported to the charge nurse when she/he self-administered the medication and if the dose was effective. Staff 36 stated he then documented in the resident's medical record of the administration and the result. On 5/20/24 at 1:57 PM Staff 12 (LPN Resident Care Manager) confirmed the resident was not assessed to self-administer ipratropium bromide nasal spray.

This Plan of Correction constitutes the facilitys written allegation of compliance for the deficiency cited in CMS 2567. However, the submission of this plan is not an admission that a deficiency exists. The Plan of Correction is prepared and executed solely because it is required by federal and state law. This response and Plan of Correction does not constitute an admission or agreement by the provider of the facts alleged or set forth in the statement of deficiencies. Resident 26 was assessed for self-administration of medications. The indicated items were removed from Resident 8s bedside. The DNS or Designee did an audit of any resident who self-administers medications. The Central Supply Coordinator or Designee audited all resident rooms to ensure there were no unapproved items at the bedside. Any adverse findings were addressed immediately. The DNS or Designee educated All Staff on unapproved items at the resident bedside and residents self-administering medications. The Central Supply Coordinator or Designee will conduct random audits of resident rooms for 4 weeks, and monthly for 2 months. The DNS or Designee will conduct random audits of residents who self-administer medications for 4 weeks and monthly for 2 months. The DNS or Designee will report the result of this audit at the monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to ensure resident personal property was identified upon admission, and clothing was retained and accessible for 2 of 4 sampled residents (#s 20 and 57) reviewed for personal property. This place residents at risk for loss of personal property. Findings include: The facility's Resident Personal Items Safekeeping policy, last revised 4/2023, specified the following: -All personal items, including but not limited to clothing, dentures, glasses, and hearing aids must be marked with the resident's name upon admission. -The facility designee will assist residents and families with marking the personal belongings. -On admission and thereafter each time a resident's personal possession is brought into the facility, the item will be recorded on the resident's inventory record by designated staff and signed by the resident or responsible party. -If any personal items is lost during a resident's stay, an investigation will be completed by the facility and the results will be communicated to the resident and/or family. -The Administrator/designee will discuss the method of replacement for lost items with the resident and/or family. 1. Resident 57 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes. The Annual MDS dated 4/19/24 revealed Resident 57 had a BIMS score of 15 and was cognitively intact. Resident 57's Inventory Record dated 4/19/24 revealed the resident had one pair of black shoes, navy blue sleeping shorts, a black pair of slacks and a black t-shirt. On 5/13/24 at 11:40 AM, the resident was observed in bed wearing a facility nightgown. Resident 57 stated she/he wanted to be dressed in her/his own clothing but it was "hit or miss" if this was offered by staff. The resident stated she/he was uncertain of the location of her/his clothes. Random observations from 5/14/24 through 5/17/24 revealed Resident 57 was either in bed wearing a facility nightgown or in bed with no nightgown on, with her/his chest exposed. On 5/14/24 at 7:22 PM Staff 15 (CNA) and on 5/16/24 at 12:53 PM Staff 14 (CNA) stated Resident 57 requested to be dressed, but the resident did not have appropriate clothing to wear. Staff 14 and Staff 15 were unsure where the resident's clothes were, which was why Resident 57 was consistently in her/his nightgown. Staff 15 stated he reported the resident's lack of clothing to a nurse. On 5/17/24 at 4:01 PM Staff 9 (RNCM) entered the room with the surveyor and located Resident 57's black shoes, a pair of shorts and a black jacket. None of the items had Resident 57's name on them. Staff 9 reviewed Resident 57's Inventory Record and acknowledged the resident admitted with a pair of slacks and a T-shirt, which were not found in her/his room. Staff 9 stated no missing form was completed or missing items were reported to her regarding Reident 57's missing clothing items. Staff 9 stated Resident 57's clothing items were to be labeled, and any missing clothing items were to be reported. Staff 9 further stated the resident was to be dressed per her/his request. , 2. Resident 20 was admitted to the facility in 2020 with diagnoses including depression and anxiety. The 4/2/24 Annual MDS indicated Resident 20 was cognitively intact. On 5/14/24 at 2:43 PM during a resident group meeting, respect of resident's personal possessions was discussed. Resident 20 stated she/he submitted a grievance form in 3/2024 regarding missing and broken personal property, but was not reimbursed. On 5/15/24 at 11:34 AM two submitted grievance forms, dated 3/21/24, were reviewed. One grievance form indicated the resident was missing several clothing items. The second grievance form indicated a staff member pulled down and damaged hanging lights in the resident's room. Both grievance forms indicated a reimbursement was approved by Staff 1 (Administrator) on 3/25/24. A copy of the receipt for reimbursement was requested on 5/15/24 by the survey team. On 5/16/24 at 11:00 AM two cash disbursement vouchers were provided and revealed a cash reimbursement for Resident 20's missing clothing and broken personal property was issued on 5/15/24. On 5/16/24 at 3:04 PM Staff 3 (Corporate Social Service Director) confirmed the resident's request for reimbursement for personal possessions was not completed timely.

Resident 57 items were located, marked, and returned. Resident 20 was reimbursed. The Environmental Services Director audited residents’ clothing to ensure it was properly marked and listed on their inventory sheets. The Medical Records Director or Designee audited grievances for timeliness. Any adverse findings were addressed immediately. The Administrator or Designee educated All Staff on the importance of marking personal clothing addressing resident grievances in a timely manner. The Environmental Services Director or Designee will conduct random audits of resident’s personal items for 4 weeks and then monthly for 2 months. The Medical Records Director or Designee will conduct random audits of resident grievances weekly for 4 weeks and then monthly for 2 months. The Medical Records Director and Environmental Services Director or Designee(s) will report the result of these audits at the monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to comprehensively assess 8 of 14 sampled residents (#s 25, 26, 32, 36, 52, 55, 57 and 114) reviewed for medications, pressure ulcers, ADLs, pain and nutrition. This placed residents at risk for unassessed needs. Findings include: 1. Resident 57 was admitted to the facility on 4/2024 with diagnoses including chronic heart failure and diabetes. The 4/25/24 Admission MDS indicated Resident 57 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 4/25/24 MDS indicated "psych meds per physician orders." The CAA did not indicate a description of the problem, causes and contributing factors or how the resident's symptoms manifested or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 2. Resident 55 was admitted to the facility on 4/2024 with diagnoses including a Stage 3 (full thickness tissue loss) pressure ulcer to the tailbone. The Pressure Ulcer CAA dated 4/22/24 indicated Resident 55 "needs assist with adls and transfers, has pressure injury to buttocks." The CAA did not include a description of the problem, causes and contributing factors, any alternatives discussed or tried or an overall analysis of the pressure ulcer. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 3. Resident 36 was admitted to the facility on 9/2022 with diagnoses including arthritis and polyneuropathy (nerve pain). The 11/17/23 Significant Change MDS and the 2/15/25 Quarterly MDS indicated Resident 36 received scheduled and PRN pain medication. The Pain CAA associated with the 11/17/23 MDS indicated "no change to plan of care." The CAA did not include a description of, how the resident displayed pain symptoms or whether the medications and any other interventions were effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. 4. Resident 114 was admitted to the facility on 2/2024 with diagnoses including end stage renal disease and depression. The 2/20/24 Admission MDS indicated Resident 57 received an antidepressant medication and was occasionally incontinent of urine and frequently incontinent of bowel. The CAAs associated with the 2/20/24 MDS revealed the following: -The Psychotropic Drug Use CAA indicated "takes anti-depressants per physician orders." The CAA did not indicate a description of the problem, causes and contributing factors, how the resident's symptoms manifested or whether the medications were effective. -The Urinary Incontinence and Indwelling Catheter CAA indicated "has occasional incontinence and requires assistance with toileting." The CAA did not indicate a description of the problem, causes or contributing factors. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive. , 5. Resident 25 admitted to the facility in 6/2022 with diagnoses including falls and chronic pain syndrome. The 6/20/23 Annual MDS indicated Resident 25 received scheduled and PRN pain medication. The Pain CAA associated with the 6/20/23 MDS indicated Resident 25 had pain that affected sleep, day-to-day activities and almost constant pain. The CAA did not include a location of the pain, how the resident displayed pain symptoms or whether the medications and other pain interventions were effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. Staff 16 further stated she communicated as needed with the Resident Care Managers and the IDT (Interdisciplinary Team). On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. 6. Resident 32 admitted to the facility in 3/2024 with diagnoses including right lower extremity cellulitis and diabetes. The 3/26/24 Admission MDS indicated Resident 32 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 3/26/24 MDS indicated "antidepressant use per physician orders." The CAA did not indicate a description of the problem, causes and the contributing factors, how the resident's symptoms manifested, or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. Staff 16 further stated she communicated as needed with the Resident Care Managers and the IDT (Interdisciplinary Team). On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. , 7. Resident 26 was admitted to the facility in 1/2024 with diagnoses including glaucoma and depression. The 1/15/24 Admission MDS indicated Resident 26 had adequate vision and received an antidepressant medication. The CAAs associated with the 1/15/24 MDS revealed the following: -The Visual Function CAA indicated "has glaucoma." No further information was provided specific to the resident's current visual functioning, use of visual appliances, or other treatments in place. -The Psychotropic Drug Use CAA indicated "takes antidepressants for depression." The CAA did not indicate a description of the problem, causes and contributing factors or how the resident's symptoms manifested or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAAs were not comprehensive. 8. Resident 52 was admitted to the facility in 4/2024 with diagnoses including depression. The 4/10/24 Admission MDS indicated Resident 52 received an antidepressant medication. The Psychotropic Drug Use CAA associated with the 4/10/24 MDS indicated "received antidepressant per physicians orders." The CAA did not indicate a description of the problem, causes and contributing factors or how the resident's symptoms manifested or whether the medication was effective. On 5/20/24 at 8:58 AM Staff 16 (MDS Coordinator) stated she was responsible for completing the MDS assessment and CAAs for all residents. Staff 16 stated she worked remotely and reviewed resident electronic medical records to complete the CAA section. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated she was unfamiliar with the process of completing the CAAs. Staff 2 stated Staff 16 was responsible for the MDS and CAA assessments, and there was daily communication regarding residents' assessments. Staff 1 (Administrator) and Staff 2 acknowledged the CAA was not comprehensive.

The CAAs for Residents 25, 26, 32, 36, 52, 55, 57, and 114 were updated and the residents were assessed for medications, pressure ulcers, ADLs, pain and/or nutrition as indicated on the MDS. Resident Care Managers (RCMs) or Designee audited CAAs for current residents, addressing any concerns identified. The DNS or Designee re-educated RCMs and MDS Coordinator on the importance of comprehensive CAAs. The DNS or Designee will conduct random audits of resident CAAs weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission for 2 of 3 sampled residents (#s 4 and 44) reviewed for care planning. This placed residents at risk for being uninformed about their plan of care. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including paralysis of left side and osteoporosis. On 5/14/24 Resident 4's clinical record was reviewed. No record was found that Resident 4 had a baseline care plan reviewed or provided to her/him. On 5/16/24 at 12:33 PM Staff 3 (Corporate SSD) confirmed no baseline care plan was discussed or provided to Resident 4. 2. Resident 44 was admitted to the facility in 2/2024 with diagnoses including heart failure and chronic kidney disease. Resident 44's 2/2024 Admission MDS indicated she/he was cognitively intact. On 5/14/24 Resident 44's clinical record was reviewed. No record was found that Resident 44 had a baseline care plan reviewed or provided to her/him. On 5/16/24 at 12:33 PM Staff 3 (Corporate SSD) confirmed no baseline care plan was discussed or provided to Resident 44.

The baseline care plan was completed for Residents 4 and 44. The DNS or Designee audited resident baseline care plans for accuracy, addressing any concerns identified. The DNS or Designee re-educated RCMs and MDS Coordinator on the importance of baseline care plans. The DNS or Designee will conduct random audits of resident care plans weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to follow physician orders and provide bowel medication in a timely manner for 1 of 6 sampled residents (#57) reviewed for medications. This placed residents at risk for medical complications from constipation. Findings include: The facility's Bowel Care Protocol Policy last revised on 2/2019, specified the following: -At beginning of each shift the nurse will pull the bowel care report and identify residents that have not had a BM (Bowel Movement) for 3 days. -Residents who have not had a BM in three days will be given MOM (Milk of Magnesia). -If no BM by the following shift, a Dulcolax suppository is given. -If resident continues without BM by the next shift a Fleets enema will be given. -Residents who are noted as having small bowel movement will be assessed for constipation. -If resident exceeds four days without a BM, the nurse will complete an abdominal assessment and the physician will be notified for further orders. Resident 57 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes. Resident 57's BM documentation from 4/19/24 through 5/9/24 revealed the following: -4/26/24 through 5/1/24 (six days) Resident 57 did not have a BM. -5/3/24 through 5/8/24 (six days) Resident 57 did not have a BM. Resident 57's Physician Order Report signed by the physician on 4/22/24 included an order for polyethylene glycol packet. Staff were to administer 17 grams by mouth one time daily as needed for bowel care. Resident 57's 5/2024 MAR revealed the polyethylene glycol packet was administered on 5/8/24 and was marked as "U" (unknown). A Nutrition Assessment dated 5/8/24 revealed Resident 57 had constipation and was placed on the bowel protocol with no BM for the prior week. Resident 57 had a large BM on 5/9/24. A review of the resident's clinical record revealed no documentation bowel care was implemented timely or an abdominal assessment was completed. On 5/16/24 at 10:53 AM Staff 4 (LPN) stated Resident 57 struggled with constipation and was frequently on the bowel list. Staff 4 stated she followed bowel protocol: if Resident 57 had no BM after three days, the resident was administered MiraLAX (a laxative) during the morning shift. If there was still no BM by the following shift, the resident received Senna (a laxative). If these measures yielded no results, Staff 4 stated she contacted the provider for a possible enema. On 5/17/24 at 4:01 PM Staff 9 (RNCM) stated Resident 57 had problems with BMs and was frequently on the bowel list. Staff 9 stated residents did not have standing PRN bowel orders and depended on the doctor. Staff 9 acknowledged the findings and stated Resident 57's bowel protocol needed to be initiated due to her/his constipation. On 5/20/24 at 1:13 PM Staff 2 (DNS) stated staff were expected to implement and adhere to the bowel protocol. Additionally, if a resident had no BM by day four staff were to contact the physician and conduct a bowel assessment.

The bowel care regimen and administration were verified for Resident 57. The DNS or Designee conducted audits of resident bowel care regimens, addressing any concerns as identified. The DNS or Designee re-educated all licensed nurses on the importance of bowel care regimens and following MD orders. The Infection Preventionist (IP) or Designee will conduct random audits of resident bowel care regimens weekly for 4 weeks and then monthly for 2 months. The IP or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 3 of 3 sampled residents (#s 26, 41 and 57) reviewed for foot care. This placed residents at risk for lack of nail care and infections. Findings include: 1. Resident 41 was admitted to the facility on 3/2024 with diagnoses including diabetes. A Physician Order dated 3/27/24 directed a licensed nurse to check Resident 41's fingernails and toenails once a week on bath day. The order indicated to trim as needed every day shift on Wednesdays for diabetic nail checks. Staff were directed to document (+) if the nails were trimmed and (-) if nail trimming was not needed. A review of the LN Task from 3/2024 through 5/2024 revealed the following: -3/27/24 nails did not need trimmed. -4/3/24, 4/10/24 and 4/17/24 nails did not need trimmed. 4/24/24 Resident 41 refused nail care. -5/1/24 nails did not need trimmed. 5/8/24 Resident 41 refused nail care. A Progress Note dated 5/9/24 revealed Staff 9 (RNCM) entered Resident 41's room to offer toenail care. Resident 41 initially stated she would allow toenail care without clippers only for toenails to be filed down. Resident 41 allowed Staff 9 to file three out of 10 toenails and then declined to have the rest of the toenails trimmed. On 5/13/24 at 10:44 AM Resident 41 stated she/he was a diabetic for "40 years" and needed her/his toenails treated by a podiatrist which was not scheduled. Resident 41 indicated staff were unable to cut her/his thick toenails and made her/him uncomfortable when staff attempted to complete the nail care. Random observations from 5/13/24 through 5/16/24 revealed Resident 41 was in bed and her/his toes were observed with all toenails discolored, deformed, thickened (half-an-inch) and longer than one inch. Resident 41's right large toenail was brownish/black. On 5/14/24 at 6:46 PM Staff 32 (CNA) and on 5/16/24 at 11:42 AM Staff 6 (CNA) entered the room with the surveyor and acknowledged Resident 41's toenails were long, thick, discolored and indicated the toenails were, "awful." Staff 32 stated she noticed the resident's long and discolored toenails. Staff 6 stated nail care was provided by the nursing staff because Resident 41 was diabetic. Staff 6 and Staff 32 stated the resident occasionally declined showers due to anxiety but accepted a bed bath. On 5/16/24 at 9:47 AM Staff 11 (LPN) stated nurses were responsible for diabetic nail care. Staff 11 stated Resident 41's toenails were thick, long, and difficult to trim and needed to be addressed. Staff 11 stated nurses completed weekly skin checks which included observing finger and toenails. On 5/16/24 at 2:54 PM Staff 9 (RNCM) stated nurses were expected to complete nail care for diabetic residents. Staff 9 stated Resident 41 was a "brittle" diabetic, who occasionally declined nail care. Staff 9 stated she attempted to file Resident 41's toenails but the resident did not allow Staff 9 to complete the task. When asked about a podiatry appointment, Staff 9 stated LTC (Long Term Care) residents were placed on the in-house podiatry list. Staff 9 stated the care managers assisted with appointments, including podiatry outside of the facility. 2. Resident 57 was admitted to the facility in 4/2024 with diagnoses including chronic heart failure and diabetes. The Annual MDS dated 4/19/24 revealed Resident 57 had a BIMS score of 15 and was cognitively intact. A Physician Order dated 4/24/24 directed a licensed nurse to check fingernails and toenails once a week on bath day. The order indicated to trim as needed every day shift every Wednesday for diabetic nail checks. Staff were directed to document (+) if nails were trimmed and (-) if nail trimming was not needed. A review of the LN Task from 4/2024 through 5/2024 revealed the following: - On 4/24/24, 5/1/24, 5/8/24 and 5/15/24 nails did not need trimmed. On 5/13/24 at 11:40 AM and 5/16/24 at 11:16 AM the resident stated her/his toenails were long, thick, and needed to be trimmed. Random observations from 5/13/24 through 5/16/24 revealed Resident 57 was in bed and her/his toes were observed with all toenails longer than one inch, and his second toenails were deformed, thickened (half-an-inch) and discolored. On 5/16/24 at 10:53 AM Staff 4 (LPN) stated Resident 57 was diabetic and nurses were responsible for addressing all nail care. Staff 4 stated she was not sure if the resident's toenails were long, but if she was unable to address Resident 57's nail care then she reported it to the care manager to schedule a podiatry appointment. On 5/16/24 at 2:54 PM and 5/17/24 at 4:01 PM Staff 9 (RNCM) stated nurses were expected to provide nail care for diabetic residents. If staff were unable to perform diabetic nail care, staff were expected to report this to her. Staff 9 entered the room with the surveyor and acknowledged Resident 57's toenails were long and were not treated appropriately. , 3. Resident 26 was admitted to the facility in 1/2024 with diagnoses including paraplegia. The 1/15/24 Admission MDS revealed Resident 26 was cognitively intact. On 5/13/24 at 2:18 PM Resident 26 stated her/his toenails were long, thick, and caught on the inside of her/his socks. Resident 26 stated she/he wanted her/his toenails trimmed and voiced her/his concern to staff, but no one followed up with her/him. Resident 26's toenails were observed to be long in length, thick, fungal, and jagged. On 5/16/24 at 10:34 AM Resident 26 stated she/he had a bath on 5/15/24 and requested her/his toenails to be trimmed or at least filed and the CNA stated they would let the nurse know. The resident stated the nurse did not talk with her/him. On 5/16/24 at 11:16 AM Staff 12 (LPN Resident Care Manager) stated toenail care was provided on bath days for the resident and Staff 12 expected it to be completed. On 5/16/24 at 2:57 PM Staff 3 (Corporate Social Services Director) stated the facility had a podiatrist that rounded every three months and podiatry services were offered to all residents. Staff 3 stated the podiatrist could not see every resident on the list, so a rotation was completed. Staff 3 stated Resident 26 was on the podiatrist's list to be seen on the next rotation.

Foot care was offered to Residents 26, 41, and 57. The DNS or Designee conducted audits of resident feet, addressing any concerns as identified. The DNS or Designee re-educated all licensed nurses on the importance of foot care and offering ancillary services. The IP or Designee will conduct random audits of resident feet weekly for 4 weeks and then monthly for 2 months. The IP or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview, and record review it was determined the facility failed to ensure interventions were in place to prevent smoking related accidents for 1 of 2 sampled residents (#32) reviewed for accidents. This placed residents at risk for smoking-related accidents. Findings include: The facility's 10/2023 Smoking Policy and Procedure indicated the following: -Residents who wish to smoke are evaluated for their ability to smoke safely. A smoking evaluation is completed at admission or at the time they decided to smoke, to evaluate their ability to smoke safely. -Definition of Smoking Materials: Cigarettes, Cigars, Pipes, Novelties - E-Cigarettes, Vapor Devices, Ignition Sources. -Residents who do not adhere to the smoking policies are subject to revocation of their ability to smoke while a resident at the facility. Resident 32 admitted to the facility on 3/19/24 with diagnoses including right lower extremity cellulitis and diabetes. A 4/28/24 progress note revealed a fire alarm was triggered when Resident 32 stated she/he burned papers in her/his room which caused the room to fill with smoke and Resident 32 was found in possession of a torch lighter. A 5/9/24 progress note revealed Resident 32 was smoking in her/his room. Staff reviewed the smoking policy with the resident. Lighters and smoking materials were removed from the resident's room. Resident 32's smoking care plan was initiated on 5/13/24 which revealed the resident was an unsupervised smoker. The care plan did not include safe storage of the smoking paraphernalia and interventions to regarding previous smoking incidents that occurred in the resident's room. On 5/15/24 at 10:36 AM Staff 28 (CNA) stated Resident 32 was a smoker who smoked in her/his room and did not smoke in the designated smoking area. Staff 28 stated Resident 32 was supposed to keep her/his smoking paraphernalia in a lockbox in her/his room. On 5/16/24 at 10:59 AM Resident 32 was observed seated at the edge of the bed with a four-inch green tubular-shaped canister with a pink bejeweled handle. Resident 32 stated it was her/his blow torch lighter and demonstrated that the lighter was operational. Resident 32 stated the facility kept taking her/his lighters and she/he kept replacing them. Resident 32 stated she/he was allowed to keep lighters in her/his lockbox. On 5/16/24 at 1:40 PM Staff 23 (CMA) stated she had seen Resident 32 with smoking paraphernalia in her/his room but was not sure what rules Resident 32 was supposed to follow. Staff 23 stated Resident 32 had been caught smoking in her/his room several times but was still allowed to keep her/his smoking paraphernalia in her/his room. Staff 23 stated she informed the charge nurse of the smoking paraphernalia. On 5/16/24 at 3:06 PM Staff 35 (LPN) stated she considered Resident 32 a smoker and all her/his smoking paraphernalia including marijuana, cigarettes and lighters were in a lockbox in her/his room. Staff 35 stated Resident 32 had smoking paraphernalia confiscated the previous week due to smoking in her/his room and staff were told to do a visual sweep of Resident 32's room whenever staff went into the resident's room. A SNF Smoking Safety Evaluation completed on 5/16/24 revealed Resident 32 was a supervised smoker, was not receptive to supervision, was unwilling to store her/his smoking items with the facility and continued to make unsafe smoking choices. On 5/20/24 at 10:42 AM Staff 2 (DNS) acknowledged the safety concerns associated with Resident 32's possession of incendiary devices in the facility, and history of unsafe behaviors including smoking in her/his room. Staff 2 acknowledged a smoking assessment was not completed until 5/16/24, and the care plan was not updated regarding the safety concerns.

Resident 32 discharged from the facility. The DNS or Designee conducted audits of residents with indications of smoking, addressing any concerns as identified. The Administrator or Designee re-educated All Staff on the importance of smoking safety. The DNS or Designee will conduct random audits of residents who smoke weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview, and record review it was determined the facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for 1 of 2 sampled residents (#46) reviewed for oxygen therapy. This placed residents at risk for increased risk for respiratory failure. Findings include: Resident 46 was admitted to the facility in 2/2024 with diagnoses including acute and chronic respiratory failure with hypoxia (not enough oxygen in the blood) and hypercapnia (buildup of carbon dioxide in the bloodstream). The 2/9/24 Admission MDS indicated Resident 46 was cognitively intact. The 5/13/24 physician order for Resident 46 revealed the resident used continuous oxygen with a flow rate of two liters since 4/25/24. On 5/13/24 at 12:04 PM Resident 46 was observed to use an oxygen concentrator with a flow rate of three liters. The external filter on the oxygen concentrator was observed to have a layer of dust when touched with a finger. The resident stated she/he used oxygen "most of the time" but could not state how many liters were prescribed. On 5/16/24 at 11:21 AM Staff 12 (LPN Resident Care Manager) observed the resident and equipment. Staff 12 acknowledged the physician's order was not followed regarding the oxygen flow rate and the external filter of the oxygen concentrator was not clean.

Resident 46’s O2 flow was adjusted, and the indicated filter was cleaned. The DNS or Designee conducted audits of residents utilizing continuous O2, addressing any concerns as identified. The Maintenance Director audited continuous O2 equipment for cleanliness, addressing any concerns as identified. The DNS or Designee re-educated All Staff on proper use of continuous O2. The IP or Designee will conduct random audits of residents with continuous O2 weekly for 4 weeks and then monthly for 2 months. The IP or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available and effectively managed the resident's severe pain for 1 of 1 sampled resident (#36) reviewed for pain management. This failure placed residents at risk for unrelieved pain. Findings include: Resident 36 was admitted to the facility in 9/2023 with diagnoses including rheumatoid arthritis, a fractured tibia and polyneuropathy (nerve pain). A Physician Order dated 4/13/24 directed staff to administer Percocet (pain medication), one tablet 10-325 MG (oxycodone with acetaminophen) by mouth six times a day related to displaced bicondylar fracture of the right tibia. Resident 36's 5/2024 MAR revealed the resident was administered Percocet on 5/13/24 at 2:00 AM. The resident was not administered Percocet on 5/13/24 at 6:00 AM, 10:00 AM or 2:00 PM. A Physician Order dated 5/13/24 directed staff to administer oxycodone 10 MG with 325 MG Tylenol, one tablet by mouth one time only for pain. Resident 36's 5/2024 MAR revealed the resident was administered a one time oxycodone dose on 5/13/24 at 1:20 PM. Resident 36 did not receive her/his pain medication on 5/13/24 for 11 hours and 20 minutes. A review of Resident 36's pain levels from a scale of zero through 10 (zero no pain and 10 being the worst pain possible) on 5/12/24 and 5/13/24 revealed the following: *5/12/24 the resident did not report any pain. *5/13/24 at 2:52 PM the resident reported a pain level of six. *5/13/24 at 6:02 PM the resident reported a pain level of nine. *5/13/24 at 9:13 PM the resident reported a pain level of six. On 5/13/24 at 11:18 AM and at 12:30 PM Resident 36 was observed in bed, lying on her/his right side facing away from the door, and rocking back and forth in bed. Resident 36 stated she/he was "painful" and "very uncomfortable" because she/he did not receive the scheduled Percocet since 3:00 AM. Resident 36 stated the facility staff were working on obtaining the medication. On 5/16/24 at 9:37 AM Staff 11 (LPN) stated the night shift nurse administered Resident 36's last dose of scheduled Percocet in the early AM hours on 5/13/24 and placed a call to the in-house physician for a new prescription because the Percocet prescription expired. Staff 11 stated the resident received a one time dose at approximately 1:30 PM. Staff 11 stated she offered ice or heat packs for the resident's pain, but she/he declined. Staff 11 stated Resident 36 was grimacing when up in her/his wheelchair. Staff 11 stated CMAs typically reordered medications, including if a resident needed a new prescription. On 5/16/24 at 11:42 Staff 6 (CNA) stated on 5/13/24 (Monday), Resident 36 was in her/his room, in bed and "rocking" back and forth due to pain. Staff 6 stated the resident was visibly painful, was less verbal and did not eat breakfast. Staff 6 stated the resident expressed frustration because the facility was out of her/his pain medication. Staff 6 reported her concern to the nurse. On 5/16/24 at 1:15 PM Staff 10 (LPN) stated he administered the last Percocet to Resident 36 in the early morning on 5/13/24. However, Staff 10 could not access the Cubex (an automated medication dispensing system) because the resident's prescription was expired and he communicated this with the oncoming nurse. Staff 10 contacted the in-house physician to request a new prescription. Staff 10 stated CMAs were responsible for ensuring timely medication reorders were completed. Staff 10 stated CMAs were expected to request refills when there were only seven days of medication remaining in the prescription. On 5/17/24 at 11:03 AM Staff 5 (CMA) stated Resident 36 received Percocet every four hours. Staff 5 stated she was responsible for ensuring residents' medications did not run out. Staff 5 stated when the resident had only four tablets remaining, she requested additional medication through the electronic record which went directly to the pharmacy. Staff 5 stated if a prescription was expired, she reported it to a nurse, who contacted the physician to request a new prescription. On 5/17/24 at 3:46 PM Staff 9 (RNCM) stated she was aware Resident 36 ran out of her/his Percocet. The resident was in pain, and it was unclear why the one time dose took so long to be received. Staff 9 stated on 5/13/24 Resident 36 was in her/his doorway, appeared anxious, and in pain. Resident 36 requested Staff 9's assistance in obtaining her/his pain medication. Staff 9 stated Resident 36 should not have run out of her/his pain medication and staff were to request new refills three days prior to running out. On 5/20/24 at 1:19 PM Staff 2 (DNS) acknowledged Resident 36's Percocet was not administered on 5/13/24 per physician orders. Staff 2 stated nonpharmacological pain interventions were offered to the resident until staff could address the situation. Staff 2 stated CMAs were responsible for ensuring medications were ordered for all residents and prescriptions did not expire. Staff 2 stated somehow Resident 36's medications were overlooked.

Resident 36 was medicated per physician orders. The DNS or Designee conducted audits of resident pain medication administration, addressing any concerns as identified. The DNS or Designee re-educated all licensed nurses on the importance of pain medication administration. The DNS or Designee will conduct random audits of pain medication administration weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNAs (#s 15, 23, 24, and 25) reviewed for staff performance reviews. This placed residents at risk for lack of care by competent staff. Findings include: On 5/17/24 at 9:58 AM a review of facility personnel records with Staff 31 (Human Resource Director) indicated the following: - Staff 15 (CNA) was hired on 8/17/22; no annual performance review was completed. - Staff 23 (CMA) was hired on 8/31/20; no annual performance reviews were completed. - Staff 24 (CNA) was hired on 6/16/16; no annual performance reviews were completed. - Staff 25 (CNA) was hired on 4/11/16; no annual performance reviews were completed. On 5/17/24 at 4:04 PM Staff 1 (Administrator) stated it was his expectation the annual performance reviews were completed annually. Staff 1 confirmed the annual performance reviews were not completed for Staff 15, Staff 23, Staff 24, or Staff 25.

Annual evaluations were completed for the indicated staff. The Human Resources Payroll Coordinator (HRPC) or Designee conducted an audit of annual staff evaluations, addressing any concerns as identified. The Administrator or Designee re-educated All Staff on the importance of completing annual performance evaluations. The HRPC or Designee will conduct random audits of annual performance evaluations weekly for 4 weeks and then monthly for 2 months. The HRPC or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview, and record review it was determined the facility failed to provide person-centered approaches to behavioral symptoms for 1 of 2 sampled residents (#32) reviewed for psychosocial well-being. This placed residents at risk for unmet psychosocial and mental health needs. Findings include: Resident 32 admitted to the facility on 3/19/24 with diagnoses including right lower extremity cellulitis and diabetes. The resident did not have a documented diagnosis related to mental health or trauma at the time of admission. A 3/22/24 psychiatric consultation note stated Resident 32 was, "labile, cycling through post traumatic memories of fighting in the war with very graphic, disturbing traumatic content, despondent memories and escalating despair." The note recommended Resident 32 continue with psychotherapy treatments. A 4/3/24 physician visit note revealed Resident 32 was distressed from experiences with her/his time in the war. On 5/15/24 at 10:36 AM Staff 28 (CNA) stated Resident 32's behaviors included talking to herself/himself about the war, keeping the curtain drawn, startling easily and overreacting at times when startled. On 5/16/24 at 10:59 AM was observed Resident 32 pacing in her/his room while appearing to talk to herself/himself and rubbing her/his head. Resident 32 stated her/his had was not good as a result of her/his experiences in war. Resident 32 recalled a mental health consult around the time of admission and stated she/he would continue to see someone for her/his mental health if offered. On 5/17/24 at 3:12 PM Staff 9 (RNCM) stated a psychiatric consult was requested for Resident 32 at the time of admission because the resident expressed concerns regarding post-traumatic stress disorder (PTSD). A review of Resident 32's clinical record on 5/17/24 revealed no care planned intervention to address Resident 32's mental health needs, and no indication the resident received follow-up treatment related to mental health needs since the 3/22/24 psychiatric consultation. On 5/17/24 at 3:17 PM Staff 37 (LPN Resident Care Manager) acknowledged there was no evidence to indicate Resident 32 received mental health treatment since the 3/22/24 psychiatric consultation. On 5/20/24 at Staff 2 (DNS) acknowledged Resident 32 did not have any follow-up mental health treatment after the initial consultation and the resident's care plan was not updated to reflect the resident's mental health needs and interventions.

Resident 32 discharged from the facility. The Social Services Director (SSD) or Designee conducted audits of residents with indications of PTSD noted on their admission paperwork, addressing any concerns as identified. The DNS or Designee re-educated the Interdisciplinary Team (IDT) on caring for residents with indications of PTSD. The SSD or Designee will conduct random audits of resident behavior monitoring for 4 weeks and then monthly for 2 months. The SSD or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on observation and interview it was determined the facility failed to ensure proper labeling of biologicals for 1 of 2 medication rooms reviewed for medication storage. This placed residents at risk for reduced efficacy of medication. Findings include: According to the Center for Disease Control and Prevention: Multi-Dose Vial Safety Reminders (2023): -When you first put a clean needle in the vial, write the date and time on the label. -The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The vial should be discarded within 28 days of the opened date. On 5/20/24 at 12:40 PM during a review of station one medication storage room with Staff 2 (DNS), one vial of lidocaine solution was observed to be opened with no open date. The vial indicated it was a multiple dose vial. On 5/20/24 at 12:44 PM Staff 2 acknowledged the vial of lidocaine solution was opened and not labeled with an open date.

The indicated item was discarded. The IP or Designee conducted audits of medication storage areas, addressing any concerns as identified. The DNS or Designee re-educated LNs on the importance of medication storage. The IP or Designee will conduct random audits of medication storage areas for 4 weeks and then monthly for 2 months. The IP or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to protect resident identifiable information and ensure records were accurate for 2 of 4 sampled residents (#s 41 and 42) reviewed for record management and insulin. This placed residents at risk for unauthorized use of their personal information and inaccurate treatment. Findings include: 1. A review of the facility's 12/2023 HIPAA (Health Insurance Portability and Accountability Act) Compliance policy indicated the facility was to safeguard all forms of PHI (Protected Health Information) for each resident. On 5/17/24 at 12:33 PM resident identifiable information including Resident 41's name, medication type, prescription number, and the resident's physician's name was observed inside a clear plastic garbage bag with no lid located on the side of a nurse treatment cart. The treatment cart was in the hallway close to the front entrance of the facility and available for anyone in the facility to see. Other items observed in the garbage bag with the resident identifiable information included used gloves and an opened alcohol wipe packet. On 5/17/24 at 12:36 PM Staff 27 (Corporate RN) acknowledged the garbage bag contained resident identifiable information and further acknowledged resident identifiable information was not to be placed in any garbage. Staff 27 stated the expectation was for staff to place any resident identifiable information in a secure confidential shred bin located inside the facility. , 2. Resident 42 was admitted 2/2024 with a diagnosis of Type 1 Diabetes. A 3/5/24 Significant Change of Condition MDS indicated Resident 42 was cognitively intact. a. The 3/11/24 at 9:48 AM progress note indicated Resident 42 was Hypoglycemic with glucose readings of 61 and 91 before breakfast. Post breakfast it was reported to the licensed nurse that Resident 42 refused breakfast, had a blood glucose level of 37, was diaphoretic and was arousable but was not completely conscious or awake. The Licensed Nurse documented giving 15oz of juice, an intramuscular shot of glucagon, and "gel" applied to gums (a substitute for oral tablets when swallowing capability is in question). The 3/2024 Diabetic administration record indicated the Glucagon emergency kit, Glucose Oral tablet Chewable 4gm (to be given if blood glucose reading was below 70), and the Hypoglycemia protocol (to be initiated for a blood glucose reading below 70 and patient is showing symptoms) was not administered. On 5/17/24 at 10:17 AM Staff 2 (DNS) stated the progress note which indicated Resident 42's blood glucose reading was 61 before breakfast was incorrect and should not have been in the progress note. Staff 2 stated the actions taken by the licensed nurse in the same progress note were documented correctly. Staff 2 confirmed the diabetic administration record did not show the interventions administered to Resident 42 on 3/11/24. b. The 5/16/24 progress note indicated "Resident's blood sugar dropped to 67, [orange juice] given, and provider notified." A review of the 5/2024 Diabetic Administration Record (DAR) revealed the record did not reflect the interventions documented in the progress note. On 5/17/23 at 11:16 AM Staff 33 (LPN) confirmed the DAR did not reflect the actions taken by Staff 34 (LPN) to remedy Resident 42's low blood glucose levels. Staff 33 stated Resident 42 had PRN orders for low blood glucose, and interventions were to be documented in the DAR. On 5/17/24 at 10:17 AM Staff 2 (DNS) was provided with these findings. Staff 2 confirmed the DAR was blank for 5/16/24.

The items with identifying information for Resident 41 were destroyed in HIPAA compliant shred bins. The incorrect information for Resident 42 was struck out. The Medical Records Director or Designee conducted audits of non-HIPAA compliant trash receptacles. The DNS or Designees conducted audits of charting in the Diabetic Administration Record (DAR). Any concerns were addressed as identified. The DNS or Designee re-educated All Staff on the importance of protecting resident information and accuracy of charting in the DAR. The Medical Records Director or Designee will conduct random audits of non-HIPAA compliant trash receptacles for 4 weeks and then monthly for 2 months. The DNS or Designee will conduct random audits of the DAR for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

********************************************************* OAR 411-085-0310 Resident Rights: Generally Refer to F550 and F557 ************************************************************ OAR 411-086-0260 Pharmaceutical Services Refer to F554 ************************************************************* OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F636 *************************************************************** OAR 411-086-0040 Admission of Residents Refer F655 *************************************************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684, F687, F695 and F697 **************************************************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 ***************************************************************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F730 ***************************************************************** OAR 411-086-0240 Social Services Refer to F742 ***************************************************************** OAR 411-086-0260 Pharmaceutical Services Refer to F761 ****************************************************************** OAR 411-085-0370 Confidentiality Refer to F842 ******************************************************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/31/2023 and 08/06/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/12/2023 and 06/18/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to have a system in place to ensure residents were provided the opportunity to formulate advance directives for 1 of 1 sampled resident (#33) reviewed for advanced directives. This placed residents at risk for not being informed of choices regarding health care decisions. Findings include: Resident 33 was admitted to the facility in 2020 with diagnoses including stroke. A 1/4/23 Social Service Quarterly Review revealed the resident made her/his own decisions and was able to make her/his needs known using an interpreter. Resident 33's clinical record revealed no documentation to indicate the resident had an advance directive or was provided information concerning the right to formulate an advance directive. On 3/22/23 at 2:41 PM Staff 4 (Social Services Director) stated Resident 33 was her/his own responsible party and she did not provide the resident with an opportunity to formulate an advance directive.

This Plan of Correction constitutes the facility’s written allegation of compliance for the deficiency cited in CMS 2567. However, the submission of this plan is not an admission that a deficiency exists. The Plan of Correction is prepared and executed solely because it is required by federal and state law. This response and Plan of Correction does not constitute an admission or agreement by the provider of the facts alleged or set forth in the statement of deficiencies. Resident 33 was provided the opportunity to formulate an advanced directive. Social Services Staff conducted an audit of residents’ records to ensure they were provided with the opportunity to formulate an advanced directive addressing concerns identified. Administrator or Designee re-educated the Inter-Disciplinary Team (IDT) on importance of providing residents the opportunity to formulate an advanced directive. Medical Records Director or Designee will conduct random audits of resident charts for advanced directive compliance weekly for 4 weeks, and monthly for 2 months. The Medical Record Director, or Designee will report the result of this audit at the facility monthly Quality Assurance & Performance Improvement (QAPI) meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment for 1 of 6 sampled resident (#38) reviewed for activities of daily living and hospitalizations. This placed residents at risk for unassessed care needs. Findings include: Resident 38 was readmitted to the facility 2/2023 after being hospitalized for longer than 24 hours. The resident's readmission diagnosis was fracture of the left femur. Resident 38's secondary diagnoses included dementia and diabetes. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15, 10/2017, a "Significant Change is a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; impacts more than one area of the resident's health status; and requires interdisciplinary review and/or revision of the care plan....The nursing home may take up to 14 days to determine whether the criteria are met. After the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines, the nursing home should document the initial identification of a significant change in the resident's status in the clinical record. A Significant Change Status Assessment is appropriate when...the resident's condition is not expected to return to baseline within two weeks." Resident 38's 2/18/23 Discharge Return Anticipated MDS assessed the resident as being independent with transfers, dressing, personal hygiene and walking in room on and off the unit. This assessment also assessed the resident as needing supervision with bed mobility and toilet use. Resident 38's 2/25/23 Quarterly MDS assessed the resident as requiring extensive assistance with transfers, bed mobility, dressing, toilet use and personal hygiene. This assessment also revealed the resident did not walk in her/his room or off the unit. The resident walked on the unit only once or twice with the assistance of a staff member. Resident 38's 3/5/23 Care Plan indicated the following ADL care needs: - Extensive assistance with transfers with the use of a gait belt; - Extensive assistance with toileting with the use of a bedside commode; - Extensive assistance with bed mobility; - Extensive assistance with dressing; and - Extensive assistance with ambulation. There was no documentation in Resident 38's medical record which indicated a significant change assessment was considered or ruled out. On 3/23/23 at 9:52 AM Staff 5 (CNA) stated Resident 38 was independent with all her/his ADLs prior to fracturing her/his leg. Staff 5 stated after the resident experienced the fracture, she/he required a lot more assistance, especially with transfers and toileting, and the resident now ambulated with a wheelchair instead of walking with her/his walker. On 3/23/23 at 10:50 AM Staff 6 (LPN) acknowledged a significant change of condition should have been completed.

Resident 38 was assessed for significant change and the medical record was updated as needed. The Director of Nursing Services (DNS) or Designee audited all resident re-admissions from the hospital in the past 30 days for potential significant change of condition. The DNS or Designee re-educated the IDT and Licensed Nurses on the importance of documenting significant changes. The DNS or Designee will conduct random audits of residents when they re-admit from the hospital for 4 weeks, and monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure a PASRR Level II (Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability) was completed for 1 of 1 sampled resident (#12) reviewed for PASRR. This placed residents at risk for not receiving specialized services. Findings include: Resident 12 was admitted to the facility in 2016 with diagnoses including anxiety, depression and cognitive-communication deficit. A 6/6/2019 PASRR Mental Health Evaluation was completed for Resident 12 which recommended a PASRR Level II be completed for an Intellectual Disability/Developmental Disability as the resident likely had a developmental disability. A review of the resident's medical record revealed a progress note dated 6/2/21 documenting the request for a PASRR Level II for Developmental Disability. No evidence was found in the resident's medical record that a PASRR Level II for Developmental Disability was completed. On 3/22/23/at 2:47 PM Staff 4 (Social Services Director) stated she was not aware Resident 12 needed a PASRR Level II related to Developmental Disability.

A PASRR II was requested for Resident 12. Resident Care Managers (RCM) or Designee audited resident PASRR’s for any indication of a PASRR II being needed, addressing any concerns identified. The DNS or Designee re-educated the IDT on the importance of residents receiving specialized services. The DNS or Designee will conduct random audits of resident PASRR’s weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's care plan accurately reflected their needs for 1 of 1 sampled resident (#8) reviewed for anticoagulant medication. Findings include: Resident 8 was admitted to the facility in 2023 with diagnoses including atrial fibrillation (irregular heart rhythm), bruising, anemia, coagulation deficit (lack of blood coagulation) and thrombosis (blood clots in large veins which may block blood flow or get lodged in the lungs). On 3/20/23 at 11:46 AM both of Resident 8's forearms were observed with numerous bruises. Her/his left forearm had a large healing scab. The resident stated she/he bruised from bumping into things and it did not matter how "gentle" it was. Resident 8's current physician's orders as of 3/2023 included aspirin once daily and Eliquis (anticoagulant) twice daily for atrial fibrillation. Resident 8's plan of care as of 3/2023 did not include monitoring for bruising or bleeding related to anticoagulant use. On 3/24/23 at 9:36 AM Staff 3 (LPN) confirmed Resident 8 received two anticoagulant medications (aspirin and Eliquis) which placed the resident at greater risk for bruising and bleeding. Staff 3 verified the resident's plan of care did not include monitoring for bruising or bleeding related to anticoagulant use.

Resident 8 discharged from the facility. RCMs or Designee audited current residents with anti-coagulant medication prescribed, for appropriate care plan, addressing any concerns identified. The DNS or Designee re-educated Licensed Nurses on the importance of accurate care plans. The DNS or Designee will conduct random audits of residents with anti-coagulant medication care plans weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to provide necessary behavioral health care and services for 1 of 1 sampled resident (#12) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: Resident 12 was admitted to the facility in 12/2016 with diagnoses including anxiety and depression. A review of Resident 12's Patient Health Questionnaire (PHQ-9, a validated interview that screens for symptoms of depression) scores from 6/2018 to 9/2022 revealed the resident's scores ranged from zero to four, which was indicative of mild depression. Resident 12's 12/12/22 PHQ-9 score was 10, which indicated moderate depression. Resident 12's 12/16/22 Social Service Quarterly Review failed to identify the resident's increased PHQ-9 score on 12/12/22 or provide an assessment of the resident's mood state. Resident 12's 12/28/22 Care Plan indicated the resident had the potential for mood and behavior fluctuations and was receiving monthly mental health services. The Care Plan also included the following interventions related to mood and behavior: - Allow the resident to voice her/his needs and concerns and validate her/his feelings; - Provide opportunities for mental health services; and - PHQ-9 was to be completed quarterly and as needed. On 3/20/23 at 11:15 AM Resident 12 stated a counselor used to come and visit her/him but the visits had stopped and she/he did not know why. The resident stated these counseling visits were helpful and she/he wished they would resume. Resident 12 stated that since her/his family died, she/he preferred not to leave her/his bed and wanted to be by herself/himself. The resident indicated she/he wished the facility provided additional support with regards to coping with her/his losses and managing her/his emotions. On 3/22/23 at 2:47 PM Staff 4 (Social Services Director) stated she did not know why the resident's PHQ-9 score declined so significantly in 12/2022. Staff 4 stated she did not inform the resident's RNCM or medical provider of this change in scoring and she should have done so. Staff 4 further stated she was not aware Resident 12 received mental health services from an outside provider and she planned to remove this intervention from the resident's care plan as it was inaccurate. On 3/22/23 at 3:29 PM Staff 6 (LPN) reviewed Resident 12's PHQ-9 score from 12/2022 and stated she would have expected the Social Services Director to have reported this decline in the resident's self-reported mood. On 3/23/23 at 3:45 PM Staff 8 (Regional RN) provided documentation Resident 12 was last seen by her/his mental health provider on 12/9/22. Staff 7 stated she was not sure why the counseling visits stopped. No attempts to communicate with the provider were made until 3/23/23 following an interview with the state surveyor.

Resident 12 was assessed for behavioral-emotional needs. Social Services Staff audited resident PHQ-9 assessments, addressing any concerns identified. The DNS or Designee re-educated the IDT on the importance of providing necessary behavioral health care. The DNS or Designee will conduct random audits of residents with behavioral or emotional needs weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 6 sampled residents (#22) reviewed for medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 22 was re-admitted to the facility in 2022 with diagnoses including cancer and was receiving hospice services. Resident 22's 2/2023 MAR revealed the following narcotic medication orders: - Clonazepam (antianxiety) 1 mg, give one tablet every eight hours at 6:00 AM, 2:00 PM and 10:00 PM. The MAR indicated the clonazepam was administered at every ordered administration time from 2/1/23 through 2/26/23. - Lorazepam (antianxiety) 0.5 mg, give 0.5 mg every four hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. The MAR indicated the lorazepam was administered at every ordered administration time from 2/18/23 through 2/26/23. Resident 22's controlled substance log book sheets revealed the following: - Page #27 indicated the clonazepam was administered on 2/20/23 at 12:00 AM and 4:00 AM. (The clonazepam was not ordered to be administered at 12:00 AM or 4:00 AM.) - Page #76 indicated the clonazepam was administered on 2/24/23 at 9:00 PM and 10:00 PM. (The clonazepam was not ordered to be administered at 9:00 PM.) - Page #56 indicated lorazepam doses were missed on 2/19/23 at 4:00 AM, 2/20/23 at 12:00 AM and 4:00 AM, 2/21/23 at 12:00 PM. On 2/20/23 at 9:24 AM the lorazepam dose was one hour and twenty four minutes late. On 3/24/23 at 9:10 AM Staff 2 (DNS) verified the clonazepam and lorazepam medication administration errors.

Resident 22 has discharged from the facility. The DNS or Designee audited resident narcotic medication orders, addressing any concerns identified. The DNS or Designee re-educated Licensed Nurses on the importance of resident risks for adverse medication consequences. The DNS or Designee will conduct random audits of resident narcotic medication orders weekly for 4 weeks and then monthly for 2 months. The DNS or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to employ a director of food and nutrition services with the required certification for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: Observations from 3/20/23 through 3/27/23 from 8:15 AM to 4:30 PM revealed Staff 7 (Food Service Manager) functioned in the capacity of the facility's director of food and nutrition services. On 3/20/23 at 3:42 PM Staff 7 reported he was currently enrolled in a program to become a Certified Food Service Manager and completed the required course. He stated he had not taken the exam yet but planned to "in the next couple of weeks." He also stated he attended culinary school but was not sure if that would satisfy the requirements to be a director of food and nutrition services. A review of Staff 7's culinary certification revealed it did not meet the minimum requirements for a director of food and nutrition services. On 3/27/23 at 1:13 PM Staff 1 (Administrator) verified Staff 7 did not have the required qualifications to be a director of food and nutrition services.

A Certified Food Service Manager was assigned to oversee the dietary department. Administrator or Designee re-educated the Inter-Disciplinary Team (IDT) on the resident risk for unmet dietary needs and qualified dietary staff. Human Resources/Payroll Coordinator (HRPC) will conduct random audits of staff certifications monthly for 3 months. The HRPC, or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on observation, interview and record review it was determined the facility failed to prepare and store foods in a manner to prevent cross contamination and spoilage for 1 of 1 kitchen reviewed for sanitary practices and 1 of 1 resident (#31) reviewed for food service and storage. This placed residents at risk of foodborne illness. Findings include: 1. On 3/20/23 at 9:10 AM during the initial tour of the facility's kitchen, the main prep island between the stove and dishwashing room was observed to have an open bag of chopped lettuce, an open container of sliced pickles, an open bin of sliced tomatoes and an open bin of sliced onions. Staff 8 (Dietary Aide) was observed scraping food debris from dishes into a garbage container. He reported the cook who was working with these items was on his break. No one else was observed working in the kitchen at that time. On 3/20/23 at 3:38 PM, Staff 7 (Food Service Manager) reported he was aware the cook left the items on the island to go to the bathroom. He reported he expected the items to be covered and stored in the refrigerator when they were not actively being used for meal preparation. , 2. On 3/20/23 at 9:18 AM an observation was made of two glasses of milk covered with plastic tops dated 3/18 on Resident 31's overbed table. The milk was room temperature with what appeared to be small and large chunks of curdled milk floating in the top of both glasses. The facility's Outside Food and Safety Tips Policy indicated the following: -Discard any food left out at room temperature for more than two hours, or one hour if the temperature is above 90 degrees. On 3/20/23 at 3:21 PM Staff 12 (CNA) stated he did not like to leave resident trays in their rooms over 45 minutes with uneaten food or drinks. Staff 12 stated he would not leave milk or other dairy products out for extended periods of time due to how quickly they can go bad. On 3/20/23 at 3:57 PM Staff 2 (DNS) stated the facility would not typically allow milk to sit out for extended periods of time. Staff 2 stated it was her expectation CNAs should have taken the milk out of Resident 31's room in a timely manner. On 3/21/23 at 10:59 AM Staff 9 (LPN) stated she talked to Resident 31 regarding the glasses of milk. Staff 9 stated Resident 31 did not like to waste food and was planning on drinking the milk until she/he was shown the milk was curdled. Staff 9 stated the CNAs should have removed the glasses from Resident 31's room with the meal tray or soon after.

Uncovered items in the kitchen were addressed when discovered by inspector. The indicated items were removed from Resident 31’s room. The Infection Preventionist or Designee conducted audits of the kitchen and resident rooms for cross contamination and spoilage, addressing any concerns as identified. The Infection Preventionist or Designee re-educated All Staff on the importance of sanitary practices and food service and storage. The Infection Preventionist or Designee will conduct random audits of the kitchen and resident rooms weekly for 4 weeks and then monthly for 2 months. The Infection Preventionist or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 13 of 31 days and the use of NAs did not exceed more than 25% of the CNA staffing ratios on 6 of 31 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: A review of the facility's Direct Care Staff Daily Reports from 7/1/22 through 7/31/22 revealed the following dates when the required state minimum CNA staffing ratios were not met for one or more shifts: - 7/1/22 night shift was short one CNA; - 7/2/22 day shift was short two CNAs; - 7/3/22 day shift was short one CNA; - 7/5/22 day shift was short one CNA, evening shift was short one CNA and night shift was short 0.5 CNA; - 7/9/22 day shift was short one CNA; - 7/10/22 day shift was short two CNAs; - 7/12/22 day shift was short one CNA; - 7/13/22 day shift was short one CNA; - 7/18/22 day shift was short one CNA; - 7/19/22 day shift was short one CNA; - 7/20/22 day shift was short two CNAs; - 7/24/22 day shift was short one CNA; and - 7/29/22 day shift was short one CNA. A review of the facility's Direct Care Staff Daily Reports from 7/1/22 through 7/31/22 revealed the following days when the facility's use of NAs exceeded the 25% maximum ratio: - 7/10/22 day shift (33%) - 7/12/22 day shift (33%) - 7/18/22 day shift (43%) - 7/19/22 day shift (43%) - 7/20/22 day shift (33%) - 7/29/22 day shift (29%) On 03/27/23 at 10:43 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the failure to meet state minimum CNA staffing ratios and the facility exceeded the 25% maximum ratio of NA utilization.

Facility is unable to adjust staffing levels for indicated dates. Administrator or Designee reviewed last 2 weeks of staffing for minimum CNA & NA staffing levels identifying any concerns or trends. The Administrator re-educated the staffing director on the minimum CNA & NA staffing levels, along with the importance of utilizing all options to find coverage and to notify Administrator if minimums are not going to be met. The Administrator or Designee will conduct random audits for minimum CNA & NA staffing levels compliance weekly for 4 weeks and then monthly for 2 months. The Administrator or Designee will report the result of this audit at the facility monthly QAPI meeting for 60 days or until substantial compliance has been achieved as determined by the committee. The Administrator is responsible for ensuring compliance.

************** 411-086-0040 Admission of Residents (Advanced Directive) Refer to F578 ************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F637 and F656 ************** 411-086-0240 Social Services Refer to F645 and F740 ************** 411-086-0110 Nursing Services: Resident Care Refer to F760 ************** 411-086-0250 Dietary Services Refer to F801 and F812 **************

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

Based on interview and record review it was determined the facility failed to ensure a resident was free from neglect for 1 of 5 sampled residents (#8) reviewed for abuse and neglect. This placed residents at risk for neglect of care. Findings include: Resident 8 admitted to the facility in 2020 with diagnoses including osteoporosis. The 11/22/21 FRI indicated Resident 8 was left in a dirty brief for 70 minutes and requested Staff 13 (Former CNA) not take care of her/him anymore. An investigation was completed and Staff 13 was terminated. The 11/22/21 Incident Note indicated Resident 8 expressed she/he did not want Staff 13 and pleaded and cried when she/he requested to never have Staff 13 care for her/him again. The 11/22/22 Facility Investigation revealed revealed several residents who believed Staff 13 took a long time to answer call lights and requested Staff 13 not to care for them anymore. Staff Interviews revealed a "strong pattern" with Staff 13. Staff 13 would "disappear", be found sleeping in the break-room and "just stopped working or answering lights". The investigation found no physical harm occurred but Resident 8 was emotionally impacted and neglect of care was substantiated. On 11/7/22 at 11:10 AM Resident 8 stated Staff 13 left her/him in a dirty brief for 70 minutes and felt she/he was neglected by Staff 13. On 11/7/22 at 11:16 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 8 was left in a dirty brief for 70 minutes, Resident 8 pleaded not to have Staff 13 work with her/him again and verified the facility investigation substantiated neglect of care.

F600 Resident #8 was interviewed and assessed to ensure the resident now feels free from neglect and feels safe in the facility. Care Plan updated as needed. The Administrator or Designee reviewed current residents to ensure that they are free from neglect and feel safe in the facility. The Administrator or Designee re-educated staff on the policies and procedures related to neglect and abuse. The Administrator or Designee will do random audits on residents to ensure residents are free from neglect and feel safe in the facility weekly X 2 weeks, then monthly X 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to thoroughly investigate a potential medication error for 1 of 3 sampled residents (#10) reviewed for medications. This placed residents at risk for receiving another residents medications. Findings include: Resident 10 was admitted to the facilty in 2021 with diagnoses including hypertension. The 11/25/21 Incident Note revealed Resident 10 possibly received the incorrect medications on "11/14 PM" [11/24/21 was date of incident]. Resident 10 remembered double checking with the nurse about the medications because she/he had never taken a "magnesium" tablet before, she/he did not take a red pill or a "puffer". The nurse double checked the surrounding rooms' medications where it was noted the room next door had a magnesium, apixaban (blood thinner/pinkish colored pill) and an Advair inhaler (respiratory medication). The physician was notified of the possible medication error and ordered Resident 10 to be monitored for any change in level of consciousness or bleeding. [Resident 10 was prescribed Lovenox (blood thinner).] The 11/24/21 Facility Investigation revealed Resident 10 asked the nurse if she was sure she had the correct medications, the nurse told Resident 10 she already double checked in the computer so Resident 10 took the medications because the nurse told her/him they were hers/his and Resident 10 believed she/he should trust the nurse. The investigation did not include a statement from the nurse if she did or did not administer the medications and did not include reviewing the other residents medications to verify if the other resident medications had the correct number of doses left for the medications in question. The investigation did not determine if Resident 10 was administered another residents medications or not. On 11/2/22 at 11:55 AM Staff 1 (Administrator) and Staff 2 (DNS) verified the facility investigation was not thorough as it did not conclude if a medication error occurred and did not review the other residents medications for missing medications.

F610 - Resident #10 no longer resides in the facility. The Director of Nursing or Designee reviewed current residents to ensure that alleged violations are thoroughly investigated. The Director of Nursing or Designee re-educated Staff on the policies and procedures related to thorough investigations. The Director of Nursing or Designee will do random audits on resident alleged violations, weekly X 2 weeks, then monthly X 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to assess a residents cognitive status for 1 of 3 sampled residents (#9) reviewed for ADLs. This placed residents at risk of incomplete cognitive assessments. Findings include: Resident 9 admitted to the facility in 2021 with diagnoses including diabetes. The RAI Manual, Section C revealed the items in this section were intended to determine the resident's attention, orientation and ability to register and recall new information. These items were crucial factors in many care planning decisions. The manual instructed a structured interview for the Brief Interview for Mental Status (BIMs) be attempted. If the BIMS was not attempted a Staff Assessment of Mental Status was to be completed. The 11/30/21 Admission MDS, Section C revealed the BIMs interview and the Staff Assessment of Mental status were coded as "not assessed". There was not evidence in the medical record why the BIMs or the Staff Assessment of Mental Status were not completed as required by the RAI Manual. On 11/8/22 at 9:43 AM Staff 1 (Administrator) verified the 11/30/21 Admission MDS, Section C was not assessed and further stated, "It certainly should have been done".

F636 - Resident #9 no longer resides in the facility. The Director of Nursing or Designee reviewed section C, cognitive status of MDSs over the last 90 days for completeness, addressing concerns identified. Director of Nursing or Designee re-educated the RCMs on the requirements to ensure MDS assessments were completed and accurate to assess resident care needs, including accurate completion of Section C. The Director of Nursing or Designee will do random audits on accurate MDSs verifying that Section C was accurate weekly X 2 weeks, then monthly X 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure pressure ulcer assessments were completed accurately and treatment was implemented timely for 1 of 3 sampled residents (#5) reviewed for skin conditions. This placed residents at risk for worsening pressure injury and infection. Findings include: The facility's 9/2020 Skin at Risk/Skin Breakdown Policy indicated: -Full body skin evaluations were to be completed weekly and completion is documented. "No" indicated no new skin impairment and "yes" indicated new skin impairment. -Upon discovery of newly identified skin impairment (abrasion, skin tear, etc.) the licensed nurse would: *Document skin impairment that includes measurements of size, color, presence of odor and exudates. The National Pressure Injury Advisory Panel utilizes the follow pressure ulcer staging guidelines: * Stage 2: Partial-thickness skin loss with exposed dermis. * Stage 3: Full-thickness skin loss. Adipose (fat) tissue is visible, slough (yellow/white material/dead cells that accumulate in wound bed) and/or eschar (dead tissue) may be visable. * Stage 4: Obscurred full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscurred by slough or eschar. If slought or eschar is removed, a Stage 3 or 4 pressure injury wil be reviewed. Resident 5 admitted to the facility in 2015 with diagnoses including multiple sclerosis (a disease affecting the central nervous system) and bilateral leg fractures. The 8/25/22 Significant Change MDS indicated Resident 5 did not have any skin breakdown but was at risk for developing pressure ulcers. A review of Resident 5's medical record starting 8/2022 revealed no evidence of weekly skin checks prior to 9/3/22. Resident 5's 9/3/22 Equipment Assessment indicated the resident was required to wear a tightly fit brace to her/his right leg related to a fracture. An exam of the skin under the brace showed a red area under the strap just below the inner knee. A hydrocolloid (moisture-retentive dressing) was applied, and a pad was placed between the brace and the resident's knee. There were no measurements or other descriptions of the wound. Resident 5's Skin Wound Evaluations were reviewed from 9/2022 through 10/2022 indicated the following: - 9/8/22: Right inner knee abrasion measuring 2.3 cm x 2 cm x 0 cm. the wound was noted to have 100% granulation. It was noted the wound was on the inner knee where the brace fit against the skin and appeared to be "friction caused." This was noted to be the first evaluation of the wound and the wound was not present on admission. -9/15/22: Right inner knee Stage 2 pressure ulcer measuring 2.6 cm x 2.5 cm x 0 cm. The wound was noted to have 75% slough and 25% granulation with serous drainage. It was noted the resident saw an outside wound provider "today" to obtain measurements and photos. [The description described a Stage 3 or unstageable pressure ulcer.] -9/22/22: Right inner knee Stage 2 pressure ulcer measuring 2.6 cm x 2.5 cm x 0 cm. The wound was noted to have 75% slough and 25% granulation with serous drainage. It was noted the resident saw an outside wound provider "today" to obtain measurements and photos. The 9/22/22 evaluation had the same wording and measurements as the 9/15/22 evaluation. [The description described a Stage 3 or unstageable pressure ulcer.] -9/29/22: Right inner knee Unstageable pressure ulcer measuring 8.5 cm x 3.5 cm x 0 cm. The wound was "beefy red" with 25% slough, 50% granulation, and 10% epithelization. The wound was noted as "improved." -10/6/22: Right inner knee Unstageable pressure ulcer measuring "1.1X1.2/" x 3.5 cm x 0 cm. The wound was "beefy red" with 100% granulation and moderate serosanguineous (watery fluid containing blood) drainage. [Does not meet definition to be staged as unstageable.] A 9/22/22 outside would provider note indicated Resident 5 had an Unstageable right medial lower leg pressure wound measuring 8.5 cm x 3.5 cm x 0 cm. The note indicated 9/22/22 was the initial assessment of Resident 5's right medial lower leg pressure ulcer. The pressure ulcer had 0-10% epithelialization, 26-50% granulation, 11-25% slough, and no eschar. Treatment orders included: 1. clean wound with wound cleanser. 2. apply skin prep to peri-wound and allow to dry. 3. apply xeroform (wound dressing) to base of wound. 4. cover with bordered foam. Place additional ABDS (cushion dressing) if necessary for extra padding. 5. change three times per week and prn for accidental removal, saturation and/or soiling. The 9/2022 TAR indicated the 9/22/22 identified treatment order from the outside wound provider was not implemented until 9/29/22. A 10/27/22 outside wound provider note indicated Resident 5's right medial lower leg pressure ulcer had resolved. On 11/7/22 at 11:51 AM Staff 3 (LPN Resident Care Manager) stated the weekly skin assessments were expected to be completed by staff but were not documented in Resident 5's medical record. Staff 3 stated Resident 5's right medial lower leg wound was a pressure ulcer due to a medical device and was unstageable as of 9/8/22. Staff 3 acknowledged the inconsistencies in the wound assessments for 9/8/22 and 9/15/22 and confirmed the 9/22/22 had the same wording as the 9/15/22 assessment. Staff 3 acknowledged the 9/22/22 facility skin evaluation was inconsistent and inaccurate compared with the outside wound provider's 9/22/22 wound assessment. Staff 3 confirmed the outside wound provider's first assessment of Resident 5's pressure ulcer was 9/22/22 and acknowledged the pressure ulcer treatment delay for the identified dates.

F686 - Resident #5 pressure ulcer has resolved and preventive measures have been put in place to prevent reoccurrence. Assessments were reviewed for accuracy and updated and further treatments were implemented timely. Care Plan updated as needed. Director of Nursing or Designee reviewed residents to ensure that pressure ulcer assessments were completed accurately, and treatment was implemented timely. Director of Nursing re-educated RCMs on policies regarding pressure ulcer assessments and timely implementation of treatment. The Director of Nursing or designee will do random audits on residents to ensure pressure ulcer assessments are accurate and treatment is implemented timely weekly X 2 weeks, then monthly X 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

Based on interview and record review it was determined the facilty failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#7) reviewed for medications. This placed residents at risk for receiving another residents medications. Findings include: Resident 7 admitted to the facility in 2021 with diagnoses including diabetes. A 7/12/22 Progress Note revealed Resident 7 was administered another residents medications which included oxycodone (narcotic pain medication), Seroquel (antipsychotic medication), melatonin (supplement), Senna (bowel medication), "multiple Parkinson's medications" and gabapentin (nerve pain medication). The physician was notified and instructed the facility to transfer the resident to the hospital for monitoring due to Resident 7's low tolerance for "that many high-power medications" and the risk for respiratory depression and adverse drug reactions. A 7/13/22 Progress Note revealed Resident 7 returned to the facility in the afternoon. A 7/14/22 Physician Note revealed the blood tests were completed in the hospital were "essentially unremarkable" and the resident was stable since her/his return to the facility. On 11/7/22 at 12:05 PM Staff 2 (DNS) verified Resident 7 received another residents medications, was transferred to the hospital for overnight monitoring and acknowledged this was a significant medication error.

F760 - Resident #7 no longer resides in the facility. The Director of Nursing or Designee reviewed residents to ensure risk factors are reduced from significant medication errors. Director of Nursing or Designee re-educated Nurses and Medication aides on the policies and procedures related to administration of medications. The Director of Nursing or Designee will do random audits on ensuring that risk factors related to significant medication errors are reduced and that residents are free from significant medication errors weekly X 2 weeks, then monthly X 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible for ensuring compliance.

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********************************* OAR 411-085-0360 Abuse Refer to F600 & F610 ********************************* OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F636 ********************************* OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686 ********************************* OAR 411-086-0100 Nursing Services: Resident Care Refer to F760 *********************************

, ******************************* OAR 411-086-0260 Pharmaceutical Services Refer to F554 *******************************

Based on interview and record review it was determined the facility failed to assess a resident's ability to safely self-administer medications for 1 of 1 sampled resident (#10) reviewed for self-administration of medications. Findings include: Resident 10 was admitted to the facility in 2022 with diagnoses including end stage renal disease, diabetes and bipolar disorder. The 11/22/22 Admission MDS indicated the resident was cognitively intact. A review of Resident 10's clinical record revealed no medication self-administration assessment or physician orders the resident could self-administer her/his medications. An investigation dated 12/19/22 indicated on 12/19/22 Resident 10 received two doses of Oxycodone 10mg within 1 hour. The order for Oxycodone was to give 10mg by mouth every 4 hours as needed for pain. Resident 10 was noted to be drowsy and was to skip her/his next dose of Oxycodone until she/he was fully awake. The 12/2022 MAR revealed Oxycodone 10mg every 4 hours as needed for pain. On 12/19/22 at 5:05 AM Resident 10 was administered Oxycodone by Staff 5 (LPN). On 12/27/22 at 12:57 PM Staff 3 (RCM) stated Staff 5 (LPN) gave Resident 10 an extra dose of pain medication for her/him to take to her/his dialysis appointment. Staff 5 had not communicated with the dialysis nurses that Resident 10 was given her/his pain medication that morning. Staff 3 stated that Resident 10 was placed on alert charting and her/his physician had been notified. On 12/27/22 at 1:04 PM Staff 4 (CMA) stated Staff 5 (LPN) gave Resident 10 an extra dose of Oxycodone for her/him to take to dialysis. Staff 4 stated the incident was treated as a medication error. The resident was monitored for adverse side effects and education was provided. In an interview on 12/27/22 at 1:26 PM Staff 5 (LPN) explained she administered Oxycodone to Resident 10 on 12/19/22 at 5:05 AM for pain. Staff 5 stated Resident 10 was scheduled for dialysis that morning so she put a 10mg Oxycodone in an envelope, labeled it with the resident's name and the name of the medication, Staff 5 stated she did not send administration instructions for the Oxycodone with the resident. Staff 5 acknowledged she did not check to see if there was a physician order for the resident to self medicate or if the resident was assessed to take her/his own medications. On 12/27/22 at 2:00 PM Staff 2 (DNS) verified the 2 doses of Oxycodone were given to Resident 10 and the resident was not assessed to be able to self-administer their medications. In an interview on 12/27/22 at 2:35 PM Witness 1 (Dialysis Nurse) stated Resident 10 showed up to dialysis on 12/19/22 with a white envelope with her/his name on it and the name of the pain medication. The envelope was in a pouch on the side of Resident 10's wheelchair with no administration instructions. Resident 10 stated she was in pain at 6:00 AM and asked for some water to take the pain pill. Witness 1 stated if a resident came to dialysis with medication, they would take it at their own will. Witness 1 stated she recalled it was unusual for Resident 10 to show up to dialysis with medication.

1. Resident #10 was evaluated by the Provider with no negative outcome to resident. Resident evaluated for self-medication. 2. The DNS or Designee reviewed current residents that want to self-administer medications. Evaluations, orders and care plans updated as indicated. 3. The DNS or Designee re-educated LNs and CMAs on the self-medication administration policy. 4. Nurse managers will review in MACC new admissions and current residents for request to self administration of medication and will start evaluation process. DNS or designee will complete random audits of dialysis residents for self-administration compliance weekly x4/weeks, then monthly x3/months or until substantial compliance is met. Audits will be brought to QAPI for review. 5. DNS is responsible for compliance.

Based on interview and record review it was determined the facility failed to ensure a resident's call light was answered timely and the resident was not left in a soiled brief for 1 of 1 resident (#22) reviewed for dignity. This placed residents at risk for psychosocial harm. Findings include: Resident 22 admitted to the facility in 2020 with diagnoses including back fractures. The 9/20/21 Quarterly MDS indicated Resident 22 was cognitively intact and required extensive assistance with bed mobility and toileting, was frequently incontinent of bladder, and always incontinent of bowel. On 2/15/22 at 10:26 AM and 2/17/22 at 9:15 AM Resident 22 reported approximately a week prior Witness 4 (Former CNA) told the resident they would not change her/him as Witness 4 was too busy passing dinner meal trays and the resident waited two hours for her/his call light to be answered for a brief change. Resident 22 stated she/he filed a grievance regarding the incident. Resident 22 stated the incident made her/him feel "terrible", "disrespected", and stated it felt "awful to sit in poop, how would you feel?" A 2/4/22 Grievance Form indicated on 2/4/22, a designated CNA [Witness 4] refused to change Resident 22's brief during the dinner meal and the resident was left for hours sitting in a soiled brief. The 2/4/22 Call Light Log for Resident 22 showed the call light was on for two hours and was answered by "Float" staff at 5:54 PM. A 2/5/22 Investigation indicated Staff 2 (DNS) received a grievance regarding brief changes for Resident 22 on 2/4/22. The investigation indicated Resident 22 was not changed timely and the resident stated she/he was "upset", but there were no concerns of abuse. Resident 22 stated she/he did not want agency staff taking care of her/him and the resident did not want "someone to forget me." Witness 4 was noted to no longer work at the facility status post the 2/4/22 incident. On 2/18/22 at 2:46 PM Staff 27 (CNA) stated he answered Resident 22's call light on 2/4/22 and the resident had a bowel movement and had soiled brief and reported she/he had been waiting "a long time" for a brief change. Resident 22 further stated a CNA stated they were passing meal and told Resident 22 she/he would have to wait. Staff 27 stated the expectation was for staff to change residents when requested so residents would not have to eat their meals in a soiled brief. On 2/23/22 at 10:10 AM Witness 4 stated she was the only CNA working Resident 22's hall on 2/4/22 evening shift. Witness 4 stated Resident 22 stated "you need to change me", but Witness 4 was busy passing trays by herself, so she stated to the resident "I cant change you at the moment I have trays on the hall." The resident further stated, "well everyone else stops what they are doing and changes me" and Witness 4 stated "I can't touch you when I have meal trays, not right now." Witness 4 stated another CNA changed the resident later in the shift. On 2/17/22 at 12:31 PM Staff 2 (DNS) stated she completed the investigation for the 2/4/22 incident and confirmed Witness 4 left Resident 22 in soiled brief and did not change the resident's brief because Witness 4 was busy serving trays. Staff 2 further confirmed the 2/4/22 Call Light Log indicated Resident 22 waited two hours for her/his call light to be answered for a brief change. Refer to F677 and F725.

Resident #22 was interviewed to identify and address any current unmet needs. The Administrator or Designee conducted a review of call light times for the last 7 days for timeliness concerns, meeting with current residents to identify and address any dignity concerns. The Administrator or Designee re-educated CNAs on the requirement to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This re-education also included the importance of answering call lights timely and not leaving a resident in a soiled brief. The Administrator or Designee will do random audits via resident and/or staff interviews and/or observations for call light compliance weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure individual needs were met for 1 of 6 sampled residents (#7) reviewed for medications. This placed residents at risk for lack of quality of life. Findings include: Resident 7 was admitted to the facility in 2015 with diagnoses including heart failure and anxiety disorder. Resident 7's clinical record indicated she/he was cognitively intact. A 2/17/22 progress note indicated on 2/16/22 the durable medical equipment company was contacted to look at Resident 7's power wheelchair that was not holding a charge and the company would call the facility when they were able to have a technician come out. On 2/17/22 at 2:55 PM Resident 7 was observed in bed and stated her/his power wheelchair broke on 2/5/22 when she/he entered the transportation van to go to an appointment and staff brought her/him back into the building and assisted her/him to bed. Resident 7 stated she/he enjoyed getting up in her/his power wheelchair but it was still broken and staff had not fixed it or communicated when it was to be fixed. On 2/17/22 at 3:00 PM Staff 19 (LPN Resident Care Manager) stated Resident 7's power wheelchair broke on 2/5/22 when she/he was loading onto the transport van. Staff 19 stated the resident was brought back into the building. Staff 19 further stated Resident 7's power wheelchair was not fixed. Staff 19 stated the durable medical equipment company was contacted on 2/16/22 regarding the broken wheelchair and acknowledged it was a long time for Resident 7 to be without a working power wheelchair.

Resident #7 was assessed by OT for chair alternatives while power wheelchair is at 3rd party vendor getting fixed. Administrator or Designee reviewed current residents using power wheelchairs for good working order, addressing concerns identified. Administrator or designee discussed with center leadership the importance of ensuring individual needs are met, to include when a power wheelchair breaks alternatives should be identified if applicable, as well as routine communication with vendor and resident. Administrator or designee will do random audits via staff/resident interview and/or observation that resident power wheelchairs are in good working order weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure a Resident Council request was provided a rationale regarding concerns for 1 of 1 Resident Council groups reviewed for grievances. This placed residents at risk for a decline in psychosocial well-being. Findings include: Resident 47 admitted to the facility in 4/2020 with diagnoses including osteoarthritis and major depressive disorder. The 1/17/22 Quarterly MDS indicated Resident 47 was cognitively intact. On 2/15/22 at 12:03 PM Resident 47 stated she/he was the Resident Council president and since July 2021, residents had been asking for their rooms to have a dry erase whiteboard as there were so many Agency staff and residents wanted to know who was working with them. Resident 47 stated when the issue was brought up in Resident Council to administrative administrative staff were not open to doing a trial for one hallway to have whiteboards. Resident Council notes for 1/2022 and 2/2022 were reviewed and indicated: *1/26/22: "Would like to try whiteboards for green zone (hall in facility)." *2/15/22: "Dry erase boards trial for 1 hall?" There was no written responses or a rationale provided for the whiteboard/dry erase board requests. On 2/17/22 at 12:23 PM Staff 2 (DNS) stated she was aware of the multiple requests for whiteboards from Resident Council. Staff 2 stated she and the administrator discussed the whiteboards and due to staff to resident ratios, the staff "do not have time to fill the boards out and get the residents ready for breakfast." Staff 2 stated administrative staff had not provided a response to the request due to other priorities.

Resident 47 was interviewed to identify current concerns pending from resident council. Administrator reviewed resident council meeting minutes from the last 90 days, addressing concerns identified. Administrator re-educated Activities Director & Center leadership on resident council, meeting minutes and follow up. Administrator or designee will do random audits via resident council meeting minutes review and/or resident interview for follow up to concerns identified in resident council weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure MDS assessments were completed and comprehensive to assess resident care needs for 2 of 6 residents (#s 22 and 40) reviewed for ADLs and dialysis. This placed residents at risk for inaccurate assessments and care. Findings include: 1. Resident 22 admitted to the facility in 2020 with diagnoses including back fractures. The 12/21/21 Quarterly MDS assessment, Section C (cognitive assessment) was not completed for Resident 22. On 2/17/22 at 12:22 PM Staff 2 (DNS) acknowledged Section C of the MDS was not completed for Resident 22 due to staffing issues as resident care managers were pulled to work the floor and were unable to complete Section C of the MDS. 2. Resident 40 admitted to the facility in 10/2021 with diagnoses including end stage renal disease and dementia. The 1/21/22 Quarterly MDS, Section C (cognitive assessment) was not completed for Resident 40. On 2/17/22 at 12:22 PM Staff 2 (DNS) acknowledged Section C of the MDS was not completed for Resident 40 due to staffing issues as resident care managers were pulled to work the floor and were unable to complete Section C of the MDS.

Resident 22 MDS reviewed and care plans updated. Resident 40 MDS reviewed and care plans updated. The Director of Nursing or Designee reviewed Section C for Quarterly MDSs over the last 90 for completion, addressing concerns identified. Director of Nursing or designee re-educated the RCMs on the requirement to ensure MDS assessments were completed and comprehensive to assess resident care needs, including completing Section C. The Director of Nursing or designee will do random audits on completed MDS verifying Section C was complete weekly x 2 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure Staff 4 (LPN) adhered to professional standards for documenting a dressing change that was not completed. This placed residents at risk inaccurate records and worsening skin conditions. Findings include: 851-045-0070 Conduct Derogatory to the Standards of Nursing Defined Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (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; Resident 10 admitted to the facility in 11/2021 with diagnoses including heart failure. The 1/5/22 physician order indicated Resident 10 was to receive the following wound care every day shift: -Right lower leg- remove all dressings and replace xeroform over graft, cover with ABD (absorbent dressing) and kerlix (woven gauze), secure with ACE wrap or coban. -Change the dressing on the right thigh once daily and PRN soiling. Leave vaseline gauze on unless it comes off, dress with vaseline gauze adaptec or xeroform (non-adherent wound dressing), pad with ABD pads, skin prep surrounding tissue and adhere with tape. On 2/16/22 at 10:35 AM Resident 10 stated staff did not complete dressing changes to her/his right leg and thigh on 2/15/22. On 2/16/22 at 10:35 AM Staff 9 (LPN) was observed to complete a dressing change to Resident 10's right lower leg and the right thigh. Both areas were covered with dressings dated 2/14/22 (indicating that was the last date the dressings were changed). Staff 9 acknowledged both dressings were dated 2/14/22 and confirmed the dressings were not changed on 2/15/22. Resident 10 stated staff do not complete dressing changes daily and missed completing dressing changes approximately twice a week. The TAR indicated Staff 4 (LPN) completed a dressing change on 2/15/22. On 2/16/22 at 1:57 PM Staff 4 indicated she documented she completed both dressing changes for Resident 10 on 2/15/22 but did not complete the dressing changes. Staff 4 stated she "got distracted" and did not amend the documentation. On 2/17/22 at 2:49 PM Staff 2 (DNS) acknowledged Resident 10 did not receive dressing changes as ordered on 2/15/22.

Resident 10 right lower leg and right thigh wounds and treatments were reviewed. Director of Nursing or designee reviewed wound dressings on current residents, addressing concerns identified. Director of Nursing or designee re-educated licensed nurses, including Staff #4, on professional standards around dressing changes done as ordered and documentation accuracy. The Director of Nursing or designee will conduct random audits on wound care dressing change compliance via observation and/or chart documentation review weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure residents who are unable to carry out ADLs independently received showers, haircuts, and incontinent care to maintain good hygiene for 5 of 5 residents (# 22, 37, 50, 107 and 108) reviewed for ADLs. This placed residents at risk for poor hygiene, undignified experience and skin breakdown. Findings include: 1. Resident 22 admitted to the facility in 2020 with diagnoses including back fractures. The 9/20/21 Quarterly MDS indicated Resident 22 was cognitively intact and required extensive assistance with bed mobility and toileting, and was frequently incontinent of bladder and always incontinent of bowel. The resident required one-person assistance with bathing. a. On 2/15/22 at 10:26 AM and 2/17/22 at 9:15 AM Resident 22 reported approximately a week prior on evening shift, her/his call light took two hours to be answered and Witness 4 (Former CNA) told the resident they would not change her/him as Witness 4 was too busy passing dinner meal trays. Resident 22 stated she/he filed a grievance regarding the incident. A 2/4/22 Grievance Form indicated that day a designated CNA refused to change Resident 22's brief during the dinner meal and the resident was left for hours sitting in a soiled brief. The 2/4/22 Call Light Log for Resident 22 showed the call light was answered by "Float" staff at 5:54 PM and was on for two hours. A 2/5/22 Investigation indicated Staff 2 (DNS) received a grievance regarding brief changes for Resident 22 on 2/4/22. The investigation summary indicated Resident 22's brief not changed timely and the resident sat in a soiled brief for two hours. On 2/18/22 at 2:46 PM Staff 27 (CNA) stated he answered Resident 22's call light on 2/4/22 and the resident had a bowel movement soiled brief and reported she/he had been waiting "a long time" for a brief change and reported a CNA stated they were passing meal and told Resident 22 she/he would have to wait. On 2/23/22 at 10:10 AM Witness 4 (CNA) stated she was the only CNA working Resident 22's hall on 2/4/22 evening shift. Witness 4 stated Resident 22 stated "you need to change me", but Witness 4 was busy passing trays so she stated to the resident "I cant change you at the moment I have trays on the hall". The resident further stated "Well everyone else stops what they are doing and changes me" and Witness 4 replied "I can't touch you when I have meal trays, not right now." Witness 4 stated another CNA changed the resident later in the shift. On 2/17/22 at 12:31 PM Staff 2 (DNS) stated she completed the investigation for the 2/4/22 incident and confirmed Witness 4 left Resident 22 in soiled brief and did not change brief because Witness 4 was busy serving trays. Staff 2 further confirmed the 2/4/22 Call Light Log indicated Resident 22 waited two hours for her/his brief to be changed. Refer to F550 and F725. b. On 2/17/22 at 9:15 AM Resident 22 stated there was a few weeks in January 2022 when she/he did not receive a shower due to staffing shortages and had filed a grievance. The resident did not report neglect concerns. The 2/15/22 Care Plan indicated Resident 22 was scheduled to receive showers on Tuesdays and Fridays, required one-person assistance with bathing, and preferred showers. The 1/2022 Shower Task Sheet indicated: *Resident 22 received a bed bath on 12/31/21. *There were no responses for 1/4/22 and 1/11/22. *Resident 22 received a bed bath on 1/14/22. A 1/18/22 Grievance Form indicated Resident 22 reported care concerns, including that she/he had not received her/his scheduled showers. The 1/18/22 Investigation indicated Resident 22 reported she/he felt "neglected" due to not receiving showers. Resident 2 reported she/he had received a bed bath more recently, but preferred showers. The investigation indicated records showed Resident 22 received a bed bath on 12/31/21, but then no showers/bed baths until a bed bath on 1/14/21. Interviews with staff indicated cares were not completed due to staffing concerns. On 2/17/22 at 12:51 PM Witness 5 (Agency CNA) stated long term residents, like Resident 22, did not get their needs met including showers, due to the high acuity and staffing shortages. On 2/17/22 at 12:27 PM Staff 2 (DNS) stated if a resident refused a shower staff were supposed to document the refusal in progress notes and re-approach the resident. Staff 2 confirmed there was no documentation to indicate Resident 22 was offered or received a shower from 1/1/22 through 1/14/22. 2. Resident 37 admitted to the facility in 2011 with diagnoses including epilepsy and an unspecified gait disorder. The 11/29/21 Quarterly MDS indicated Resident 37 was cognitively intact. On 2/15/22 at 12:34 PM Resident 37 stated the facility had a beautician who came to the facility to cut resident hair, but the facility no longer had one. Resident 37 reported the last time she/he received a haircut was "so long ago" and the resident reported wanting a haircut to multiple staff and her/his daughter. Resident 37 stated the facility did not offer to set up transportation to receive a haircut outside the facility. On 2/16/22 at 12:38 PM Staff 28 (Social Services) stated she was not aware Resident 37 wanted a haircut. Staff 28 stated since COVID-19 there was no beautician in the facility and no one to cut residents' hair. Staff 28 stated she would "sometimes" sent a resident out of the facility to receive a haircut. On 2/16/22 at 1:10 PM Staff 11 (CNA) stated Resident 37 had not mentioned to her that the resident wanted a haircut, but since the onset of COVID-19 no one came into the building to provide haircuts. Staff 11 stated there was no process to send residents out of the facility to receive haircuts. Staff 11 stated other residents had stated to her they wanted haircuts. On 2/18/22 at 2:04 PM Staff 2 (DNS) stated no one came into the facility to provide haircuts to residents and if a resident wanted a haircut the facility would coordinate transportation. Staff 2 acknowledged residents were not provided haircuts or offered transportation to receive haircuts. , 3. Resident 107 was admitted to the facility on 2/9/22 with diagnoses including diabetes and glaucoma. The 2/9/22 care plan indicated Resident 107 was a one person extensive assist with bathing. The care plan indicated the resident was scheduled to receive showers on Tuesday and Thursday afternoon. On 2/14/22 at 11:35 AM Resident 107 stated she/he had not been offered or received a shower since admission. Review of the 2/22 bathing record indicated Resident 107 received her/his first shower on 2/15/22 (six days after admission). On 2/11/22 at 12:17 PM Staff 3 (CNA) stated staff try to give showers on scheduled days but due to being sometimes short staff they are not able to provide showers. Staff 3 stated Resident 107 was compliant with all cares. On 2/18/22 at 1:55 PM Staff 2 (DNS) stated residents were to have showers scheduled and set up upon admission and were to receive the shower on the next scheduled day. Staff 2 confirmed Resident 107 did not receive her/his first shower in a timely manner. 4. Resident 108 was admitted to the facility on 2/4/22 with diagnoses including kidney disease and restless leg syndrome. The 2/8/22 revised care plan indicated Resident 108 was a one person extensive assist with bathing. Showers were scheduled for Monday and Thursday afternoon. A progress note dated 2/14/22 indicated Resident 108's family member called the facility and informed staff that the resident had not received a shower for a week. The note indicated a shower was provided by the evening CNA. Review of Resident 108's bathing record indicated on 2/8/22 and 2/11/22 staff marked "activity did not occur". The bathing record indicated the resident received her/his first shower on 2/14/22 (nine days after admission). On 2/15/22 at 9:35 AM Resident 108 stated she/he did not receive a shower for a week and finally received her/his first shower on the night of 2/14/22. On 2/17/22 at 2:36 PM Staff 13 (CNA) stated she could not recall why she marked "activity did not occur" on the resident's 2/8/22 bathing record and she did not never gave the resident a shower due to staffing issues. On 2/18/22 at 1:30 PM Staff 15 (LPN) confirmed she provided Resident 108 with her/his first shower on the night of 2/14/22. On 2/18/22 at 1:55 PM Staff 2 (DNS) stated residents were to have showers scheduled and set up upon admission and were to received the shower on the next scheduled day. Staff 2 confirmed Resident 108 did not receive her/his first shower in a timely manner. , 4. Resident 50 was admitted to the facility on 1/22/22 with diagnoses including heart failure and lung disease. The 1/2022 admission MDS indicated Resident 50 was cognitively intact and bathing self -performance was listed as total dependence with one person physical assist. On 2/14/22 at 12:57 PM Resident 50 stated she/he was not given a choice regarding bathing. Resident 50 stated she/he preferred showers but since admission had only received two bed baths. Resident 50 was unsure of her/his current orders regarding bathing. A 2/17/22 Master Shower Sheet indicated Resident 50 was scheduled to receive showers weekly on Tuesdays and Saturdays. The 1/2022 and 2/2022 Shower Task Sheet indicated: -Resident 50 received no bathing in January -Resident 50 received bed baths on 2/1/22 and 2/13/22 On 2/18/22 at 12:19 PM Staff 2 (DNS) confirmed staff did not honor Resident 50's bathing preferences, the shower orders for Resident 50 were missed and Resident 50 only received 2 bed baths since admission.

Resident #22 received a shower and was interviewed to identify and address any other current unmet needs Resident #37 received a haircut and was interviewed to identify and address any other current unmet needs. Resident #50 received a shower and was interviewed to identify and address any other current unmet needs. Resident #107 received a shower and was interviewed to identify and address any other current unmet needs. Resident #108 no longer resides at center. The Administrator or Designee conducted a review of call light times for the last 7 days for timeliness concerns, meeting with current residents to identify and address any dignity concerns. Director of Nursing or Designee reviewed the shower schedule and showers given over the last seven day, addressing concerns identified Director of Nursing or Designee identified current residents wanting a haircut, establishing a plan to address concerns identified. Director of Nursing of Designee re-educated direct care staff on the requirement the residents who are unable to carry out ADLs independently receive showers, haircuts and incontinent care to maintain good hygiene. Inservice also included importance of documentation including refusals, honoring bathing preference (bed bath or shower), importance of answering call lights timely and not leaving a resident in a soiled brief. The Administrator or Designee will do random audits via resident and/or staff interviews, and/or observations for call light compliance weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will do random audits via resident observation, resident interview, and/or documentation review for hair cut and shower compliance weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on observation, interview, and record review it was determined the facility failed to ensure residents received activities in accordance with their preferences and plans of care for 2 of 2 residents (#s 27 and 37) reviewed for activities. This placed residents at risk for a decrease in psychosocial well-being. Findings include: 1. Resident 37 admitted to the facility in 2011 with diagnoses including epilepsy and an unspecified gait disorder. The 11/29/21 Quarterly MDS indicated Resident 37 was cognitively intact. On 2/15/22 at 12:34 PM and 2/16/22 at 1:06 PM Resident 37 stated she/he was bored due to the facility not having group activities and having very limited activities for individuals. Resident 37 stated multiple residents enjoyed bingo, but instead of including more bingo the facility took away a day of bingo, so now there was only bingo twice a week. Resident 37 further stated "the people are bored and activities are bad. It is a shame." From 2/15/22 through 2/17/22 Resident 37 was not observed in group activities or activities consistent with her/his care plan. Resident 37's current care plan indicated the resident needed to be encourage to participate in activities and conversations with staff and other residents as the resident liked to feel involved. Staff were to provide Resident 37 with helping tasks during activities to satiate her/his desire to help and be involved. The resident's activity interests indicated the resident preferred: *Religious services, bingo, card games, word puzzles, entertainment/music, movies, socials and special events, baking/cooking, crafts, reminiscing, pet visits, spending time outside, reading, watching TV/movies, plant care/gardening, coloring pages, exercise group/physical activities, meditation/aromatherapy, games (horseshoes, bean bag toss, balloon ball, RV car racing, bowling, etc.), manicures, hair care/makeup, and outings. The 2/2022 Activity Calendar indicated for 2/17/22 there were two activities: 10:00 AM Good News and 1:00 PM Fish Tank Game. Neither were group activities. On 2/16/22 at 1:10 PM Staff 11 (CNA) stated residents were bored, including Resident 37. Resident 37 was observed by the surveyor and Staff 11 in the activity room alone, the television was on, but the resident was not watching the television show. On 2/16/22 at 1:24 PM Staff 10 (LPN) stated "what activities" when asked about resident activities. Staff 10 stated residents were provided "a page for coloring and a few jokes" on a piece of paper in their rooms, but that was it for activities. Staff 10 further stated activities were not consistently provided on weekends. On 2/17/22 at 1:42 PM Staff 35 (Activities) confirmed there were only two activities for 2/17/22 and none were group activities. Staff 35 stated there were no group activities as two administrative staff had COVID-19. Staff 35 stated the Resident Council president mentioned to her that residents were bored with activities and wanted more bingo. Staff 35 stated bingo was changed from three days a week to two days a week as she was new. Staff 35 further stated there were no activities on Sundays and intermittently on Saturdays as the activities assistant had to screen staff and visitors on Saturdays instead of overseeing activities. 2. Resident 27 was admitted to the facility in 2019 with diagnoses including a stroke and schizophrenia. The 9/11/21 Annual MDS indicated Resident 27 had cognitive limitations. Resident 27's care plan indicated the resident was care planned for activities including: playing bingo, Po-Keno, arts and crafts, Lego's, watching movies and TV in his room, jokes, listening to music (especially Led Zeppelin, Rock n' roll), going for walks outside and helping staff with projects, reading (mysteries, westerns), animals (dogs, Boston Terrier), gardening/plant care, nail care/manicures, ball toss, horseshoes, balloon ball, and RV remote cars. The resident was care planned for multiple behavioral issues and interventions included: *Utilize diversional activities such as painting and simple puzzles to redirect resident when [he/she was] restless, agitated, and excessively impatient. Observations of the resident throughout 2/15/22, 2/17/22, and 2/18/22 did not reveal Resident 27 in activities consistent with the resident's care plan, except watching television. On 2/18/22 at 2:36 PM Resident 27 was observed in her/his room in bed without the television on. The activity calendar indicated a "popcorn social" was scheduled for 2:00 PM, but there was no activity observed in the facility. The 2/2022 Activities Task Sheet indicated no group activities and only one activity marked daily for Resident 27 for 2/2022. On 2/15/22 at 11:20 AM Staff 6 (CNA) stated Resident 27 was restless and wandered around the facility due to her/his diagnoses and the resident did not receive activities except bingo or painting the resident's nails. Staff 6 stated she/he did not participate in other activities and it "would be nice" to keep Resident 27 engaged. On 2/16/22 at 8:47 AM Staff 9 (LPN) stated Resident 27 was only offered bingo and word searches and if the resident was offered more activities she/he would participate. On 2/16/22 at 1:24 PM Staff 10 (LPN) stated "what activities" when asked about resident activities. Staff 10 stated residents were provided "a page for coloring and a few jokes" on a piece of paper in their rooms, but that was it for activities. Staff 10 further stated activities were not consistently provided on weekends. On 2/17/22 at 1:42 PM Staff 35 (Activities) stated there were no group activities for over a month as two administrative staff had COVID-19. Staff 35 stated since she was doing more 1:1 activities for 55 residents and she did not have time for more activities. Staff 35 further stated there were no activities on Sundays and intermittently on Saturdays as the activities assistant had to screen staff and visitors on Saturdays instead of overseeing activities. Staff 35 stated Resident 27 had a short attention span but would attend activities and "come and go", but was redirectable and enjoyed participating in activities.

Resident #27 was interviewed by the Activities director on activity preferences, care plan updated. Resident #37 was interviewed by the Activities director on activity preferences, care plan updated. The Administrator met with resident council regarding activity programming to gather additional feedback, addressing concerns identified. The Administrator re-educated the Activity Director on the requirement to provide activities in accordance with their preferences and plan of care. Re-education included reviewing alternate activities, individual activities, when unable to have group activities and coverage for activities each day. The Administrator or Designee will do random audits via resident observation, resident/staff interview and/or documentation review for activity programming weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on observation interview and record review it was determined the facility failed to administer medications and treatments as ordered for 4 of 6 sampled residents (#s 10, 11, 17 and 27) reviewed for medications and catheter care. This placed residents at risk for adverse side effects of medication, worsening skin conditions and hospitalization. Findings include: 1. Resident 17 admitted to the facility in 2021 with diagnoses including diabetes and renal dialysis. The revised 1/19/22 care plan indicated Resident 17 was diabetic and was to receive diabetic medications as ordered by the physician. The residents care plan also indicated she/he went to dialysis three days a week (Monday, Wednesday and Friday). Resident 17's 12/2021 physician orders revealed the following: - insulin aspart 8 units before meals. - insulin aspart sliding scale insulin before meals. - CBGs checked twice a day before breakfast and before bed. The 1/2022 and 2/2022 Diabetic Administration Record indicated the following: -1/3/22, 1/5/22, 1/28/22 and 1/31/22 insulin was not administered and morning CBG was not checked. -2/2/22 and 2/4/22 insulin was not administered and morning CBG was not checked. Review of Resident 17's progress notes indicated on 1/3/22, 1/5/22, 1/28/22, 1/31/22, 2/4/22 and 2/6/22 insulin was not administered and CBG's was not checked due to the resident being at dialysis. Review of Resident 17's medical record revealed no indication the physician was notified of the missed insulin and CBG checks. On 2/17/22 at 12:40 PM Staff 10 (LPN) stated Resident 17 she did not administer insulin and CBG was not checked because the resident was at dialysis and did not document if the physician was notified. On 2/18/22 at 1:30 PM Staff 15 (LPN) confirmed she did not administer Resident 17's insulin or check CBG's due to the resident being at dialysis and could not verify if the physician was notified. On 2/18/22 at 2:00 PM Staff 2 (DNS) confirmed Resident 17 was not given insulin per physician orders and did not have CBGs checked for the identified dates and confirmed the physician was not notified. 2. Resident 27 admitted to the facility in 2019 with diagnoses including stroke, diabetes, Schizophrenia and dysphasia (difficultly swallowing food or liquids). The 9/27/21 revised care plan indicated Resident 27 used a G tube (Gastronomy tube that brings nutrition directly to the stomach) and all ordered medications were administered through the G tube. The 2/2022 physician orders indicated Resident 27 received the following medications: - famotidine (antacid) BID - ferrous sulfate supplement (dietary supplement) BID - frozen supplement (nutritional supplement) BID - metformin (diabetic medication) BID - olanzapine (antipsychotic) BID - risperidone (antipsychotic) BID - Biotene (medication used to treat dry mouth) BID - Haldol (antipsychotic) TID Review of the 2/22 MAR indicated the following afternoon medications were not received on 2/8/22 and/or 2/12/22: - famotidine - ferrous sulfate liquid supplement - frozen supplement - metformin - olanzapine - risperidone - Biotene dry mouth liquid - Haldol A progress note dated 2/9/22 indicated the resident's provider was notified of the missed dose of medication on 2/8/22. There was no other progress note that indicated the physician was notified of the 2/12/22 missed medications. A 2/9/22 Medication Error report indicated Resident 17 did not receive her/his afternoon medications on 2/8/22 as ordered. The provider was not notified until 2/9/22. A witness statement indicated the nurse got busy with treatments and blood sugars and missed administering the residents medications. No negative outcome was reported. On 2/23/22 at 9:08 AM and 9:24 AM Staff 19 (LPN Resident Care Manager) stated the missed medication on 2/8/22 was done by an agency staff. She stated the staff person forgot to give Resident 17 her/his medications via the G tube. Staff 19 confirmed she was not aware of the missed medications on 2/12/22 and stated the physician was not notified. , 3. Resident 11 admitted to the facility in 11/2021 with diagnoses including diabetes and end stage renal disease. The 2/1/22 physician order indicated Resident 11 was to receive insulin glargine (long-acting insulin) once daily every Monday, Wednesday and Friday prior to dialysis. The 2/2022 Diabetic Administration Record indicated Resident 11 did not receive insulin glargine as ordered on 2/9/22, 2/11/22 and 2/16/22. On 2/17/22 at 11:22 AM Resident 11 stated she/he often did not receive insulin prior to dialysis and it caused her/him to have high CBGs. A review of progress notes from 2/1/22 through 2/17/22 and indicated there was no adverse outcomes to the resident regarding her/his CBGs. On 2/23/22 at 11:23 AM Staff 23 (LPN) stated she was Resident 11's nurse on 2/11/22 and 2/16/22 and did not administer glargine insulin to Resident 11 because the resident went to dialysis before she was able to administer insulin. On 2/23/22 at 11:44 AM Staff 24 (LPN) stated she was Resident 11's nurse on 2/9/22. Staff 24 stated she did not administer glargine insulin to Resident 11 because the resident went to dialysis and it was supposed to be completed by the prior shift. On 2/23/22 at 1:19 PM Staff 25 (Physician Assistant) acknowledged Resident 11 did not receive glargine insulin before dialysis as ordered on 2/9/22, 2/11/22 and 2/16/22. 4. Resident 10 admitted to the facility in 11/2021 with diagnoses including heart failure. The 1/5/22 physician order indicated Resident 10 was to receive the following wound care every day shift: -Right lower leg- remove all dressings and replace xeroform over graft, cover with ABD (absorbent dressing) and kerlix (woven gauze), secure with ACE wrap or coban. -Change the dressing on the right thigh once daily and PRN soiling. Leave vaseline gauze on unless it comes off, dress with vaseline gauze adaptec or xeroform (non-adherent wound dressing), pad with ABD pads, skin prep surrounding tissue and adhere with tape. The 2/22 TAR indicated the following: -Resident 10 did not receive a dressing change to the right thigh on 2/7/22. -Resident 10 did not receive a dressing change to the right lower leg on 2/7/22. On 2/16/22 at 10:35 AM Resident 10 stated staff did not complete dressing changes to her/his right leg and thigh on 2/15/22. Resident 10 further stated staff do not complete dressing changes daily and missed completing dressing changes approximately twice a week. On 2/16/22 at 10:35 AM Staff 9 (LPN) was observed to complete a dressing change to the Resident 10's right lower leg and the right thigh. Both areas were covered with dressings dated 2/14/22 (indicating that was the last date the dressings were changed). Staff 9 acknowledged both dressings were dated 2/14/22 and confirmed the dressings were not changed on 2/15/22. The TAR indicated Staff 4 (LPN) completed a dressing change on 2/15/22. On 2/16/22 at 1:57 PM Staff 4 indicated she documented she completed both dressing changes for Resident 10 on 2/15/22 but did not complete the dressing changes. Staff 4 stated she "got distracted" and did not amend the documentation. On 2/17/22 at 2:49 PM Staff 2 (DNS) acknowledged Resident 10 did not receive dressing changes as ordered on the identified dates.

Resident #10 right lower leg and right thigh wounds and treatments were reviewed. Resident #11 insulin administration record last 7 days was reviewed. Resident #17 insulin administration record last 7 days was reviewed. Resident #27 medication administration record last 7 days was reviewed. Director of Nursing or Designee identified current diabetic residents receiving insulin reviewing their insulin administration record and CBGs for the last 2 weeks, addressing concerns identified. The Director of Nursing or Designee reviewed the missed medication report for the last week, addressing concerns identified. Director of Nursing or designee reviewed wound dressings on current residents, addressing concerns identified. The Director of Nursing or designee re-educated Licensed nurses and Certified Medication Aides on the requirement to administer medications and treatments as ordered. Inservice included: orders carried out timely taking into account the schedule for residents that receive dialysis, physician notification, what to do if medication gets missed, and dressing changes done as ordered with accurate documentation. The Director of Nursing or Designee will conduct random audits on the administration record and CBGs for residents receiving insulin weekly x 3 weeks then monthly x 2 months. The Director or Nursing or Designee will conduct random audits on the missed medication administration report weekly x 3 weeks then monthly x 2 months. The Director of Nursing or designee will conduct random audits on wound care dressing change compliance via observation and/or chart documentation review weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

, , Based on interview and record review it was determined the facility failed to administer insulin as ordered and failed to assess a resident's ability to safely administer medications including insulin for 2 of 4 sampled residents (#s 11 and 17) reviewed for medication administration. This failure was determined the be an immediate jeopardy situation because the facility continued to not have systems in place to ensure residents received insulin timely and safely which placed Resident 11 at risk for potentially fatal hypoglycemia (low blood sugar) and hyperkalemia (high potassium level). Findings include: 1. Resident 11 was admitted to the facility in 2021 with diagnoses include diabetes type 1 with retinopathy (damage to the blood vessels in the eye) and end stage kidney disease. Resident 11's 11/19/21 MDS indicated the resident's ability to see in adequate light, with glasses or other visual appliances, was highly impaired. Resident 11's 4/2022 Order Recap Report revealed the resident had the following physician's orders: - Dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) every Monday, Wednesday and Friday. - Insulin glargine (long-acting insulin is an injectable medication to treat high blood sugar) at bedtime. - Insulin lispro (fast-acting insulin) before meals and at bedtime. Resident 11's Care Plan initiated 11/2021 included the resident had a history of: - Leaving the facility with family and returning with abnormal CBGs. - Not following diet recommendations related to diabetes. - Refusing insulin. - Refusing dialysis with resulting high potassium levels. - Refusing to go to the hospital for very low or very high CBGs. Resident 11's Care Plan also indicated the resident was legally blind. Resident 11's 4/2022 Diabetic Administration Record (DAR) and 4/2022 Progress Notes revealed the facility did not administer physician ordered insulin injections to the resident on the following dates and administration times: - 4/6/22 at 11:30 AM the resident was noted as "OF" (out of the facility without medications) - 4/8/22 at 11:30 AM and 4:30 PM the resident was noted as "9" (other/see Progress Notes). A Progress Note dated 4/8/22 at 4:10 PM indicated the resident was at home with medications. - 4/8/22 at 6:00 PM the resident was noted as "OF". - 4/9/22 at 7:30 AM, 11:30 AM, 4:30 PM and 6:00 PM the resident was noted as "FM" (out of the facility with medications). - 4/10/22 at 7:30 AM the resident was noted as "FM", at 11:30 AM, 4:30 PM and 6:00 PM the resident was noted as "OF". Progress Notes dated 4/10/22 at 7:58 AM and 11:30 AM indicated the resident was out of the facility with family with medications. - 4/15/22 at 11:30 AM the resident was noted as "OF". At 4:30 PM and 6:00 PM the resident was noted as "FM". A Progress Note dated 4/15/22 at 4:47 PM indicated the resident went home for the weekend and had her/his medication. - 4/16/22 at 7:30 AM, 11:30 AM, 4:30 PM and 6:00 PM the resident was noted as "FM". - 4/17/22 at 7:30 AM, 11:30 AM and 4:30 PM the resident was noted as "FM". - 4/20/22 at 11:30 AM the resident was noted as "OF". However, a Progress Noted dated 4/20/22 at 2:00 PM indicated the resident walked out of the facility to a private vehicle. A review of Resident 11's clinical record from 11/2021 through 4/2022 revealed no physician's order for the resident to self-administer medications and no assessment by the facility demonstrating the resident was able to safely self-administer medications. A SNF Self Administration of Medication Evaluation dated 11/29/21 was completed by Staff 3 (LPN) to assess Resident 11's ability to safely check her/his CBG level for which the provider had written an order allowing the resident to do so. The assessment documented the resident was "Completely capable" under each of the following: - The resident could correctly read label and identify each medication. - The resident could correctly state the name of each medication and what each medication is for. - The resident could correctly state common side-effects of each medication - The resident could correctly state the time/frequency medications are to be taken. - The resident could correctly state the correct dosage/quantity for each administration. - The resident could open medication packages/containers. - The resident could appropriately document self-administration of the medications listed (choose Not Applicable if nurse documents administration). - The resident could demonstrate secure storage of medications kept in room (choose not applicable if medication not kept in resident room). - Could state the appropriate situations for self-administration of PRN medications (choose not applicable if resident has no PRN medications). - The resident could correctly document the administration of PRN medications (choose not applicable if resident has no PRN medications). - The resident could demonstrate proper hand washing technique prior to and following medication administrations. - The resident could correctly measure the appropriate amount of medication from the container (choose not applicable if medications do not require a measurement). - The resident could open and close medication containers. - The resident could correctly request medications stored in med cart. - The resident could correctly administer subcutaneous injections. - The resident could correctly administer inhalant medications according to proper procedure. - The resident could correctly administer eye drops or eye ointments correctly. - The resident could apply topical ointments, creams, or trans-dermal patches according to proper procedures. - The resident could administer ear drops correctly. - The resident could administer suppositories according to proper procedure. (The above assessments were pertinent to medication administration and were not applicable to assessing the resident's ability to safely check her/his CBG level. No comments or narrative were provided to indicate how the assessment was performed.) A review of Resident 11's Blood Sugar Summary from 11/23/21 through 4/20/22 revealed the resident's blood sugar level was inconsistent and varied from as low as 30 to as high as 600 (Normal is 72 to 108. Symptoms of low blood sugar can include: confusion, sweating, fast heart rate, blurred vision, lightheadedness, being clumsy and seizures. Emergency treatment to restore blood sugar levels is important because the brain does not store glucose (sugar) and needs a constant supply to sustain life.). Resident 11's Lab Results Report dated: - 1/21/22 indicated the resident had a critical potassium level of 6.4 (normal is 3.3 to 5.0). - 1/22/22 indicated the resident had a critical potassium level of 7.0. (Potassium levels higher than 5.2 can be caused by kidney disease and uncontrolled diabetes which can cause heart rhythm problems, heart attack and paralysis.) On 4/21/22 at 12:19 PM Resident 11's 4/2022 DAR was reviewed with Staff 2 (DNS) who confirmed the resident went home on the weekends to be with family and medications were sent with the resident. Staff 2 verified there were no physician's orders for the resident to self-administer medications and no facility assessment of the resident's ability to safely self-administer medications. On 4/25/22 at 9:00 AM Staff 1 (Administrator) was notified of the Immediate Jeopardy (IJ) situation and was provided a copy of the IJ Template related to the facility's failure to provide and ensure safe insulin administration. An immediate plan of correction was requested. On 4/25/22 at 9:56 AM Staff 3 stated she did not specifically remember conducting Resident 11's assessment to safely check her/his CBG level but when she does that kind of assessment she has the resident demonstrate the task. Staff 3 was asked if she assessed the resident's ability to self-administer medications as indicated by her documentation of "Completely capable" on the 11/29/22 SNF Self Administration of Medication Evaluation. Staff 3 stated she did not assess the resident for safe medication self-administration and had been told she was not allowed to indicate "Not Applicable" on the form. On 4/25/22 at 10:29 AM Staff 4 (LPN) Stated Resident 11 went home every weekend and she would prepare the resident's medications including all oral medications, insulin and supplies (such as needles) for the resident to take with her/him. Staff 4 reviewed Resident 11's physician's orders and confirmed there was no order for the resident to self-administer her/his medications. On 4/25/22 at 11:25 AM the facility submitted a plan of correction which included: - Resident 11 was discharged from the facility. - Resident 17's clinical record was reviewed, CBGs reviewed, orders obtained. Licensed Nurses were educated to administer insulin at the dialysis unit if needed. - Diabetic residents in the facility will have their CBGs reviewed and if needed, self-administration assessments completed and ensure physician orders are in place for self-administration. - Assess for non-compliant residents who may have CBGs out of parameters as a result of refusals or non-compliance. Physicians will be notified per policy and further directions obtained. - Licensed nurses have been educated to administer insulin as ordered, including the in-house dialysis unit as needed. If insulin is not administered notify the practitioner and document in the medical record. Nurses will also be educated to complete an assessment and obtain a physician's order before providing medications to residents for self-administration. Education will be completed for nurses either in-person or by phone by Staff 2 by 4/2622 at 12:00 PM. - Insulin administration audits will occur daily including out of facility parameters for two weeks and then weekly for four weeks. - The Medical Director will review insulin administration audits and audits will be reviewed by the QAPI committee for further recommendations. On 4/26/22 at 8:56 AM Staff 1 was notified the immediacy was removed based on staff interviews and record review which demonstrated the IJ abatement plan was fully implemented. 2. Resident 17 was admitted to the facility in 2021 with diagnoses including end stage kidney disease and diabetes. Resident 17's active Clinical Physician Orders included the following: - Dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) every Monday, Wednesday and Friday with a start date of 3/30/22. - Insulin aspart (short acting insulin) three times daily with varying administration times based on the day of the week and dosage based on the resident's CBG. Resident 17's 4/2022 Diabetic Administration Record and 4/2022 Progress Notes revealed the resident was not administered physician ordered insulin injections on the following dates and administration times: - 4/6/22 at 7:00 AM the resident was noted as "OF" (out of the facility without medications). - 4/8/22 at 7:00 AM the resident was noted as "9" (other/see Progress Notes). A Progress Note dated 4/8/22 at 7:54 AM indicated the resident was at a dialysis appointment. - 4/11/22 at 7:00 AM the resident was noted as "OF". - 4/13/22 at 7:00 AM the resident was noted as "OF". A Progress Note dated 4/13/22 at 10:25 AM indicated the resident was at a dialysis appointment. - 4/13/22 at 11:30 AM the resident was noted as "9". A Progress Note dated 4/13/22 at 12:35 PM indicated the resident was out of insulin. - 4/15/22 at 7:00 AM the resident was noted as "OF". - 4/18/22 at 7:00 AM the resident was noted as "OF". A Progress Note dated 4/18/22 at 7:50 AM indicated the resident was at a dialysis appointment. On 4/21/22 at 10:47 AM Staff 2 (DNS) verified the resident was not administered insulin according to the physician's orders. ,

No PoC required

Based on observation, interview and record review it was determined the facility failed to ensure a resident received pressure ulcer treatments for 1 of 1 sampled resident (#52) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 52 was admitted to the facility in 10/2021 with diagnoses including a Stage 3 pressure ulcer of the sacrum. The 2/3/22 physician order indicated Resident 52 was to receive dressing changes daily and PRN to the Stage 3 pressure ulcer on the coccyx. On 2/16/22 at 11:12 AM Staff 9 (LPN) stated Resident 52 needed a dressing change to her/his pressure ulcer. Staff 9 was observed to remove the resident's brief, there was no dressing covering the pressure ulcer. Staff 9 stated there was supposed to be a dressing on the area. Staff 9 applied a dressing to the pressure ulcer and stated she was not aware her/his dressing was not in place prior to this observation. On 2/16/22 at 11:29 AM and 1:53 PM Staff 6 (CNA) and Staff 11 (CNA) stated they completed a brief change for Resident 52 prior to breakfast [on 2/16/22] and there was no dressing in place during the brief change. Staff 6 stated the expectation was to tell the nurse if the dressing was not in place and she did not tell the nurse because it was during breakfast and she was busy passing trays. On 2/16/22 at 1:13 PM Staff 10 (LPN) stated she was the primary nurse for Resident 52 and staff did not inform her that the resident did not have a dressing in place this morning [2/16/22] after her/his brief change. On 2/17/22 at 2:49 PM Staff 2 (DNS) acknowledged Resident 52 did not have a dressing change in place on 2/16/22 and stated the expectation was for CNA staff to alert nursing staff if a dressing fell off.

Resident #52 wounds and treatments were reviewed. Director of Nursing or designee identified residents with pressure ulcers and conducted a review via observation of dressings, addressing concerns identified. Director of Nursing or Designee re-educated the licensed nurses on the requirement to ensure residents receive pressure ulcer treatments. Director of Nursing or Designee re-educated the CNAs on the importance of notifying the nurse timely if a dressing on a pressure ulcer is noted to be missing. The Director of Nursing or Designee will do conduct random audits on current residents with pressure ulcers for treatment compliance weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on observation, interview and record review it was determined the facility failed to ensure residents received restorative therapy to prevent ADL decline for 3 of 4 residents (#s 8, 22, and 37) reviewed for RA. This placed residents at risk for physical decline. Findings include: 1. Resident 22 admitted to the facility in 2020 with diagnoses including back fractures. The 9/20/21 Quarterly MDS indicated Resident 22 was cognitively intact and required extensive assistance with transfers and bed mobility. An 8/11/20 Therapy RA Referral Order indicated Resident 22 was to receive the following RA: *Arm Bike Resistance "4" for 10-15 minutes three times a week. *Leg Bike Resistance "1" for 8-10 minutes two times a week. The 1/2022 and 2/2022 RA Task Sheet indicated Resident 22 received/was offered ordered RA on the following dates: *January: 6, 13, and 22. *February: 8, 14, 15, and 16. On 2/16/22 at 2:14 PM Staff 26 (RA/Central Supply/CNA) stated nearly every other day he could not perform RA duties because he was pulled to the floor to work as a CNA and/or perform Central Supply duties. Staff 26 stated if he could not perform the order on the task sheet, he would leave it blank or mark "NA" [Not Available] and stated he did not have a "good system" for tracking RA. On 2/17/22 at 9:15 AM Resident 22 stated "once in a great while" she/he received RA and it "felt so good" when it was completed, but staff were too busy to complete RA. Resident 22 stated she/he did not have any outcome due to not receiving RA, but she/he stated it just "feels better" when RA was completed. On 2/18/22 at 1:51 PM Staff 2 (DNS) confirmed RA was not performed as ordered for Resident 22 and this was due to facility staffing shortages. Refer to F725. 2. Resident 37 admitted to the facility in 2011 with diagnoses including epilepsy and an unspecified gait disorder. The 11/29/21 Quarterly MDS indicated Resident 37 was cognitively intact and required limited assistance with bed mobility, supervision with transfers, and extensive assistance with dressing. A 3/26/19 Therapy RA Referral Order indicated Resident 37 was to receive the following RA: *Arm Bike Resistance "5" for 15 minutes three times a week. The 1/2022 and 2/2022 RA Task Sheet indicated Resident 37 received/was offered ordered RA on the following dates: *January: 8 and 26. *February: 8, 14, and 16. On 2/16/22 at 2:14 PM Staff 26 (RA/Central Supply/CNA) stated nearly every other day he could not perform RA duties because he was pulled to the floor to work as a CNA and/or perform Central Supply duties. Staff 26 stated if he could not perform the order on the task sheet, he would leave it blank or mark "NA" [Not Available] and stated he did not have a "good system" for tracking RA. On 2/18/22 at 1:51 PM Staff 2 (DNS) confirmed RA was not performed as ordered for Resident 37 and this was due to facility staffing shortages. Refer to F725. , 4. Resident 8 admitted to the facility in 5/2021 with diagnoses including fracture and osteoporosis. The 5/24/21 Admission MDS indicated Resident 8 was cognitively intact and required one person physical assist with walking in room and corridor. From 2/14/22 through 2/23/22 multiple observations of Resident 8 revealed her/him utilizing a wheelchair for locomotion in her/his room and corridor. On 2/14/22 at 11:23 AM Resident 8 stated upon admission she/he received physical therapy and was discharged and placed on an RA program. She/he further stated staff were unavailable to assist her/him regularly with RA and she/he wanted to get stronger and walk independently. A 7/16/2021 RA Referral Order indicated Resident 8 was to receive the following RA: -Ambulate with 4WW (4 wheeled walker) to skilled nurses station and back to room three days a week. -Seated resisted exercise three to four days a week The 1/2022 and 2/2022 RA Task sheet indicated Resident 8 received/was offered ordered RA on the following dates: -January: 26 -February : 8, 14, and 16. On 2/16/2022 at 2:14 PM Staff 26 (RA/Central Supply/CNA) stated nearly every other day he could not perform RA duties because he was pulled to the floor to work as a CNA and/or perform Central Supply duties. Staff 26 stated if he could not perform the order on the task sheet, he would leave it blank and mark it "NA" [Not Available] and stated he did not have a "good system" for tracking RA. On 2/18/22 at 12:14 PM Staff 2 (DNS) confirmed RA was not performed as ordered for Resident 8 and this was due to the lack of adequate staffing in the facility. Refer to 725.

Resident #8  RA program was reviewed. Resident #22  RA program was reviewed. Resident #37 - RA program was reviewed. Director of Nursing or Designee will review current residents with Therapy RA referral order, addressing concerns identified. The Director of Nursing or Designee re-educated the restorative aide(s) on the restorative program. The Director of Nursing or Designee will conduct random audits on the restorative program via record review, observation and/or staff/resident interview weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to investigate the root cause, ensure care plan interventions were appropriate, and update the care plan to prevent falls for 1 of 2 residents (#40) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 40 admitted to the facility on 10/15/21 with diagnoses including end stage renal disease (ESRD) and dementia. The 10/15/21 Baseline Care Plan indicated Resident 40 was a high fall risk. Interventions included: call light/personal items within reach, nonskid footwear when transferring, and remind to use call light for assistance. The 10/15/21 Initial Fall Assessment indicated Resident 40 had a history of falls and was a high fall risk. The 10/21/21 Admission MDS indicated the resident had moderately impaired cognition, was incontinent, required limited two-person assistance for transfers and had one fall since admission, but none prior to admission. The Fall CAA indicated Resident 40 had a non-injury fall on 10/23/21 and "interventions have been applied" and the care plan would address "how to prevent falls in the future." A 10/23/21 Fall Investigation indicated Resident 40 fell when trying to self-transfer out of her/his wheelchair as the wheelchair was not locked and the chair moved as the resident stood up. The resident was wearing footwear, the call light was in reach, and the resident was observed five minutes prior to the fall. Staff 30 (CNA) stated he had worked with Resident 40 the day previously and after the incident on 10/23/21 and stated he saw the resident in her/his room "all the time trying to self ambulate and walking around in [her/his] room without help." Staff 31 (CNA) stated she saw Resident 40 previously that day ambulating without assistance in her/his room and redirected the resident. The 10/26/21 investigation summary indicated Resident 40 was educated on using the call light. On 11/3/21 an intervention was added: "Will look for pressure break for [wheelchair], meanwhile increase visual checks." Resident 40's Care Plan was not updated status post the 10/23/21 fall. On 2/23/22 at 9:08 AM Staff 30 (CNA) stated Resident 40 self-ambulated "often" and was impulsive. Staff 30 stated the resident would use the call light "sometimes" to request assistance. An 11/2/21 Fall Investigation indicated Resident 40 sustained a fall at 4:02 PM. Resident 40 stated she/he attempted to self-transfer and the wheelchair moved so she/he fell down. Resident 40 sustained a 10 cm laceration that required stitches at the hospital. The resident did not sustain significant pain or limitations from the injury after hospitalization. Staff 33 (CNA) stated the resident was last seen at 2:40 PM and the call light was on "about 10 minutes" when she arrived after the fall. Staff 32 (Occupational Therapist) stated the call light was not on when she found the resident. The investigation did not include if fall interventions were in place and if the call light was initiated. The 11/4/21 investigation summary included updated interventions: "signage" placed on doors to use call light and not self-ambulate, frequent checks and door open, and resident educated on fall safety and asking for assistance. The care plan was noted to be updated. The cause of the fall was noted to be Resident 40's dementia diagnoses and the resident forgot to use the call light before self-ambulating. Resident 40's Care Plan was updated on 11/2/21 and indicated: "Add [wheelchair] pressure break when available (supply not available) and was updated 12/15/21 "Add [wheelchair] pressure break." Resident 40 sustained two more falls on 11/15/21 and 11/19/21 self-transferring from her/his wheelchair. The care plan was not updated until 12/15/21 and included interventions: "Dycem non-slip cushion to [wheelchair]" and "move to high visibility room after fall." On 2/23/22 at 10:58 AM Staff 32 (Occupational Therapist) stated she found Resident 40 on the floor on 11/2/21. Staff 32 stated Resident 40 had non-skid socks on at the time of fall. Staff 32 further stated the resident was impulsive with transfers, intermittently pressed the call light for assistance, and was not cognitively aware to use call light for assistance, so reminders were placed on the wall to use the call light. Staff 32 stated when she found the resident, she did not believe the call light was on, but she could not be sure as she did not have an "iphone" device used by nursing staff for answering call lights. On 2/23/22 at 12:31 PM Staff 5 (CNA) stated when Resident 40 was up in her/his wheelchair in her/his room, staff made sure at least one of the wheelchair wheels was locked. On 2/22/22 at 1:09 PM and 2/23/22 at 1:45 PM Staff 19 (LPN Resident Care Manager) stated Resident 40 was impulsive and did not remember to use the call light to ask for assistance. Staff 19 stated the expectation was to have care plan interventions in place for falls and discuss if interventions in place were appropriate and updated as needed. Staff 19 confirmed there was no evidence interventions status post the 10/23/21 and 11/2/21 falls were discussed and stated the interventions of having the call light in reach and reminding the resident to use call lights was a "generic intervention" and agreed the intervention was not appropriate for Resident 40. Staff 19 stated Resident 40 received an "anti-tilt" wheelchair after the 11/2/21 fall. Staff 19 confirmed Resident 40 fell on 10/23/21 transferring out of her/his unlocked wheelchair and fell the same way on 11/2/21 and then twice more before the 12/15/21 interventions of a wheelchair brake, a non-slip wheelchair cushion, and a room closer to the nursing station were implemented. Staff 19 confirmed the investigation for 11/2/21 was not thorough and did not indicate if Resident 40's fall care plan was followed and acknowledged no interventions were put in place post the 10/23/21 fall until after the 11/2/21 fall.

Resident #40 fall investigations were thoroughly reviewed and interventions/care plan updated. Director of Nursing or designee reviewed current residents with falls over the last 30 days for investigation thoroughness, appropriate intervention and care plans updated, addressing concerns identified. The Director of Nursing or designee re-educated licensed nurses on the requirement to investigate the root cause, ensure care plan interventions were appropriate and update the care plan to prevent falls. Director of Nursing or designee will do random audits on falls for investigation thoroughness, interventions and care plans updated weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure the resident received nutritional supplements as ordered to prevent weight loss for 1 of 2 residents (#40) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: Resident 40 admitted to the facility in 10/2021 with diagnoses including end stage renal disease (ESRD) with hemodialysis and dementia. Resident 40 was care planned for being at risk for weight loss due to ESRD and received NAR (Nutrition at Risk) assessments monthly. The 1/18/22 NAR Note indicated Resident 40 experienced weight loss since the prior month and the resident agreed to try Nepro (a nutrition drink supplement) daily in the afternoon. A 1/19/22 Order indicated Resident 40 was to receive Nepro 237 ml every evening for weight loss. Review of the 1/2022 and 2/2022 MARs indicated the following dates Resident 40 did not receive Nepro and the reason was marked "NA" (not available): *1/2022: 25, 27, 28, 30, and 31. *2/2022: 1, 2, and 3. The identified dates marked "NA" were signed off by Staff 29 (CMA) and Staff 34 (CMA). On 2/23/22 at 11:44 AM Staff 29 (CMA) stated the Nepro supplement was not on the medication cart where it was supposed to be and he thought the Nepro was unavailable. Staff 29 stated he later realized the supplement was in the medication room. Staff 29 stated no one told him the Nepro was in the medication room and he did not ask anyone where is was when it was not on the medication cart. Attempts were made to contact Staff 34 (CMA) with no response. On 2/23/22 at 11:53 AM Staff 19 (LPN Resident Care Manager) and the surveyor observed an ample supply of Nepro in the medication storage room. Staff 19 stated both CMAs and nurses had access to the medication room to retrieve Nepro if it was not available on the medication carts. On 2/23/22 at 2:00 PM Staff 19 acknowledged the identified dates marked "NA", when Resident 40 did not receive Nepro as ordered. Staff 19 stated if Nepro was not on the medication cart, staff were expected to go check the medication room and not mark "NA" as Nepro was available.

Resident #40 was reviewed by RD. The Director of Nursing or Designee reviewed current residents with Nepro orders, addressing concerns identified. The Director of Nursing or Designee re-educated licensed nurses and certified Medication Aides on the requirement to ensure the resident receives nutritional supplements. Re-education included where to find Nepro if not on medication cart and steps to take if unable to locate supplement. The Director of Nursing or Designee will do random audits on nutritional supplement administration for compliance weekly x3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on observation, interview, and record review it was determined the facility failed to ensure adequate staffing to meet resident needs for 2 of 3 halls reviewed for staffing. This placed residents at risk for unmet physical and psychosocial needs. Findings include: 1. On 2/15/22 at 12:03 PM and 2/17/22 at 1:53 PM Resident 47 stated she/he was the Resident Council president and stated residents at the meeting "always" complained about call light timing and staffing and it was still a concern. Resident 47 stated there had been times she/he would call the nurses station because her/his call light would not be answered. Resident Council notes were reviewed for 1/2022 and 2/2022 and indicated: *1/18/22: Short staffed. CNAs seem unhappy, overwhelmed and grumpy. Call light wait times 30-60 minutes. *2/15/22: Call lights still an issue during the night. On 2/23/22 at 10:58 AM Staff 1 (Administrator) confirmed the facility staffing shortages and long call light wait times. 2. Resident 106 admitted to the facility in 2/2022 with diagnoses including an arm fracture. The 2/8/21 Care Plan indicated Resident 106 required one-person extensive assistance using a bedside commode for toileting. The 2/9/22 Annual MDS indicated Resident 106 required extensive assistance with toileting and was occasionally incontinent of bowel and bladder. On 2/17/22 at 10:33 AM Resident 106's call light was observed to be initiated at the nurses station since 10:21 AM. On 2/17/22 at 10:36 AM Resident 106 stated she/he needed to use the restroom and had been waiting about 15 minutes. Resident 106 further stated "this always happens and it usually takes longer", in regards to call lights being answered. Resident 106 stated there were no outcomes, but long call light times occurred daily. Resident 106 stated waiting a long time for assistance to the restroom made her/him feel "not good, having to wait so long". On 2/17/22 at 10:42 AM Resident 106's call light was answered at by Staff 36 (CNA). Staff 36 acknowledged the long call light time (21 minutes after the light was initiated) and stated she was busy "running around answering lights." 3. Resident 22 admitted to the facility in 2020 with diagnoses including back fractures. The 9/20/21 Quarterly MDS indicated Resident 22 was cognitively intact and required extensive assistance with bed mobility and toileting, and was frequently incontinent of bladder and always incontinent of bowel. The resident required one-person assistance with bathing. On 2/15/22 at 10:26 AM and 2/17/22 at 9:15 AM Resident 22 reported in about a week prior on evening shift, her/his call light took two hours to be answered and an Former CNA [Witness 4] told the resident they would not change her/him as Witness 4 was too busy passing dinner meal trays. Resident 22 stated she/he filed a grievance regarding the incident. A 2/4/22 Grievance Form indicated that day a designated CNA refused to change Resident 22's brief during the dinner meal and the resident was left for hours sitting in a soiled brief. The 2/4/22 Call Light Log for Resident 22 showed the call light was answered by "Float" staff at 5:54 PM and was on for two hours. A 2/5/22 Investigation indicated Staff 2 (DNS) received a grievance regarding brief changes for Resident 22 on 2/4/22. The investigation summary indicated Resident 22's brief not changed timely and the resident sat in a soiled brief for two hours. On 2/18/22 at 2:46 PM Staff 27 (CNA) stated he answered Resident 22's call light on 2/4/22 and the resident had a bowel movement soiled brief and reported she/he had been waiting "a long time" for a brief change and reported a CNA stated they were passing meal and told Resident 22 she/he would have to wait. On 2/23/22 at 10:10 AM Witness 4 (Former CNA) stated she was the only CNA working Resident 22's hall on 2/4/22 evening shift. Witness 4 stated Resident 22 stated "you need to change me", but Witness 4 was busy passing trays so she stated to the resident "I cant change you at the moment I have trays on the hall". The resident further stated "well everyone else stops what they are doing and changes me" and Witness 4 replied "I can't touch you when I have meal trays, not right now." Witness 4 stated another CNA changed the resident later in the shift as she was too busy. On 2/17/22 at 12:31 PM Staff 2 (DNS) stated she completed the investigation for the 2/4/22 incident and confirmed Witness 4 left Resident 22 in soiled brief and did not change brief because Witness 4 was busy serving trays. Staff 2 further confirmed the 2/4/22 Call Light Log indicated Resident 22 waited two hours for her/his brief to be changed. 4. a. Resident 22 admitted to the facility in 2020 with diagnoses including back fractures. An 8/11/20 Therapy RA Referral Order indicated Resident 22 was to receive the following RA: *Arm Bike Resistance 4 for 10-15 minutes three times a week. *Leg Bike Resistance 1 for 8-10 minutes two times a week. The 1/2022 and 2/2022 RA Task Sheet indicated Resident 22 received/was offered ordered RA on the following dates: *January: 6, 13, and 22. *February: 8, 14, 15, and 16. On 2/16/22 at 2:14 PM Staff 26 (RA/Central Supply/CNA) stated nearly every other day he cannot perform RA duties because he is pulled to the floor to work as a CNA and/or perform Central Supply duties. Staff 26 stated if he could not perform the order on the task sheet, he would leave it blank or mark "NA" [Not Available] and stated he did not have a "good system" for tracking RA. On 2/17/22 at 9:15 Resident 22 stated "once in a great while" she/he received RA and it "felt so good" when it was completed, but staff were too busy to complete RA. Resident 22 stated she/he did not have any outcome due to not receiving RA, but she/he just "feels better" when RA is completed. On 2/18/22 at 1:51 PM Staff 2 (DNS) confirmed RA was not performed as ordered for Resident 22 and this was due to facility staffing shortages. b. Resident 37 admitted to the facility in 2011 with diagnoses including epilepsy and an unspecified gait disorder. A 3/26/19 Therapy RA Referral Order indicated Resident 37 was to receive the following RA: *Arm Bike Resistance 5 for 15 minutes three times a week. The 1/2022 and 2/2022 RA Task Sheet indicated Resident 37 received/was offered ordered RA on the following dates: *January: 8 and 26. *February: 8, 14, and 16. On 2/16/22 at 2:14 PM Staff 26 (RA/Central Supply/CNA) stated nearly every other day he cannot perform RA duties because he is pulled to the floor to work as a CNA and/or perform Central Supply duties. Staff 26 stated if he could not perform the order on the task sheet, he would leave it blank or mark "NA" [Not Available] and stated he did not have a "good system" for tracking RA. On 2/18/22 at 1:51 PM Staff 2 (DNS) confirmed RA was not performed as ordered for Resident 37 and this was due to facility staffing shortages. c. Resident 8 admitted to the facility in 5/2021 with diagnoses including fracture and osteoporosis. The 5/24/21 Admission MDS indicated Resident 8 was cognitively intact and required one person physical assist with walking in room and corridor. From 2/14/22 through 2/23/22 multiple observations of Resident 8 revealed her/him utilizing a wheelchair for locomotion in her/his room and corridor. On 2/14/22 at 11:23 AM Resident 8 stated upon admission she/he received physical therapy and was discharged and placed on an RA program. She/he further stated staff were unavailable to assist her/him regularly with RA and she/he wanted to get stronger and walk independently. A 7/16/2021 RA Referral Order indicated Resident 8 was to receive the following RA: -Ambulate with 4WW (4 wheeled walker) to skilled nurses station and back to room three days a week. -Seated resisted exercise three to four days a week The 1/2022 and 2/2022 RA Task sheet indicated Resident 8 received/was offered ordered RA on the following dates: -January: 26 -February : 8, 14, and 16. On 2/16/2022 at 2:14 PM Staff 26 (RA/Central Supply/CNA) stated nearly every other day he could not perform RA duties because he was pulled to the floor to work as a CNA and/or perform Central Supply duties. Staff 26 stated if he could not perform the order on the task sheet, he would leave it blank and mark it "NA" [Not Available] and stated he did not have a "good system" for tracking RA. On 2/18/22 at 12:14 PM Staff 2 (DNS) confirmed RA was not performed as ordered for Resident 8 and this was due to the lack of adequate staffing in the facility. Refer to F688. , 5. Resident 28 admitted to the facility on 12/8/21 and discharged on 2/1/22 with diagnoses including mood disorder and ankle fracture. On 1/14/22 Resident 28 reported there was not enough staff to meet her/his needs. Review of Resident 28's call light logs revealed the following call light times: -12/28/21 call light time of 46 minutes and 40 minutes. - 12/29/21 call light time of 29 minutes and hour. - 1/2/22 call light time of 44 minutes. - 1/4/22 call light time of 38 minutes. - 1/10/22 call light time of 1 hour 50 minutes. - 1/17/22 call light time of 42 minutes. On 2/23/22 at 10:58 AM Staff 1 (Administrator) confirmed the long call lights times for Resident 28. , 6. The facility provided a list of 26 residents who required mechanical lifts and two person transfers. The following information was reported to the State Survey Agency: Residents: On 2/14/22 at 10:33 AM Resident 9 stated it took up to two hours for a CNA to respond to her/his call light requests. On 2/14/22 at 11:45 AM Resident 7 stated she/he waited 30 minutes after pressing her/his call light and then started "screaming" for staff assistance. Resident 7 further stated she/he did not receive brief checks and changes timely. On 2/15/22 at 9:45 AM Resident 11 stated she/he waited between one to three hours after pressing her/his call light for staff to assist her/him. On 2/15/22 at 9:59 AM Resident 108 stated she/he sometimes waited two to three hours for her/his call light to be answered and night shift was the "worst". On 2/15/22 at 10:05 AM Resident 22 stated she/he went three weeks without a shower due to staffing shortages. Resident 22 stated it consistently took longer than 20 minutes and sometimes up to two hours for her/his call light to be answered. Resident 22 stated she/he would call the nurses station when her/his call light was not answered. On 2/15/22 at 10:31 AM Resident 44 stated she/he waited over and hour after pushing her call light on the evening of 2/14/22 and she/he was sick. The resident stated she/he typically waits 30 minutes for the call light to be answered by staff. On 2/15/22 at 10:55 AM Resident 54 stated night shift and day shift staffing was "the worst" and she/he waited 30 minutes to an hour for her/his call light to be answered. Resident 54 stated she/he was discharging that day because staffing was inadequate. On 2/15/22 at 12:34 PM Resident 37 stated there was not enough staff in the facility to provide care. Resident 37 stated when she/he initiated her/his call light on it would take anywhere from 20 minutes to over an hour for the call light to be answered. Resident 37 further stated sometimes staff would answer the call light and state they would "be right back", but would not return because they were too busy. On 2/15/22 at 12:59 PM Witness 6 (Family Member) stated staffing at the facility was "horrible" and she came almost daily to visit Resident 36 and had to request staff perform frequent brief changes for the resident. Witness 6 stated she wondered if the resident was checked and changed as often when she was not at the facility. On 2/17/22 at 1:53 PM Resident 47 stated she/he and other residents had discussed how management was not approachable, especially the administrator. Resident 47 stated the facility was only staffed appropriately due to "state" being at the facility. Resident 47 stated there had been multiple times when there were only four CNAs working for the whole building and one time the resident laid in bed all night in pee and no one got her out of bed so she/he cried. Staff: On 2/15/22 at 11:08 AM Staff 3 (CNA) stated there are not enough staff to care for all of the residents. Staff 3 stated often times residents who prefer showers are given bed baths instead due to not having enough staff to get the residents' out of bed. Staff 3 further stated CNA staff are often assigned to care for 10 to 12 residents each. On 2/15/22 at 1:48 PM Staff 5 (CNA) stated the facility is so short staffed it was difficult to give residents showers and care had to be prioritized due to the workload. Staff 5 stated staff are often assigned 11 residents and a large number of those residents required mechanical lifts for transfers. Staff 5 further stated staff often call in sick and there are not enough staff to cover those shifts. On 2/16/22 at 1:19 PM Staff 10 (LPN) on 1/30/22 there were only three CNAs in the building taking care of 55 residents for day shift and management was aware of the staffing shortages ahead of time and did not assist. On 2/16/22 at 7:03 AM Staff 9 (LPN) stated often times there were only two nurses and five CNAs working for the whole building, which was difficult, especially since the facility had a specialized dialysis unit. Staff 9 stated the resident acuity had nursing staff "overwhelmed." On 2/17/22 at 3:02 PM Staff 13 (CNA) stated showers were not provided due to staffing and there were times when there were just two staff working on the floor. On 2/23/22 at 10:58 AM Staff 1 (Administrator) confirmed facility staffing shortage concerns.

F725 Resident 47, 106, 22, 27, 37, 8, 28, 9, 7, 11, 108, 44, 54, 36 were interviewed to identify and address current unmet needs. The Administrator or Designee did a comprehensive review to identify staffing trends to address; this was done through resident interviews, staff interviews, call light response audits, and documentation review. The Administrator or Designee met with resident council to review focus areas identified, current and proposed solutions and gathered additional feedback from the council. The Administrator re-educated Staffing Coordinator on requirement to ensure adequate staffing to meet resident needs. The Administrator re-educated leadership team and floor nurses on requirement to ensure adequate staffing to meet resident needs and what to do if additional staff is needed. The Administrator or Designee will conduct random audits through resident interview, staff interview, documentation review, and/or observation to ensure adequate staffing is in place to meet resident care needs in a timely matter weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours for 12 days out of 76 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: A review of Direct Care Staff Daily Reports from 12/1/21 through 2/13/22 revealed the following dates with no RN coverage: -12/10/21 -12/11/21 -12/21/21 -12/28/21 -12/31/21 -1/10/22 -1/11/22 -1/12/22 -1/17/22 -1/18/22 -1/19/22 -2/2/22 On 2/23/22 at 10:58 AM Staff 1 (Administrator) acknowledged the lack of RN coverage on the identified dates.

No residents were cited. Administrator conducted review of payroll records for the last 7 days for RN coverage, addressing concerns identified. The Administrator re-educated the staffing coordinator on the requirement to have eight hours of RN coverage between day and evening shift. The Administrator re-educated the licensed nurses and center leadership on the staffing safety plan. The Administrator will Audit RN coverage within Stand-Up meeting for 2 weeks then weekly for 3 weeks. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on observation, interview and record review it was determined the facility failed to offer residents a menu to accommodate their preferences for 2 of 2 sampled residents (#s 11 and 108) reviewed for food choices. This placed residents at risk for not having food preferences honored and weight loss. Findings include: The following interviews were completed with Resident 11 and Resident 108 regarding food menus: -On 2/15/22 at 9:43 AM Resident 11 stated she/he was not offered a menu and often got food items that she/he was not supposed to have on her/his diet. Resident 11 stated she/he would like a menu. -On 2/15/22 at 9:57 AM Resident 108 stated she/he was not offered a menu and there were no options for food choices. Resident 108 stated she/he would like a menu. On 2/23/22 at 7:58 AM Staff 3 (CNA) stated residents were not given menus or food choices. On 2/23/22 at 9:33 AM Staff 22 (CNA) stated residents are not given menus or food options and they "get what they get." On 2/23/22 at 9:42 AM Staff 16 (Dietary Manager) acknowledged residents were not given menus.

Resident #11 was interviewed for food preferences and provided a menu. Resident #108 no longer resides at center. The Administrator or Designee met with resident council to review food preferences & menu process and to gather additional feedback, addressing concerns identified. The Administrator re-educated the Dining Services Manager on the requirement to offer residents a menu to accommodate their preferences. The Administrator or Designee will conduct random audits via observation and/or resident/staff interviews on menu process weekly x 3 weeks then monthly x 2 month. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on observation, interview and record review it was determined the facility failed to provide palatable and appealing food for 4 of 4 residents (#s 17, 39, 107 and 108) reviewed for food. This placed at residents at risk for weight loss. Findings include: The following interviews were received from residents regarding the facility food: - On 2/14/22 at 1:29 PM Resident 17 stated the food was low quality and contained no healthy options. - On 2/15/22 at 9:57 AM Resident 108 stated the food was "crappy" and scrambled eggs were served every morning. Resident 108 further stated the meals served were all the same with no variety. - On 2/15/22 at 10:26 AM Resident 107 stated the toast served was not browned or toasted and contained no butter. Resident 107 stated she/he did not like the food. -On 2/14/22 at 10:48 AM Resident 39 stated the food was cold half the time and she/he had to send her/his cold oatmeal back. Resident 39 further stated the kitchen was always out of butter and brown sugar. On 2/16/22 at 9:06 AM a test tray was sampled of a regular and puree diet texture meal. The meal consisted of one piece of bacon, toast, eggs, chicken gravy and one small pancake with no syrup provided. The toast was not toasted, limp and no butter was provided. The puree scrambled eggs were watery, mushy and lacked taste. The regular diet texture scrambled eggs were rubbery in texture and lacked taste. On 2/16/22 at 9:09 AM Staff 1 (Administrator) sampled the test meal. Staff 1 confirmed the puree eggs were mushy, slimy and chicken gravy served with breakfast was "odd". Staff 1 also confirmed the regular diet scrambled eggs were rubbery. Staff 1 acknowledged both meals sampled did not look palatable and overall lacked taste.

Resident #17 was interviewed to identify and address any additional current concerns with food taste and palatability. Resident #39 was interviewed to identify and address any additional current concerns with food taste and palatability. Resident #107 was interviewed to identify and address any additional current concerns with food taste and palatability. Resident #108 no longer resides at center. The Administrator or Designee met with resident council to review and gather additional feedback on overall food taste and palatability, addressing concerns identified. The Administrator re-educated the Dining Services Manager and cooks on the requirement to provide palatable and appealing food. The Administrator or Designee will conduct random audits via observation and/or resident/staff interviews on palatable and appealing food weekly x 3 weeks then monthly x 2 month. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on observation, interview and record review it was determined the facility failed to honor a resident's food preference for 1 of 4 sampled residents (#11) reviewed for food. This placed residents at risk for not having their food preferences honored. Findings include: Resident 11 admitted to the facility in 11/2021 with diagnoses including diabetes and end stage renal disease. On 2/15/22 at 9:43 AM and 9:58 AM Resident 11 stated she/he constantly got wrong food items that she/he was not supposed to have including wheat bread. Resident 11 stated every day she/he was served scrambled eggs and toast and did not like either. Resident 11 was observed to have scrambled eggs and wheat toast on her/his breakfast tray, the meal was untouched. The 2/15/22 breakfast diet slip indicated Resident 11's dislikes included eggs and wheat toast. On 2/15/22 at 10:00 AM Staff 4 (LPN) entered the room and observed Resident 11's breakfast tray. Staff 4 acknowledged the meal consisted of eggs and wheat toast and the diet slip indicated they were both on the resident's dislikes diet slip. On 2/23/22 at 7:35 AM Resident 11 stated she/he had not ate breakfast but was served a hard boiled egg in her/his brown bag breakfast. A hard boiled egg was observed to be in the bag along with other items. Resident 11 stated she/he was not going to eat the breakfast because she/he did not like the egg and other items. On 2/23/22 at 8:54 AM Staff 17 (CNA) was observed in Resident 11's room and her/his brown bag breakfast was still on the bedside table. Staff 17 stated Resident 11's brown bag breakfast contained a hard boiled egg and the resident did not want to eat the breakfast prior to going to an appointment. Staff 17 stated she did not check the brown bag breakfast prior to giving it to the resident. Staff 17 further stated residents got the wrong food items and it "happened a lot." On 2/23/22 at 9:42 AM Staff 16 (Dietary Manager) acknowledged Resident 11 received eggs on two occasions and wheat bread toast on one occasion despite the items being on her/his dislikes list. Staff 16 acknowledged residents should get preferred food items and stated it was a known issue with resident's getting wrong food items.

Resident #11 food preferences were reviewed with resident and ticket updated. The Administrator or Designee met with resident council to review and gather additional feedback on food preferences on diet slips, addressing concerns identified. The Administrator or Designee re-educated the Dietary Manager and cooks on the requirement to honor food preferences for residents as indicated on the diet slips. The Administrator or Designee will conduct random audits via observation and/or resident/staff interview on food preferences as indicated on diet slips weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure medical records were accurate for 1 of 6 residents (#11) reviewed for medication. This placed residents at risk for unmet care needs. Findings include: Resident 11 admitted to the facility in 11/2021 with diagnoses including diabetes and end stage renal disease. The 2/16/22 nursing communication to the physician indicated the following: -Resident 11 refused scheduled sliding scale insulin depending on what she/he ate. -"Would you like to be notified of every refusal or would you like to be notified only is resident is hypoglycemic or hyperglycemic." -Please advise. The 2/18/22 signed order by Staff 25 (Physician Assistant) indicated the following: -No notification for refusal. -Notify only if CBG outside of parameters. Resident 11's electronic health record indicated Staff 18 (LPN Resident Care Manager) entered the following order on 2/22/22: -"No need to notify provider of medication/insulin refusals." On 2/23/22 at 10:35 AM Staff 18 stated Resident 11 was a very brittle diabetic and had high and low CBGs "all of the time." Staff 18 further stated Staff 25 wrote the order for "no need to notify provider of medication/insulin refusals." On 2/23/22 at 1:19 PM and 2:51 PM Staff 25 stated she wanted to be notified of Resident 11's medication refusals but not insulin refusals unless her/his CBG was outside of parameters. Staff 25 stated the order in Resident 11's electronic health record was inaccurate. On 2/23/22 at 2:14 PM Staff 18 stated the order she added to the electronic health record was inaccurate and Staff 25 asked her to change it to reflect the actual order.

Resident #11 insulin orders and resident refusal notification orders were reviewed. Director of Nursing or Designee identified residents receiving insulin and reviewed insulin orders and resident refusal notification orders, addressing concerns identified. The Director of Nursing or Designee re-educated the Licensed Nurses on the importance of accuracy when transcribing orders. Re-education included clarifying as much as possible, when applicable, when a physician wants to or does not want to be notified about a resident refusal. The Director of Nursing or Designee will conduct a random audit on insulin orders and resident refusal insulin notification orders weekly x 3 weeks then monthly x 2 months. The Director of Nursing or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Director of Nursing is responsible to ensure compliance.

Based on observation interview and record review it was determined the facility failed ensure rooms were clean and sanitized and failed to ensure showers were in working order 2 of 2 sampled residents (#s 11 and 28) reviewed for environment. This placed residents at risk for an unclean environment and lack of preferences. Findings include: 1. Resident 28 admitted to the facility on 12/8/21 with diagnoses including mood disorder and PTSD (Post Traumatic Stress Disorder). On 1/14/22 a Grievance/Concern form completed by Resident 28 indicated her/his room floor was not cleaned. On 2/16/22 at 7:30 AM Staff 7 (Housekeeper) indicated resident rooms were to be cleaned daily. Staff 7 stated Resident 28 had a sign on her/his room door that indicated "nursing staff only" and therefore did not enter the resident's room. Staff 7 stated she did not clean Resident 28's room for four days. Staff 7 stated she recalled Resident 28 complained of her/his room not being cleaned. On 2/23/22 at 10:00 AM Staff 20 (Housekeeping Supervisor) confirmed resident rooms were to be cleaned daily and housekeeping staff were to offer residents to have the room cleaned even with a sign posted. , 2. Resident 11 admitted to the facility in 11/2021 with diagnoses including diabetes and end stage renal disease. On 2/15/22 at 9:45 AM Resident 11 stated her/his shower was broken her/his bathroom and was missing a handle and a shower head. Resident 11 stated staff knew about the broken shower but it was not fixed it and she/he would like to use the shower. On 2/2/22 at 3:19 PM Resident 11's shower was observed with Staff 21 (Maintenance Director) and there was no faucet handle and a shower hose was hanging from the wall but with no shower head attached. On 2/22/22 at 3:19 PM Staff 21 stated staff told him Resident 11's shower was broken in January 2022 but there were no maintenance logs or work orders for the shower. Staff 21 further stated he took the shower apart and had the parts to fix it but had not yet fixed it.

Resident #11 shower was fixed. Resident #28 room was cleaned. The Administrator or Designee inspected resident rooms cleanliness, addressing concerns identified. The Administrator or Designee inspected shower rooms working order, addressing concerns identified. The Administrator or Designee re-educated the Housekeeping Manager on the requirement to ensure resident rooms were clean and sanitized. The Administrator or Designee re-educated the Maintenance Director on the requirement to ensure the shower rooms were in working order. The Administrator or Designee will conduct random audits via observation and/or resident/staff interview room cleanliness and showers in working order weekly x 3 weeks then monthly x 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure eight hours of RN coverage between day and evening shifts for 34 of 76 days reviewed for staffing. This placed residents at risk for lack of timely assessments. Findings include: A review of the Direct Care Staff Daily Reports from 12/1/21 through 2/13/22 indicated the facility did not have an RN charge nurse on duty for eight consecutive hours between day and evening shifts for the following days: -12/1/21 -12/10/21 -12/11/21 -12/12/21 -12/15/21 -12/16/21 -12/20/21 -12/21/21 -12/25/21 -12/28/21 -12/30/21 -12/31/21 -1/1/22 -1/2/22 -1/5/22 -1/6/22 -1/7/22 -1/8/22 -1/10/22 -1/11/22 -1/12/22 -1/13/22 -1/14/22 -1/17/22 -1/18/22 -1/19/22 -1/20/22 -1/23/22 -1/26/22 -1/29/22 -1/30/22 -1/31/22 -2/2/22 -2/2/22 -2/11/22 On 2/23/22 at 10:58 AM PM Staff 1 (Administrator) acknowledged the lack of RN coverage on the identified dates.

No residents were cited. Administrator conducted review of payroll records for the last 7 days for RN coverage, addressing concerns identified. The Administrator re-educated the staffing coordinator on the requirement to have eight hours of RN coverage between day and evening shift. The Administrator re-educated the licensed nurses and center leadership on the staffing safety plan. The Administrator will Audit RN coverage within Stand-Up meeting for 2 weeks then weekly for 3 weeks. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure minimum CNA staffing ratios were maintained for 43 of 76 days reviewed. 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. A review of the facility's Direct Care Staff Daily Reports from 12/1/21 through 2/13/22 revealed the following dates when the required state minimum CNA staffing ratios were not met for one or more shifts: -12/1/21 -12/4/21 -12/11/21 -12/17/21 -12/18/21 -12/19/21 -12/22/21 -12/24/21 -12/25/21 -12/26/21 -12/29/21 -12/30/21 -1/1/22 -1/2/22 -1/3/22 -1/4/22 -1/5/22 -1/7/22 -1/8/22 -1/9/22 -1/10/22 -1/12/22 -1/13/22 -1/16/22 -1/17/22 -1/18/22 -1/19/22 -1/20/22 -1/25/22 -1/26/22 -1/27/22 -1/28/22 -1/29/22 -1/30/22 -1/1/22 -2/1/22 -2/6/22 -2/7/22 -2/9/22 -2/10/22 -2/12/22 -2/13/22 On 2/23/22 at 10:58 AM Staff 1 (Administrator) confirmed the shortage of CNA staff for the identified dates.

No residents were cited. The Administrator or Designee did a comprehensive review to identify staffing trends to address; this was done through resident interviews, staff interviews, call light response audits, and documentation review. The Administrator or Designee met with resident council to review focus areas identified, current and proposed solutions and gathered additional feedback from the council. The Administrator re-educated Staffing Coordinator on CNA Staffing Ratios. Facility will utilize the emergency staffing plan when there is possibility of falling under mandated staffing ratio. The Administrator re-educated leadership team and floor nurses on CNA staffing ratios and Emergency Staffing Plan. The Administrator or Designee will conduct random audits through resident interview, staff interview, documentation review, and/or observation to ensure sufficient staffing is in place to meet resident care needs in a timely matter weekly x 3 weeks then monthly x 2 months. The Administrator will Audit CNA staffing ratios within Stand-Up meeting for 2 weeks then weekly for 3 weeks. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved or sustained as determined by the committee. The Administrator is responsible to ensure compliance.

********************************* OAR 411-085-0310 Residents ' Rights: Generally Refer to F550 and F565 ********************************* OAR 411-086-0360 Resident Furnishings, Equipment Refer to F558 ********************************* OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F636 ********************************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F658 and F684 ********************************* OAR 411-086-0100 Nursing Services: Resident Care Refer to F677 ********************************* OAR 411-086-0230 Activity Services Refer to F679 ********************************* OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F686, F689 and F692 ********************************* OAR 411-086-0150 Nursing Services: Restorative Care Refer to F688 ********************************* OAR 411-086-0100 Staffing Refer to F725 and F727 ********************************* OAR 411-086-0250 Dietary Services Refer to F803, F804 and F806 ********************************* OAR 411-086-0300 Clinical Records Refer to F842 ********************************* OAR 411-087-0100 Physical Environment Generally Refer to F921 *********************************

********************************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 *********************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/29/2021 and 12/05/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.