Avalon Care Center - Portland

The facility's Resident Rights: Right to Self-Determination Policy, dated 7/2018, indicated the following:-á -The facility would support each resident to have the opportunity to exercise his or her autonomy regarding those things that are important to his or her life. This included the resident's interests and preferences.-á -The resident had a right to, and the facility would promote and facilitate resident self-determination through support of resident choices, including but not limited to the rights specified in the regulation.-á -The resident had the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments and plan of care.-á -The resident had a right to make choices about aspects of his or her life in the facility that are significant to the resident.-á Resident 1 was admitted to the facility in 5/2024 with diagnoses including Parkinson's Disease (a progressive neurological disorder) and anxiety.-á Resident 1's 5/30/25 revised Trauma Care Plan instructed staff to involve Resident 1 in her/his cares and daily decisions.-á Resident 1's 11/6/25 Modification Quarterly MDS and 2/4/26 Quarterly MDS indicated the resident had no cognitive impairment.-á On 4/6/26 at 9:39 AM, Resident 1 stated she/he spoke with several staff members and administration about not wanting Staff 3 in her/his room or providing care to her/him, on several occasions. Resident 1 stated she/he tried to ""get her to not work with me"" but Staff 3 continued to be assigned to her/him and was her/his CNA, today. Resident 1 stated she/he ""told them and told them"" she/he did not want Staff 3 as her/his CNA, but nothing changed.-á On 4/6/26 at 11:16 AM, Witness 1 (Complainant) stated Resident 1 did not want Staff 3 to be her/his CNA. Witness 1 stated ""we"" complained to the facility several times but ""it doesn't do anything."" Witness 1 stated they had ""no idea"" why the facility continued to assign Staff 3 as Resident 1's CNA but was told the facility did not have ""anyone else."" -á A review of the 3/24/26 through 4/6/26 staff assignment sheets indicated Staff 3 (CNA) was assigned to Resident 1 on the following days:-á -3/25/26, 3/26/26, 3/27/26, 3/28/26, 3/29/26, 3/31/26, 4/1/26, 4/2/26, 4/3/26, 4/5/26 and 4/6/26.-á Observations on 4/6/26 between the hours of 9:30 AM and 2:30 PM revealed Staff 3 provided care and services to Resident 1 during day shift.-á On 4/6/26 at 1:04 PM, Staff 3 stated Resident 1 did not like her as her/his CNA and the nursing staff and upper management were aware. Staff 3 stated they continued to assign her as Resident 1's CNA despite being aware Resident 1 ""doesn't want me.""-á On 4/7/26 at 9:19 AM, Staff 8 (CNA) stated her and Staff 3 worked as partners in Resident 1's section and had been assigned to care for Resident 1 for ""awhile."" Staff 8 stated Resident 1 did not want Staff 3 assisting her/him.-á On 4/7/26 at 10:04 AM, Staff 9 (Social Services) stated Resident 1 reported she/he did not want Staff 3 as her/his CNA, several times. Staff 9 stated the concern was talked about ""amongst us all"" for a while. Staff 9 stated Resident 1 mentioned it to him again on Monday (4/6/26) and he passed the information ""up the line"" to Staff 1 (Administrator) and Staff 2 (DNS).-á On 4/7/26 at 10:50 AM, Staff 10 (Staffing Coordinator/Human Resources) stated she was responsible for assigning CNAs to specific resident rooms in conjunction with Staff 2. Staff 10 confirmed Resident 1 verbalized complaints regarding Staff 3 and stated changes in CNA assignments were made if a ""teammate"" asked to make a change and Staff 3 did not have any issues providing care to Resident 1. Staff 10 stated Staff 1 and Staff 2 were aware of Resident 1's request and had spoken to the resident and her/his sister.-á On 4/7/26 at 11:10 AM, Staff 2 stated she was aware Resident 1 did not want Staff 3 assigned to her/him. Staff 2 reviewed CNA assignment sheets for 3/24/26 through 4/6/26 and confirmed Staff 3 was assigned to Resident 1 on 3/25/26, 3/26/26, 3/27/26, 3/28/26, 3/29/26, 3/31/26, 4/1/26, 4/2/26, 4/3/26, 4/5/26 and 4/6/26. Staff 2 stated it was Resident 1's right to have a choice regarding who cared for her/him, but there were challenges with staffing and many considerations when it came to CNA assignments.-á -á

Corrective Action: On 4/06/26, assignments were finalized based on updated census and CNA ratio and CNA #3 was shifted out of area where Resident #1 . Resident care plan updated based on expressed preferences. Grievance was completed and resolved with resident #1 on staffing concerns. Education provided to CNA #3 on resident #1s staffing preferences. Identification of Other : Current residents have potential to be affected by the alleged deficient practice. Current interview able residents interviewed for staffing concerns. Grievances implemented if indicated. Systemic Change : Care partners check in list revised to include questions to assess resident concerns with staff. Resident preferences related to staffing concerns will be tracked and investigated by the facility grievance process Education to IDT on care partners update was completed in 4/14/2026 Education to the IDT on grievance process was completed on 4/14/2026 Monitoring: Administrator/Designee will audit 3 resident grievances weekly x4 weeks and then monthly x 2 months to ensure that abuse and neglect are ruled out, and resident preferences are followed. Audit findings will be reviewed monthly at QAPI for further review and recommendations if indicated in 3 months. Person responsible for ensuring corrections and compliance: Administrator Date of Compliance: 4/16/2026

The facilityGÇÖs 7/2018 Notification of Changes of Condition Policy instructs the facility to promptly notify the resident representative when there was a decision to transfer a resident from the facility to the hospital. Resident 4 was admitted to the facility in 2/2025 with diagnoses including peripheral vascular disease (a condition that restricts blood flow usually with legs and feet). Resident 4GÇÖs Admission Profile indicated Witness 4 (Complainant) was the residentGÇÖs responsible party and emergency contact. A review of Resident 4's clinical record revealed she/he was transferred to the hospital on 12/16/25 and 12/18/25. No evidence was found in Resident 4's clinical record to indicate the residentGÇÖs representative was notified of the hospital transfers.-á On 4/7/26 at 8:56 AM Staff 17 (LPN) stated the emergency contact or representative listed on the face sheet was to be notified before or immediately after the resident left the facility and the information was to be documented in the residentGÇÖs clinical record. On 4/7/26 at 9:34 AM Staff 4 (LPN) stated family were to be contacted when residents transferred out of the facility to the hospital by who was listed as emergency contact or responsible party on the face sheet and he documented who was contacted in the clinical record.-á On 4/7/26 at 1:06 PM Staff 2 (DNS) and Staff 1 (Administrator) confirmed Witness 4 was not notified on 12/18/25 when Resident 4 was transferred to the hospital and acknowledged nursing staff were not contacting resident representatives. The deficient practice was identified as Past Noncompliance based on the following: On 12/19/25, the deficient practice was identified by the facility and was corrected when the facility did a root cause analysis of the incident and determined the facility had not consistently notified required parties for condition changes including hospital transfers. 1. Nursing staff were educated on Notification of Changes and Best Practices for Nursing Documentation on 12/19/25, 2. One-to-one education was provided on 12/19/25 with Staff 18 (RN), the nurse on shift at time of the transfer, 3. Notification of Changes was added as a focus area for the facilityGÇÖs Quality Assurance Performance Improvement (QAPI) team on 12/19/25, 4. Ongoing audits and tracking were initiated on 1/2026.-á Staff 2 continued to complete audits and ongoing education was provided as needed.-á

The facility's 11/2017 Freedom from abuse, neglect, and exploitation policy defined sexual abuse as ""non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent or a resident who does not want the contact."" Resident 2 was admitted to the facility in 11/2017 with diagnoses including relapsing multiple sclerosis (a disease where the immune system attacks the lining of nerve cells in the brain and spinal cord) and mild cognitive impairment.-á Resident 2GÇÖs 11/26/25 Quarterly MDS indicated she/he had severe cognitive impairment. Resident 2GÇÖs 10/27/25 care plan identified the resident had past sexual assault trauma, preferred female staff, and had impaired cognition. Resident 3 was admitted to the facility in 8/2023 with diagnoses of alcohol-induced persisting dementia and high-risk heterosexual behavior.-á Resident 3GÇÖs 4/30/25 Annual MDS indicated she/he had moderate cognitive impairment. Resident 3GÇÖs 5/6/25 care plan identified the resident had a history of sexual behaviors towards female residents and instructed staff to ensure she/he was supervised when around female residents. Staff were to redirect Resident 3 when sexual behaviors were anticipated and place the resident on intermittent one to one supervision after incidents for safety of others.-á Review of Resident 3GÇÖs clinical records revealed the resident had attempted to touch a female resident on 10/15/25, was found in a female residentGÇÖs room twice and sexually touched female staff on 10/31/25, and, on 11/3/25, been having increased sexual behaviors. -áNo evidence was found in the residentGÇÖs clinical record to indicate Resident 3 had been placed on 1:1s after these incidents.-á Review of the facilityGÇÖs 11/5/25 incident report revealed on 11/5/25 at 3:50 PM Staff 10 (Staffing Coordinator/Human Resources) saw Resident 3 with her/his hand under Resident 2GÇÖs shirt while in the dining room.-á The report did not list any other witnesses but did identify that Resident 3 had been involved in similar incidents in the past.-á On 4/6/26 at 11:12 AM Staff 13 (CNA), 4/6/26 at 1:56 PM Staff 14 (CNA), 4/7/26 at 9:23 AM Staff 15 (CNA), and 4/7/26 at 9:45 AM Staff 16 (CNA) reported Resident 3 was not supposed to be alone with female residents due to a known history of sexually inappropriate behaviors towards female residents and when Resident 3 was not on 1:1s, staff were to redirect Resident 3 from entering resident rooms or when she/he demonstrated sexual behaviors.-á On 4/7/26 at 10:32 AM Staff 10 (Human Resources/Staffing Coordinator) stated on 11/5/25 she walked to the nursing station and observed Resident 3 fondling Resident 2GÇÖs breast from under Resident 2GÇÖs shirt. Staff 10 stated Resident 2 was trying to push Resident 3GÇÖs hands away at the time of the incident. Staff 10 reported no other staff were in the area and confirmed Resident 3 was not supposed to be alone with female residents.-á-á On 4/7/26 at 1:34 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 3 had a known history of sexual behaviors towards others and acknowledged the incident between Resident 2 and Resident 3 on 11/5/25 was considered abuse. -á

F600: Free from Abuse and Neglect Corrective Action: Education to Administrator and DON on investigation of resident behaviors and implementation of immediate safety interventions completed on 4/7/2026. Resident #2 had no changes from baseline needs for psychosocial distress or physical changes related to incident on 11/5/2025. Resident #3 no longer resides in the facility Identification of Other: Current residents have the potential to be affected by the alleged deficient practice. Progress notes were reviewed for the past 7 days to identify any new or worsened sexual behaviors from residents. No behaviors were identified at this time. Systemic Change: Education to IDT on immediate interventions for residents with physical/sexual behaviors. Education completed on 4/14/2026 Stand up meeting form revised to include new or worsening behavior alerts for all residents. Monitoring: Administrator/Designee will audit 3 new resident behaviors weekly x4 weeks and then monthly x 2 months to ensure that abuse and neglect are ruled out, and resident preferences are followed. Audit findings will be reviewed monthly at QAPI for further review and recommendations if indicated in 3 months. Person responsible for ensuring corrections and compliance: Administrator Date of Compliance: 4/16/2026

The facilityGÇÖs 7/2018 Notification of Changes of Condition Policy instructs the facility to promptly notify the resident representative when there was a decision to transfer a resident from the facility to the hospital. a. Resident 7 was admitted in 6/2024 with diagnoses including urinary tract infections (UTIs) and sepsis (an infection that enters the bloodstream). Resident 7GÇÖs Admission Profile indicated she/he was responsible for themselves. Review of Resident 7's clinical record revealed she/he was transferred to the hospital on 2/12/26 but no evidence was found in Resident 7's clinical record to indicate the resident was provided with the notice of transfer and facility bed-hold policy. b. Resident 4 was admitted to the facility in 2/2025 with diagnoses including peripheral vascular disease (a condition that restricts blood flow usually with legs and feet). Resident 4GÇÖs Admission Profile indicated Witness 4 (Resident 4GÇÖs Daughter) was the residentGÇÖs responsible party. A review of Resident 4's clinical record revealed she/he was transferred to the hospital on 12/16/25 and 12/18/25. No evidence was found in Resident 4's clinical record to indicate the residentGÇÖs representative was notified of the hospital transfers.-á c. Resident 8 was admitted to the facility in 4/2025 with diagnoses including chronic heart failure. Resident 8GÇÖs Admission Profile indicated she/he was responsible for themselves. A review of Resident 8's clinical record revealed she/he was transferred to the hospital on 2/12/26 but no evidence was found in Resident 8's clinical record to indicate the written notice of transfer and facilityGÇÖs bed-hold policy were provided to the resident. On 4/7/26 at 8:56 AM Staff 17 (LPN) stated she did not document which documents she sent with residents transferring to the hospital and the facility did not have written transfer notices to provide to residents or resident representatives. On 4/7/26 at 9:34 AM Staff 4 (LPN) stated he was unaware he needed to provide a bed hold policy or a transfer notice when residents were transferred to the hospital.-á On 4/7/26 at 1:06 PM Staff 2 (DNS) was unable to locate documentation confirming the bed hold policy or written notification of transfer were provided to Resident 4, Resident 7, Resident 8, or their representatives. Staff 2 stated she was unaware a written transfer notification was required when transferring a resident out of the facility, but Staff 1 (Administrator) acknowledged a written notification of transfer and the facility bed-hold were supposed to be provided to residents or residentsGÇÖ representatives when transferred out of the facility.

F628: Discharge Process Corrective Action : By 4/14/2026 all LNs were provided education on bed hold policy and discharge process. A checklist was developed and shared with LNs which includes giving the Bed Hold Policy to residents at the time of transfer and documentation required. 4/08/26 DON, SSD, and administrator reviewed Bed Hold Policy and discharge process. SSD educated on sending Bed Hold Policy and Notice of Transfer Form to appropriate parties within 24 hours of transfer. Identification of Other: Current residents and their responsible parties have the potential to be affected by the alleged deficient practice. Audit residents who have been discharged in the past 7 days will be reviewed for bed hold policy notification. Systemic Change : LNs will include bed hold policy with forms sent with resident at time for discharge.  During clinical morning meetings, discharges (planned or emergent) will be reviewed.  All discharges will be checked for bed hold policy and notice of transfers forms.  Education provided to LN’s on completing bed hold policy.  SSD to complete and document any missing items in resident’s chart. Monitoring: Weekly audits of 3 residents with a discharge with intent to return x 4 weeks, then monthly x2 months. Audits will be for completion of bed hold completion and documentation. Results will be presented at QAPI for tracking, trending, and ensuring compliance. Person responsible for ensuring corrections and compliance: Director of Nurses Date of Compliance: 4/16/2026

The facilityGÇÖs Resident Right Policy dated 7/2018 indicated the resident has a right to and the facility will promote and facilitate resident self-determination through support of resident choice. Resident 19 was admitted to the facility in 11/2022 with diagnoses including cerebral infarction (blockage of blood flow to the brain) and depression. A 5/8/25 Occupational Therapy Evaluation included a goal for Resident 19 to operate a power chair with standby assist in the facility to maximize socialization skills. Review of Occupational Therapy Encounter Notes from 5/8/25 through 7/21/25 revealed Resident 19 received therapy services from Staff 5 (Rehabilitation Director) focused on improving skills involved with operating a power wheelchair, but no assessment on the use of a power wheelchair was performed. The residentGÇÖs plan of treatment included power wheelchair mobility training in therapy on 5/23/25, 5/27/25, and 5/28/25, however power wheelchair training did not occur on those dates. On 6/3/25, an Occupational Therapy Encounter Note stated the use of power wheelchair was trialed and discontinued, stating Resident 19 experienced tactile feedback and visual scanning deficiencies. A cognitive assessment dated 5/12/25 revealed Resident 19 had a BIMS score of 13 which indicated the resident had normal cognitive function. A 5/23/25 Quarterly MDS stated Resident 19 had adequate vision without corrective lenses. A 6/3/25 Therapy to Facility Communication note stated Resident 19 was unsafe to continue use of a power wheelchair due to her/his decreased tactile feedback in her/his hands and visual scanning. On 7/22/25 at 9:08 AM Resident 19 stated she/he wanted to use her/his power wheelchair to increase her/his freedom to move in the facility and community. Resident 19 stated therapy would assess her/him to determine if she/he was safe with using the power wheelchair, but no time was spent in a power wheelchair to determine Resident 19GÇÖs abilities to use a power wheelchair safely. On 7/22/25 at 1:49 PM Staff 6 (CNA) stated Resident 19GÇÖs functional use of her/his hands improved in the last month with Resident 19 demonstrating an ability to perform self-care tasks like brushing teeth, caring for dentures, face washing, upper body dressing and using a call button without assistance. On 7/22/25 at 1:56 PM Staff 5 stated Resident 19 had a goal to use a power wheelchair with standby assist, meaning a staff member was next to Resident 19. Skills related to power wheelchair use including sitting balance, fine motor skills and spatial reasoning were assessed, but no assessment which involved the use of a power wheelchair was performed with Resident 19. Staff 5 stated fine motor skills and spatial reasoning were impaired. When asked for a record of these assessments, no information related to operating a power wheelchair was provided. On 7/23/25 at 3:14 PM Resident 19 was observed independently participating in bingo which required fine motor and visual scanning techniques. The resident was also able to visually scan the bingo card and bin containing bingo markers, pick up a small bingo marker and place that marker on the correct number. On 7/23/25 at 3:33 PM Staff 7 (CNA) stated Resident 19 was not observed to have any difficulty with her/his vision or fine motor skills when participating in activities. Staff 7 stated Resident 19 previously had grasping problems when performing activities, but those impairments improved in the last month. On 7/24/25 at 10:14 AM Staff 2 (DNS) stated Resident 19 actively participated in occupational therapy which was focused on improving skills required to operate a power wheelchair and confirmed an assessment with Resident 19GÇÖs use of a power wheelchair should have been performed to make a determination of Resident 19GÇÖs independent use of a power wheelchair. -á -á

Corrective Action: Resident #19 was evaluated by Therapy with Power Wheelchair Trial and was deemed unsafe. Power Wheelchair Safety Skills Assessment notes Resident #19 failed multiple tasks during the evaluation. Identification of other: Current residents with requests to use personal power wheelchairs have the potential to be affected by the alleged deficient practice. An audit of current residents was completed to review any resident that has been deemed unsafe to use personal power wheelchair or had requested to be evaluated for a power wheelchair in the past 6 months. Systemic Change: Administrator/Designee educated Interdisciplinary team, including therapy on resident's rights to ensure resident requests to use personal power wheelchairs are being adequately reviewed and trialed prior to deeming resident unsafe. Monitoring: Administrator/Designee will audit resident grievances for requests related to Personal Power Wheelchairs weekly x4 weeks and Monthly x 2 months to ensure requests are being communicated to therapy and proper screening/trail measures are in place. Audit findings will be reviewed at QAPI for further recommendations if indicated. The Title of the person responsible for ensuring correction: The Administrator is responsible for ensuring corrections.

An 8/2018 facility policy revealed, a PASARR will be completed for each resident prior to admission. The applicants are evaluated for a serious mental disorder. Specialized services will be offered to individuals with mental disorders. 1. Resident 34 admitted in 2/2025 with diagnoses including schizophrenia and anxiety. A PASARR I assessment completed on 5/5/24 revealed Resident 34 should receive a PASARR-II due to her/his diagnoses of schizophrenia. A review of Resident 34GÇÖs electronic health record revealed no PASARR II was completed for Resident 34. On 7/24/25 at 10:06 AM Staff 2 (DNS) confirmed a PASARR-II had not been completed for Resident 34 to address her/his schizophrenia diagnoses. 2. Resident 8 was admitted in 11/2024 with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and PTSD (Post Traumatic Stress Disorder).-á A review of the resident's electronic health record (EHR) at the time of the survey revealed there was no PASARR I available in the record.-á In an interview on 7/23/25 at 3:26 PM Staff 14 (Admissions/Social Services) stated he reported the lack of PASARR I screenings to Staff 1 (Administrator). 7/23/25 at 3:37 PM, Staff 4 (MDS Coordinator) acknowledged a PASARR 1 was not completed for Resident 8. On 7/23/25 at 3:48 PM Staff 1 stated Resident 8 should have had a PASARR I completed upon admission to the facility.-á

Corrective Action: Social Services Director contacted state PASARR evaluators and requested PASARR Level 2 review for Resident #8 and Completed Level 1 Screen for Resident #34. Identification of other: New admissions have the potential to be affected by the alleged deficient practice. Social Services/Designee completed audit of current residents PASARR to ensure proper screening was completed upon admission. Systemic change: Administrator/Designee educated Admissions coordinator and social services director/ designee on the regulations/requirements for PASARR’s.  The importance of obtaining proper PASARR screening prior to admission to facility and on how to identify PASARR screening requirements for level 2. Admission Coordinator/ Designee will communicate new resident referrals with social services to ensure proper PASARR level screening is completed prior to resident admission. Monitoring: Social Services/Designee will audit new admits ensuring proper PASARR screening is completed and upload to medical records weekly x4 weeks, then monthly x 2 months to ensure ongoing compliance. Audit findings will be brought to the Administrator and reviewed at QAPI for further recommendations if indicated. The title of the person responsible to ensure correction: The Administrator is responsible for ensuring corrections.

Resident 9 was admitted to the facility in 12/2024 with diagnoses including dementia and PTSD (Post Traumatic Stress Disorder). The resident's Admission MDS dated 12/11/24 indicated the resident had a BIMS score of six which indicated the resident had severe cognitive impairment. The MDS revealed it was very important for Resident 9 to be around animals such as pets, do her/his favorite activities, go outside when the weather was good, and listen to music she/he liked. The resident's care plan initiated on 12/20/24 revealed Resident 9 liked music. The resident was provided an activity calendar, invited to activities, and calling family/friends. The care plan-á did not include specific preferences for Resident 9 which included, pet visits, listening to music of her/his choice, doing things with groups of people, and going outside on nice days .-á Random observations from 7/21/25 through 7/24/25, revealed Resident 9 sitting alone either in the main dining room or in the halls with little to no staff interaction and no activities of interest provided to her/him. Group activities were observed to be occurring near Resident 9. On 7/22/25 at 2:25 PM Resident 9 was observed sitting in the main dining room at a table alone. Two activities were occurring in the dining room; the resident was not included in either one. Resident 9 told a staff member she/he was looking for a hiding place because no one wanted to hang out with her/him. On 7/23/25 from 2:15 PM to 3:20 PM Resident 9 was sitting in the hallway staring at the floor and no staff interacted with her/him and no activities were offered.-á During an interview on 7/21/25 at 2:05 PM and 7/24/25 at 10:30 AM Witness 1 (Resident Representative) stated, Resident 9 slept when she/he was bored, was usually in bed or out sitting in the hallway when Witness 1 came to visit. Witness 1 stated the resident enjoyed listening to country music and older rock music.-á On 7/24/25 at 10:10 AM-áResident 9 stated she/he liked country music, going outside, and liked dogs. Resident 9 stated she/he would like to be invited to activities. During an interview on 7/24/25 at 1:07 PM and 7/25/25 at 9:05 AM Staff 9 (CNA) stated Resident 9 enjoyed visiting with dogs and would go to activities if she/he was invited. During an interview on 7/24/25 at 1:30 PM Staff 17 (CNA) stated Resident 9 would go to activities if she/he was invited but was unaware of activity preferences. During an interview on 7/25/25 at 9:18 AM Staff 12 (Activities Director) stated she completed one on one visits twice weekly, but Resident 9 was not on her list. Staff 12 confirmed three activities which were very important to Resident 9 were missing from the care plan and were not being offered to Resident 9. During an interview on 7/25/25 at 10:02 AM Staff 1 (Administrator) stated she expected activities to be offered to all residents and ensure preferences and activities were reflected on the care plan. Staff 1 acknowledged Resident 9's care plan was not reflective of her/his activities and was not being offered to participate in activities.

Corrective Action: The Activities director updated Resident #9’s preferences and care plan for Resident #9 to include specific activities/topics for staff to engage with the resident in a meaningful way to meet resident's needs and interests. Identification of other: Current residents with a diagnosis of Dementia or other cognitive impairment have the potential to be affected by the alleged deficient practice. Activities Department/Designee conducted audit of residents with a diagnosis of Dementia or other cognitive impairment to ensure preferences updated and Care plan reflects specific activities/topics for staff to engage with the resident in a meaningful way to meet resident's needs and interests. Systemic change: The administrator/designee educated the Activities department staff in the process to accurately reflect residents' preferences upon admission and with quarterly updates to ensure preferences are individualized with specifics added to care plan for floor staff access to ensure implementation. Monitoring: MDS/Designee will audit new admissions, and quarterly assessments weekly x 4 weeks and Monthly x 2 months for residents with a diagnosis of Dementia or other cognitive impairment to ensure activities care plans are individualized with specific activities/topics. Audit findings will be reviewed at QAPI for further recommendations if indicated. The title of the person responsible to ensure correction: The Administrator is responsible for ensuring corrections

Resident 4 was admitted to the facility in 1/2025 with diagnoses including right leg amputation. Resident 4's 4/2025 and 6/2025 care plan revealed the resident required two-person assistance with a mechanical lift when moving from bed to a shower chair.-á A Fall Incident dated 5/21/25 revealed Resident 4 had a fall while being transferred out of bed into a shower chair. The resident was transferred by one CNA who did not utilize a mechanical lift. On 7/24/25 at 2:19 PM Staff 11 (CNA) stated she was told by Resident 4 she/he no longer used the mechanical lift and only needed one staff person to assist with her/his transfer status because the resident was working with therapy. On 7/24/25 at 3:00 PM Staff 13 (LPN) stated Resident 4's transfer status in 5/2025 (before the fall) was a two-person mechanical lift transfer. On 7/25/25 at 10:22 AM Staff 2 (DNS) stated Resident 4 told Staff 11 she/he did not need the mechanical lift anymore because the resident was working with therapy utilizing a slide board transferring. Staff 2 stated she was aware of the fall on 5/21/25 and acknowledged Staff 11 did not follow the care plan. Staff 2 indicated she expected all staff to review and follow the residents care plan. On 5/28/25,-á the Past Noncompliance was corrected by the facility with the following: 1. Staff 11 was educated and retrained in the moment regarding reviewing and following the care plan.-á 2. All CNAs were educated regarding reviewing and implementing the care plan.-á 3. All staff attended monthly CNA meetings to ensure they provided safety checks for those residents which were considered a high fall risk. 4. The QAPI team monitored/audited any kind of falls whether a resident was injured or not and ensured staff reviewed, implemented and followed the care plan.

The facility's Infection and Control: Antibiotic Stewardship policy, last revised 3/2019, indicated the facility would validate antibiotics were prescribed for the correct indication, the correct dose, the correct route and the correct duration.-á -á -á Resident 12 was admitted to the facility in 5/2024 with diagnoses including acute kidney failure, dysuria (painful or uncomfortable urination) and urinary retention (inability to completely empty the bladder).-á -á -á A 10/15/24 physician order indicated Resident 12 was prescribed Bactrim (an antibiotic) one time a day for UTI prophylaxis (ongoing antibiotic administration not intended to treat an existing infection, but to reduce the risk of developing one).-á -á -á A 6/14/25 progress note written at 6:40 PM indicated Resident 12 reported complaints of a possible UTI including burning with urination, weakness and low back pain. Resident 12 was transported to the Emergency Department (ED) for evaluation.-á -á -á A 6/14/25 progress note written at 11:00 PM indicated Resident 12 returned to the facility from the ED. Resident 12 had no UTI and blood work revealed no infection. The resident was diagnosed with possible muscle pain. Resident 12 was to follow-up with her/his PCP (Primary Care Physician). -á -á A 6/14/25 ED After Visit Summary revealed Resident 12 was evaluated for a possible UTI, no infection was identified and the resident was diagnosed with flank pain (discomfort located in the side of the abdomen, between the lower ribs and hips).-á -á -á Resident 12's 6/15/25 through 6/19/25 progress notes indicated there were no further concerns of burning with urination, weakness or low back pain voiced by the resident.-á -á -á A 6/19/25 PCP After Visit Summary indicated Resident 12 was started on cefuroxime (an antibiotic) twice a day for seven days (6/19/25 through 6/25/25) due to trace leukocytes (a small amount of white blood cells) identified during a urine dipstick test (a quick way to access various aspects of urine).-á -á -á Resident 12's June 2025 MAR indicated the resident received prophylactic Bactrim in addition to, cefuroxime from 6/19/25 through 6/25/25. -á -á A 6/20/25 progress note written at 9:29 AM indicated nursing staff attempted to contact Resident 12's PCP to clarify the resident's Bactrim usage due to Resident 12 receiving Bactrim and cefuroxime at the same time for the same condition. A review of Resident 12's electronic health record indicated the resident's PCP did not respond.-á -á -á On 7/22/25 at 1:04 PM, Staff 8 (LPN) stated Resident 12 was prescribed Bactrim for UTI prophylaxis in 10/2024. She stated on 6/14/25, Resident 12 went to the ED for abdominal pain and a possible UTI. Staff 8 reported when Resident 12 returned from the ED, there was no UTI found. Staff 8 reported Resident 12 was prescribed cefuroxime on 6/19/25, after a visit to the resident's ""outside"" provider. Staff 8 reported she was unsure why Resident 12 received two antibiotics at the same time for the same condition, and if she noticed a resident being prescribed two different antibiotics for the same condition, she would contact the provider for clarification.-á -á -á On 7/22/25 at 1:22 PM and 7/24/25 at 12:24 PM, Staff 2 (DNS) reported Resident 12 was placed on Bactrim, prophylactically for a history of UTI's, in 10/2024. On 6/14/25, Resident 12 went to the ED with symptoms of a possible UTI and was found to have no UTI. In addition, Resident 12's bloodwork indicated no infection. Staff 2 stated on 6/19/25, Resident 12 had a follow-up appointment with her/his PCP and returned to the facility with orders for a second antibiotic. Staff 2 stated she attempted to contact Resident 12's PCP office for clarification and to have a ""conversation"" regarding the resident's antibiotic use, but the PCP office did not return her call. Staff 2 stated Staff 4 (Infection Control Preventionist/MDS Coordinator) should have reached out to the PCP office to discuss the ongoing need and appropriateness of Resident 12's antibiotics. Staff 2 stated her expectations were for staff to have a clear understanding of why Resident 12 was on two antibiotics, Resident 12's antibiotics were evaluated and assessed to be appropriate and there was a rationale for dual antibiotic use.-á -á -á On 7/22/24 at 3:16 PM, Staff 4 stated she was aware Resident 12 received two different antibiotics at the same time for UTI management. Staff 4 stated she ""wondered"" why Resident 12 had two antibiotics and an antibiotic time-out form was faxed to the resident's PCP. Staff 4 stated Resident 12's PCP was not responsive, and she was unable to ""get through"" to the PCP office thus no follow-up regarding Resident 12's dual antibiotic use was completed. Staff 4 stated she would not want to see a resident receive two antibiotics for the same condition without clarification and a rationale provided and confirmed there was no clarification or rationale for Resident 12's dual antibiotic use.-á

Corrective Action: Resident #12 had a PCP appointment 8/5/25 to address ongoing urinary concerns. Urine culture was completed through PCP and PCP ordered discontinuation of Bactrim. Identification of other: Current residents on prophylaxis antibiotic orders have potential to be affected by alleged deficient practice. IP/Designee completed audit of residents receiving prophylaxis antibiotic treatments to ensure dual therapy is not rendered unless provider recommendations are clarified and documented in resident record. Residents will have their care plan updated based on provider recommendations related to use of prophylaxis antibiotics while receiving active infection treatment. Systemic change: The DON/designee educated the Infection prevention nurse on unnecessary medications relating to antibiotic use and the importance of documenting communication with provider when clarifying antibiotic time outs or dual therapy orders to ensure proper use of antibiotics for active infection and infection prevention measures. Monitoring: DON/Designee will audit new antibiotic orders weekly x 4 weeks and Monthly x 2 months for any dual therapy and prophylactic antibiotic orders and ensure provider communication and recommendations are accurately clarified and documented to rule out unnecessary use of antibiotics. Audit findings will be reviewed at QAPI for further recommendations if indicated. The title of the person responsible to ensure correction: The Director of Nursing is responsible for ensuring corrections

Based on observation, interview, and record review it was determined the facility failed to ensure the facility's smoking policy was implemented and followed for 1 of 3 (#2) sampled residents reviewed for accidents and hazards. As a result, Resident 2 sustained a second degree burn to her/his left hand. Findings include: The facility's 1/20/23 Smoking Policy indicated the facility will furnish a supervised designated smoking area where smoking and smoking paraphernalia items will be managed and distributed by staff. The facility indicated residents who smoke must return all smoking and smoking paraphernalia items to the facilities centralized storage box. Residents who smoke were to be informed that a violation of the facility smoking policy could place other residents at risk for endangerment which could lead to a facility initiated discharge. Resident 2 was admitted to the facility in 2/2024, with diagnoses including chronic kidney disease. A 10/4/24 Facility Incident Report stated Resident 2 set her/his hand on fire while refilling Resident 3's butane (gas) lighter. Resident 2 stated she/he was refilling Resident 3's butane lighter when she/he striked Resident 3's lighter and set fire to her/his middle, ring, and left finger of her/his left hand. A 10/8/24 Skin and Wound Evaluation indicated Resident 2 sustained 2nd degree burns to her/his middle, ring, and little finger of her/his left hand. On 10/16/24 at 10:28 AM, Resident 2 stated she/he sustained a 2nd degree burn to her/his left hand as a result of striking the flint of Resident 3's lighter that she/he had overfilled with butane liquid fluid. Resident 2 was observed with significant burns on her/his left hand near the middle, ring and little finger. Resident 2 also stated the facility used to have a designated smoking area, but residents decided to leave the facility to smoke independently. Resident 2 stated the facility was aware of this and did not enforce the smoking policy and did not ask for residents to return smoking materials after use. On 10/16/24 at 11:27 AM, Resident 3 stated the facility did not enforce their smoking policy to return all smoking paraphernalia after use, which led to her/his continued use of her/his butane lighter fluid and butane lighter in the facility. On 10/16/24 at 1:00 PM, Staff 4 (CNA) confirmed residents were required to grab all smoking materials from the nurse's station and return the materials after use. Staff 4 indicated the facility did not enforce this requirement due to facility's inability to manage the smoking policy with residents. On 10/24/24 at 10:36 AM, Staff 1 (Administrator) acknowledged the facility failed to ensure resident safety related to the possession and management of smoking paraphernalia.

¿ POC F689¿ Preparation and execution of the Plan of Correction does not constitute admission or agreement by Avalon Care Center Portland of the facts alleged or the conclusions set forth in this statement of deficiencies. This Plan of Correction is prepared and executed solely because the provisions of Federal and State law require it. Avalon Care Center Portland maintains that the alleged deficiencies do not, individually, or collectively, jeopardize the health or safety of our residents nor are they of such character as to limit our capacity to render adequate resident care. Furthermore, Avalon Care Center Portland asserts that it is in substantial compliance with regulations governing the operation and licensure of this long-term care facility, and this plan of correction, in its entirety, constitutes this providers allegation of compliance.¿¿ F689 Free of Accident Hazards/Supervision/Devices¿ Immediate Action:¿ Hazardous items were secured, the provider was notified, transport to ER was offered and first aid was provided to the burn site. Identify others at risk:¿ Residents who smoke have the potential to be affected by this practice. Rooms of residents who smoke were searched with their consent to ensure no smoking paraphernalia was being kept. Smoking assessments were completed on those residents identified as current smokers and care plans were updated to reflect the outcome of the assessment. Smoking cessation alternatives were offered. Education was provided to current smokers on safe smoking practices and facility rules on smoking, the approved smoking area, and the rules of storage/possession of smoking related materials. Systemic Changes:¿ Residents, families, and employees have been educated regarding the smoking policy, securement of hazardous materials with facility staff, and the location of the designated smoking area. Smoking policy with explanations for change were presented to the residents that smoke via written communication and through Resident Council. Residents’ smoking paraphernalia will be kept safe and locked in the smoking safe. Residents assessed as needing assistance with smoking have been placed on a smoking schedule and are supervised when smoking. Smoking schedules have been given to current residents that smoke, and a schedule is posted by the designated smoking area visible to residents. Facility is no longer accepting new residents that smoke, new residents will be notified during the admission process of the policy prohibiting smoking and offered cessation products. For residents grandfathered into the smoking program, smoking assessments will be completed upon re-admission, quarterly and with significant change of condition. Education of smoking policy along with Risk and Benefits will be completed when identification of non-compliance is found, and care plan will be updated. The administrator will educate staff related to smoking policy, practice changes and staff early identification and report to management on resident safety risks related to being non-compliance with facility smoking rules and possession of hazardous materials. All residents who smoke have been offered smoking cessation alternatives. Cessation alternatives will be offered quarterly. Changes to the smoking policies were reviewed and adopted by the facility QAPI committee. ¿ Monitor:¿ Administrator/designee will audit smoking practice through random observation of smoking area and disposition of smoking paraphernalia to verify that residents and staff are following smoking policy and procedures with supervised smoking and safe keeping of smoking materials. 3 x a week x 4 weeks, then weekly x 2 months. DON/designee will audit smoking assessments for timeliness and accuracy of completion, care planned interventions in place and resident compliance. Weekly x 4 weeks then Monthly x 2 months. Findings will be reported to QAPI committee for monthly review for 3 months or until a lesser frequency is deemed appropriate. ¿ Responsible Party: Administrator¿ Date of Compliance: 11/22/24¿

****************************** OAR 411-086-0350 - Smoking Refer to F689 ******************************

Based on observation, interview and record review it was determined the facility failed to ensure resident needs and preferences related to lighting were accommodated for 1 of 3 sampled residents (# 13) reviewed for accommodation of needs. This placed residents at risk for lack of access to lighting and an unhomelike environment. Findings include: Resident 13 was admitted to the facility in 3/2024 with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). A review of Resident 13's 4/4/24 Admission MDS revealed her/his cognition was moderately impaired. On 5/29/24 at 9:34 AM Resident 13 stated her/his overbed light switch only had a short cord and she/he could not reach it to turn her/his light on or off. Resident 13 stated she/he reported it to staff but she/he was still waiting for it to be fixed. On 6/3/24 at 1:42 PM Staff 19 (Maintenance Director) stated he expected CNAs to report maintenance issues to him using the facility's work order system. He also stated he is notified of maintenance issues via word of mouth from staff members and residents. On 6/3/24 at 2:08 PM Staff 19 acknowledged the pull cord for Resident 13's overbed light was not long enough for her/him to use independently. Staff 19 stated the pull cord should be fixed. On 6/3/24 at 3:39 PM Staff 1 (Administrator) stated she expected residents to be able to turn their lights on and off and the broken pull cord needed to be repaired.

Preparation and execution of the Plan of Correction does not constitute admission or agreement by Avalon Care Center of Portland of the facts alleged or the conclusions set forth in this statement of deficiencies. This Plan of Correction is prepared and executed solely because the provisions of Federal and State law require it. Avalon Care Center of Portland maintains that the alleged deficiencies do not, individually, or collectively, jeopardize the health or safety of our residents nor are they of such character as to limit our capacity to render adequate resident care. Furthermore, Avalon Care Center of Portland asserts that it is in substantial compliance with regulations governing the operation and licensure of this long-term care facility, and this plan of correction, in its entirety, constitutes this providers allegation of compliance. F558 Reasonable Accommodations Needs/Preferences 1. R13 overbed light switch was immediately corrected by Maintenance so that she/he could reach to turn light on and off. 2. Current residents have the potential to be affected by alleged deficient practice. A full facility audit was conducted by the Maintenance Director/Designee, and all light switches have been checked for proper length and repaired if identified as not within reach. 3. Education was provided to maintenance director and direct care staff related to communication of resident request for repairs by Administrator/Designee. Requests are to be placed into the TELS system for logging and tracking of needed repairs in facilities and resident rooms. Repairs will be completed promptly to comply with facility policy and regulation for F558 Reasonable Accommodation of needs and preferences. 4. A continued monitoring Audit will be conducted by Maintenance Director/Designee of overbed light switch cords for appropriate length will be conducted weekly x 4 weeks and then Monthly x 2 months to ensure reasonable accommodation of needs. Any identified concerns on audit will be corrected promptly. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for compliance: Administrator Date of compliance: 07/11/24

Based on interview and record review it was determined the facility failed to obtain copies of advance directives and inform residents of the right to formulate advance directives for 2 of 2 sampled residents (#s 8 and 13) reviewed for advance directives. This placed residents at risk of not having their health care decisions honored. Findings include: 1. Resident 8 was admitted to the facility in 8/2017 with diagnoses including Type 2 Diabetes (a condition that happens as a result of the way the body regulates sugar as fuel) and morbid (severe) obesity. Resident 8's 2/16/24 Quarterly MDS revealed she/he was cognitively intact. Resident 8's Care Plan revealed the following: -Focus: I have a Living Will or other Advance Directive: Health Care Agent. -Goal: I will have my desires and wishes followed according to my signed directive. -Interventions: Facility will place my Advance Directive in my medical record. Staff will review my healthcare directives with me at least quarterly to verify that my wishes have not changed. Staff will understand and follow my healthcare directives. (Date initiated: 6/8/23) No evidence was found in Resident 8's health record to indicate the facility obtained a copy of her/his advance directive or discussed it with her/him since the date the care plan intervention was initiated. On 5/30/24 at 9:33 AM Staff 1 (Administrator) stated she expect advance directives to be discussed with each resident at a minimum on a quarterly basis. She acknowledged the facility did not obtain a copy of Resident 8's advance directive and there was no documentation in her/his health record to indicate it was discussed with her/him since her/his care plan was initiated. 2. Resident 13 was admitted to the facility in 3/2024 with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). Resident 13's 4/4/24 Admission MDS revealed her/his cognition was moderately impaired. A review of Resident 13's health record revealed she/he was her/his own responsible party. No evidence was found in Resident 13's health record to indicate she/he had an advance directive or that staff discussed her/his wishes related to creating an advance directive. On 5/30/24 at 9:33 AM Staff 1 (Administrator) stated she expect advance directives to be discussed with each resident at a minimum on a quarterly basis. She acknowledged there was no documentation in Resident 13's health record to indicate the facility discussed her/his wishes related to developing an advance directive.

F578 Request/refuse/Discontinue Treatment for Advanced Directive 1. R8 and R13 Advance directives have been discussed with resident obtained and updated to medical record to reflect her/his wishes. 2. Current Residents have the potential to be affect by alleged deficient practice. A full facility audit was conducted by the Social Services Director/Designee to ensure residents advance directive wishes have been reviewed and obtained and updated to medical record. 3. Education was delivered to the social service director and interdisciplinary team by Administrator/designee on resident right to formulate advance directive to reflect his/her wishes in relation to F578 facility policy and regulation on Advance directives. Social Service director or member of IDT will meet with resident and/or resident representative upon admit and at least quarterly to obtain, review and update resident medical record with his/her wishes. 4. A continued monitoring audit will be conducted by Unit Manager/Designee of all new admissions and a sample of 10 residents for current advance directive obtained in medical record and reviewed with resident for his/her wishes weekly x 4 weeks and then Monthly x 2 months. Any identified deficiencies noted in the audit will be reported to Social Services and corrected promptly. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

Based on interview and record review it was determined the facility failed to notify a resident's representative of an appointment out of the facility for 1 of 1 sampled resident (#289) reviewed for notification of change. This placed residents at risk of their representatives being uninformed. Findings include: Resident 289 was admitted to the facility in 12/2016 with diagnoses including chronic congestive heart failure (a long-term condition in which the heart cannot pump blood efficiently) and type 2 diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). A review of Resident 289's 8/29/22 CAA related to cognition revealed she/he had severe cognitive decline including impaired memory and decision making. Resident 289's admission agreement indicated her/his representative/legal guardian was her/his daughter. A review of Resident 289's health record revealed she/he was sent out of the facility for an appointment on 11/10/2022. No evidence was found in Resident 289's health record to indicate her/his representative was notified she/he would be attending an appointment out of the facility. On 6/3/24 at 2:16 PM Staff 1 (Administrator) acknowledged Resident 289 was out of the facility for an appointment on 11/10/22 and she expected her/his representative to be notified of this.

F580 Notify of Changes (injury/Decline/Room,etc.) 1. R289 is no longer in the facility. 2. Residents with cognitive decline, memory impairment or legal guardian/representative in place that require outside facility appointments have the potential to be affected by alleged deficient practice. An audit conducted for a 14 day look back and 14-day future period of appointments has been conducted by Scheduler/Designee to ensure resident representatives have been or are notified of attending outside appointments. 3. Administrator/Designee provided education to facility interdisciplinary team, and appointment scheduler on the importance of record review related to cognitive ability or guardian in place for appropriate notification of appointments needed outside of facility based on F580 facility policy and regulation related to notification of changes. Appointment scheduler/Designee will notify resident representatives regarding all scheduled appointments needed outside of the facility for residents that have a legal guardian in place or cognitive decline/memory impairment condition prior to appointment. This notification will then be documented in resident medical record for tracking and verification. 4. A continued monitoring Audit will be conducted by Administrator/Designee of appointment schedule and resident record weekly x 4 weeks and then Monthly x 2 months to ensure notification of appointments have occurred and reflected in documentation. Any identified deficiencies noted in the audit will be corrected promptly with proper notification and documentation. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 3 sampled residents (# 13) reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Resident 13 was admitted to the facility in 3/2024 with diagnoses including a non-pressure chronic ulcer and type 2 diabetes (a condition that happens as a result of the way the body regulates sugar as fuel). A review of Resident 13's 4/4/24 Admission MDS revealed her/his cognition was moderately impaired. On 5/29/24 at 9:40 AM a gouge approximately 16 inches in length and 36 inches above the floor was observed in the wall adjacent to the head of Resident 13's bed. On 6/3/24 at 1:42 PM 19 (Maintenance Director) acknowledged the gouge in the wall and stated it should have been fixed prior to the resident moving into the room. On 6/3/24 at 3:39 PM Staff 1 (Administrator) stated the gouge in Resident 13's wall was unacceptable and she expected residents' rooms to be painted and homelike before they move in.

F584 Safe/Clean/Comfortable/Homelike Environment 1. R13 wall was repaired. 2. Current Residents have the potential to be affected by alleged deficient practice. A full facility audit was conducted by the Administrator/Designee to ensure walls in resident rooms do not have any holes and exhibit a safe, clean, comfortable homelike environment. 3. Education was provided to the Maintenance director and all nursing staff, housekeeping and laundry related to communication of room repairs needed by Administrator/Designee. Repair needs are to be placed into the TELS system for logging and tracking of repairs in facilities and resident rooms. Repairs will be completed promptly to comply with facility policy and regulation for F584 Safe/Clean/Comfortable/Homelike Environment. 4. A continued monitoring Audit will be conducted by the Maintenance Director/Designee weekly x 4 weeks and then Monthly x 2 months to ensure no wall repairs are needed in resident areas. Any identified deficiencies noted in the audit will be corrected promptly to maintain a safe, clean, comfortable, homelike environment. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from physical and sexual abuse for 2 of 7 sampled residents (#s 3 and 12) reviewed for abuse. This placed residents at risk for physical and psychological harm. Findings include: 1. Resident 12 was admitted to the facility in 6/2023 with diagnoses including a communication deficit and dementia. Resident 12's behavioral care plan initiated on 6/7/23 indicated the following: -The resident had a behavior issue related to a lack of spatial awareness (Resident does not recognize when she/he is close to others personal space.) -[Staff] consistently check on whereabouts of resident if found in room other than her/his or attempting to enter other rooms . -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resident 12's 3/10/24 Quarterly MDS revealed the resident had short and long-term memory problems, no memory recall ability, and her/his decision making was severely impaired. Resident 17 was admitted to the facility in 1/2023 with two different types of dementia. Resident 17's 2/6/24 behavioral care plan indicated the following: - The resident had potential to be physically aggressive. - The resident's triggers for physical aggression were interactions with another resident invading her/his space. The resident's behavior was de-escalated by removing the other resident or this resident from the situation. Resident 17's 3/20/24 Quarterly MDS indicated the resident was moderately cognitively impaired. A Facility Reported Incident (FRI) dated 8/6/23 revealed Resident 12 was observed to be on her/his hands and knees on the floor next to Resident 17's bed. Resident 17 was observed to be holding a book in both hands and Resident 12 was noted to have multiple skin tears on both arms. A facility event report dated 8/11/23 revealed the following: - Resident 17 used to be homeless and had no space to call her/his own. - Resident 12 had behavioral issues related to other people's personal space. - Resident 12's location was to be consistently checked on due to her/his tendency to wander into other resident rooms. - Resident 17 stated she/he struck Resident 12 and considered striking her/him again. - Resident 12 was unable to be interviewed due to cognitive status. On 5/27/24 and 5/28/24 Resident 12 and 17 were interviewed. Neither resident had any recollection of an altercation. On 6/3/24 at 12:13 PM Staff 18 (Housekeeper) stated she witnessed Resident 12 on the floor on her/his hands and knees. Staff 18 witnessed Resident 17 holding a book over Resident 12 and told Staff 18 to "get her/him out of here before I hit her/him again." There were no other witnesses to this altercation. On 5/31/24 at 7:48 AM Staff 17 (CNA) stated Resident 12's skin was "very very fragile" something as simple as trying to help Resident 12 transfer, if not done properly, will cause a skin tear. Staff 17 confirmed physical contact with Resident 12's arms by Resident 17 could easily cause skin tears. 05/30/24 07:42 AM Staff 8 (CNA) stated knowledge of Resident 12's and Resident 17's behaviors. Staff 8 stated an altercation and physical contact occurred but was unsure of the exact specifics. 05/31/24 10:45 AM Staff 3 (LPN/RCM) and Staff 4 (RNCM) - confirmed the facility knew Resident 12 wandered and had a history of climbing into other resident's beds. Staff 3 and 4 confirmed the facility was aware Resident 17 had a history of being aggressive when people entered her/his personal space. Staff 3 and 4 confirmed Residents 12 and 17 had a physical altercation and Resident 12 was injured as a result. , 2. Resident 3 was admitted to the facility in 1/2020 with diagnoses including anxiety. The 6/16/23 Annual MDS indicated Resident 3 was cognitively intact. Resident 33 was admitted to the facility in 4/2023 with diagnoses including dementia. The 4/30/24 Annual MDS indicated Resident 33 was cognitively intact and was ambulatory using a walker. A facility investigation dated 4/29/24 indicated on 4/23/24 around 8:45 PM Resident 3 reported that Resident 33 touched her/his breast inappropriately. Resident 3 stated Resident 33 walked by her/his room, stopped, stated she/he looked good and grabbed her/his breast and left the room. Resident 3 reported she/he was in her/his wheelchair in between the door and the bed at the time of the incident. On 5/28/24 at 12:32 PM Resident 3 stated she/he had arrived back to her/his room after breakfast on 4/23/24 and was in her/his wheelchair watching tv. Resident 3 stated Resident 33 entered the room, made a comment to her/him, then grabbed her/his breast inappropriately. Resident 3 stated she/he told Resident 33 to go away, and Resident 33 left the room. Resident 3 stated she/he did not report the incident until later that evening to the nurse. Resident 3 stated she/he does feel safe in her/his room and the facility. On 5/30/24 at 10:43 AM Witness 2 (Resident 3's roommate) stated she/he witnessed the incident on 4/23/24. Witness 2 stated she/he was laying in bed when Resident 3 arrived back to the room after breakfast and sat in her/his wheelchair watching tv and was in direct line of sight of her/him. Resident 33 entered the room, stood next to Resident 3 and Resident 3 told Resident 33 to leave which she/he did not. Resident 33 proceeded to approach Resident 3 and touched her/his breast inappropriately then left the room. Witness 2 stated she/he does feel safe in her/his room and the facility. On 6/3/24 at 10:02 AM Staff 20 (RN) stated Resident 3 reported the incident to her on 4/23/24 during the evening rounds. Resident 3 explained after breakfast that morning she/he went back to her/his room, watched tv while in her/his wheelchair and Resident 33 entered the room and touched her/his breast inappropriately. Staff 20 stated since the incident occurred Resident 3 did not have a change in mood or behavior. On 6/3/24 at 1:54 PM Resident 33 declined she/he ever touched a resident inappropriately and did not remember the incident. On 6/3/24 at 2:15 PM Staff 2 (DNS) stated she talked with Resident 3 frequently and since the incident occurred Resident 3 did not have a change in mood or behavior and her/his daily routine had not changed.

F600 Freedom from Abuse 1. R3 now has a STOP sign across her door to remind other residents not to enter. R3 also has a whistle that she wears that she can use to summon immediate assistance if she feels unsafe. R3 is monitored and followed closely with medication management by Cascadia mental health with family involvement in sessions. R 33 had medication changes to help limit impulsive behavior. He was on 1:1 monitoring while waiting for the medication to reach therapeutic levels. Provider conducted current assessment on resident and will continue to monitor the effectiveness of medication regimen. R12 is on hospice and his declining condition has limited his ability to wander around the facility when up in wheelchair. There is now a stop sign up across the door of the aggressor (R17) to prevent unwanted visitors. IDT reviewed and updated both residents care plans for current effective interventions. 2. Current Residents have the potential to be affect by alleged deficient practice. A full facility audit was conducted by DON/Designee to ensure residents that have behavioral care plans in place related to physical aggression and/or wandering behaviors have interventions in place to protect residents from potential abuse risks. 3. DON/Designee provided education to direct care staff on following care planned interventions related to residents with known physical aggression and/or wandering behaviors to provide appropriate redirection and facility policy on F600 Freedom from abuse and neglect to prevent incidents of abuse from occurring in facility. A current list of residents triggering physical aggression and/or wandering behaviors will be placed at nurses' station for easy identification by staff for intervention. 4. A continued monitoring Audit will be conducted by Unit manager/Designee weekly x 4 weeks and then Monthly x 2 months that list at nurses' station is updated, and staff are providing the proper intervention per resident need. Any identified deficiencies noted in the audit will be corrected promptly to ensure prevention of abuse measures are in place. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

Based on interview and record review it was determined the facility failed to ensure written summary of a baseline care plan was provided to residents within 48 hours of admission for 2 of 4 sampled residents (#s 7 and 241) reviewed for baseline care plans. This placed residents at risk for being uninformed about their plan of care. Findings include: 1. Resident 7 was admitted to the facility in 5/2024 with diagnoses including kidney failure and anxiety. On 5/31/24 Resident 7's clinical record was reviewed. No record was found to show Resident 7 had a baseline care plan reviewed or provided to her/him. On 5/31/24 at 7:40 AM Resident 7 stated she/he had not been provided a baseline care plan. On 5/31/24 at 10:39 AM Staff 3 (LPN/RCM) and Staff 4 (RNCM) stated they were not aware baseline care plans were to be provided to and reviewed with residents. 2. Resident 241 was admitted to the facility in 5/2024 with diagnoses including heart failure and high cholesterol. On 5/31/24 Resident 241's clinical record was reviewed. No record was found to show Resident 241 had a baseline care plan reviewed or provided to her/him. On 5/31/24 at 10:39 AM Staff 3 (LPN/RCM) and Staff 4 (RNCM) stated they were not aware baseline care plans were to be provided to and reviewed with residents.

F655 Baseline Care Plan 1. R7 was a new admit and R2 is a long-term Resident who was readmitted to the facility. Care plans have been reviewed with residents and/or resident representative with copy provided and documented in their medical record. 2. Newly admitted residents have the potential to be affected by alleged deficient practice. An audit of the last 30 days of admissions conducted by MDS/Designee to ensure baseline care plan is developed and has documentation of review and copy provided to resident and/or resident representative. Identified deficiencies in audit correctly promptly with proper documentation. 3. DON/Designee provided education to Nurse Mangers and Interdisciplinary team on facility policy F655 Baseline Care plan requirements of development and importance of documenting review and copy of care plan being provided to resident and/or resident representative. Nurse Manager to develop baseline care plan and conduct review with Resident and/or resident representative within 48 hours of admission and provide copy of care plan with documentation in resident record for proper tracking of compliance. 4. A continued monitoring Audit will be conducted by MDS/Designee weekly x 4 weeks and then Monthly x 2 months on all newly admitted or readmitted residents that a baseline care plan has been completed with resident and/or resident representative involvement, copy provided with proper documentation in resident record. Any identified deficiencies noted in the audit will be corrected promptly to ensure compliance. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

Based on interview and record review it was determined the facility failed to develop a person-centered comprehensive care plan for 1 of 4 residents (#16) reviewed for mood and behavior. This placed residents at risk for lack of care planning. Findings include: Resident 16 was admitted to the facility in 1/2024 with diagnoses including post-traumatic stress disorder (PTSD). The Mood State CAA from Resident 16's 2/6/24 Admission MDS noted Resident 16 had a diagnosis of PTSD and the care plan addressed the PTSD symptoms with interventions to assist with mood. A review of Resident 16's comprehensive care plan (last revised 4/14/24) revealed no focus, goals or interventions for Resident 16's PTSD symptoms. On 6/3/24 at 9:30 AM Staff 16 (Social Services Director) stated he completed a PTSD evaluation for Resident 16, and thought he completed the comprehensive care plan. Staff 16 confirmed Resident 16's comprehensive care plan related to PTSD symptoms with interventions to assist with mood was not completed.

F656 Develop/Implement Comprehensive Care Plan 1. R16 care plan was reviewed and updated to reflect Focus, Goal, and Interventions to support Diagnosis of PTSD. 2. Residents that reside in the facility diagnosed with PTSD have the potential to be affected by alleged deficient practice. An audit was conducted by Social Services to ensure any resident with this diagnosis has a Mood care plan in place with a focus, goal, and interventions in place to support resident needs. 3. Administrator/Designee provided education to Social Service Director on facility policy and regulation requirements for F656 Development/Implementation of Comprehensive Care Plan as it relates to mood/behavior and resident with PTSD diagnosis. Social Services Director will ensure completion of mood and behavior comprehensive care plan is complete with individualized measures to support identified mood/behavior needs of the resident per social services evaluation and diagnosis review with IDT involvement. 4. A continued monitoring Audit will be conducted by MDS/Designee weekly x 4 weeks and then Monthly x 2 months on all residents with PTSD diagnosis to ensure Complete Comprehensive assessment is in place for Mood/Behavior. Any identified deficiencies noted in the audit will be corrected promptly to ensure compliance. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

Based on observation, interview and record review it was determined the facility failed to follow physician orders regarding wound care for 1 of 1 resident (# 241) reviewed for wound care. This placed residents at risk of unmet care needs. Findings include: Resident 241 was admitted to the facility in 1/2018 with diagnoses including lymphedemia (swelling of the extremities) and erythmia (skin redness caused by swelling or irritation). A cognitive assessment from 1/18/24 indicated Resident 241 had normal cognitive function. A Physician Order from 4/3/24 instructed staff to apply ACE wraps to both lower extremities in the morning before Resident 241 got out of bed and take them off at night. Review of the 5/2024 TAR revealed the ACE wraps were documented as not applied to Resident 241's lower extremities on the following dates: - 5/20/24, - 5/21/24, - 5/22/24, - 5/23/24, - 5/24/24, - 5/25/24, - 5/26/24, - 5/28/24, - 5/29/24, - 5/30/24 and - 5/31/24. On 5/28/24 at 1:13 PM Resident 241 was observed wearing ACE wraps which appeared ragged and nearly falling off. Resident 241 stated she/he had worn the same ACE wraps for a week with the wraps never being taken off during the night. On 5/31/24 at 11:08 AM Staff 3 (LPN RCM) reviewed Resident 241's active orders and stated ACE wraps were to be applied to Resident 241's lower extremities in the morning and removed in the evening. Staff 3 was requested to determine if these orders were being followed. Upon observation of Resident 241 legs, Staff 3 confirmed Resident 241 was not wearing ACE wraps as ordered.

F684 Quality of Care 1. R241 order for ACE wraps to lower extremities has been reviewed with the provider and corrected to ensure proper administration of treatment occurs. 2. Residents with orders for ACE wrap applications have the potential to be affected by alleged deficient practice. An audit was conducted by DON/Designee on orders to ensure residents with ACE wrap orders are correctly inputted and that treatments delivered per provider order. 3. DON/Designee provided education to Nurse Managers and Nursing staff on proper inserting of ACE wrap orders and proper administration of provider orders. When ACE wrap orders are received, the Nurse Manager is to review administration time entered to ensure proper application and removal occurs per providers' order. The nurse assigned to provide resident care is to apply and remove ACE Wraps timely per provider orders. 4. A continued monitoring Audit will be conducted by DON/Designee weekly x 4 weeks and then Monthly x 2 months on all residents with ACE wrap orders to ensure accurate administration times enter in order and application/removal is occurring per provider order. Any identified deficiencies noted in the audit will be corrected promptly to ensure compliance. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

Based on observation, interview and record review it was determined the facility failed to provide adequate care and hazard removal for 2 of 2 residents (#s 239 and 240) reviewed for accidents. This placed residents at risk of injury. Findings include: 1. Resident 239 was admitted to the facility in 5/2022 with diagnoses including obesity and dementia. A Care Plan from 3/16/23 included instructions for two staff members to be present when providing all care. An 8/18/23 Progress Note stated Resident 239 rolled out of bed onto the floor when care was provided. On 5/30/24 at 1:13 PM Staff 10 (CNA) stated she recalled Resident 239 falling out of bed. Staff 10 stated care was provided by only one staff member when Resident 239 experienced the fall out of bed when care was being provided. On 5/31/24 at 2:37 PM Staff 1 (Administrator) confirmed Resident 239 was ordered to receive care from two staff members but care was only provided by one staff member when the fall occurred. 2. Resident 240 was admitted to the facility in 5/2024 with diagnoses including dementia. A cognitive assessment from 5/2024 indicated Resident 240 had severe cognitive impairment. On 5/31/24 at 12:39 PM two electric burners were observed unplugged on the floor of Resident 240's room. Resident 240 stated she/he has not used the electric burners but intended to use them. On 5/31/23 at 1:19 PM Staff 21 (CNA) stated she/he was unaware of the burners. On 5/31/23 at 1:25 PM Staff 1 (Administrator) confirmed the electric burners were unsafe and immediately removed them from Resident 240's room.

F689 Free of Accident Hazards/Supervision/Devices 1. R239 is no longer a resident at facility and R240 electric burners were immediately removed from room upon identification. Resident has asked daughter to pick up burners. 2. Residents with assistance level of 2 can be affected by alleged deficient practice of accidents related to falls from improper assistance. An audit was completed of Care plans by MDS/Designee to ensure proper ADL assist level if reflected on Care Plan and Kardex. Newly admitted Residents bringing in belongings from home have potential to be affected by alleged deficient practice of having unsafe items in room. An Audit was conducted by Activities Director/Designee to ensure newly admitted residents for a 30 day look back period have personal inventory completed and no hazardous or unsafe items stored in room. Any identified deficiencies noted in audits will be corrected immediately. 3. Administrator/Designee provided education to all staff on facility policy F689 free of accidents hazards/supervision. DON/Designee to educate direct care staff on use of Kardex to ensure proper assistance level during care is followed per individual resident care plan to prevent accidents related to falls. Social Services/Designee to educate all Nursing staff, Housekeeping and Laundry on personal inventory of belongings upon admit and identification of hazardous or unsafe items to be brought to Social Services for proper review and disposition of items. 4. A continued Observation audit will be conducted by Unit Manager/Designee weekly x 4 weeks and then Monthly x 2 months on each shift for residents with ADL assist level of 2 to ensure proper assist level being provided during care. A continued audit of newly admitted residents will be completed by Social Services weekly x4 weeks and Monthly x 2 months on personal inventory and rooms to identify any Hazardous or unsafe items brought from home. Any identified deficiencies noted in the audit will be corrected promptly to ensure compliance. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

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 2 of 3 sampled residents (#s 4 and 21) reviewed for oxygen therapy. This placed residents at increased risk for respiratory failure. Findings include: 1. Resident 4 was admitted to the facility in 8/2023 with diagnoses including multiple sclerosis and chronic obstructive pulmonary disease (COPD). The 4/25/24 Quarterly MDS indicated Resident 4 was cognitively intact. On 5/28/24 at 1:28 PM Resident 4 was observed to use an oxygen concentrator. The external filter on the oxygen concentrator was observed to have a thick layer of dust. On 5/29/24 at 8:44 AM Staff 7 (LPN) observed the resident's equipment and acknowledged the external filter of the oxygen concentrator was not clean. On 5/29/24 at 8:56 AM Staff 2 (DNS) stated it was her expectation the external filters were cleaned once a month. 2. Resident 21 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure and chronic respiratory failure. The 5/2/24 Quarterly MDS indicated Resident 21 had moderate cognitive impairment. The 5/6/24 physician order for Resident 21 revealed the resident used continuous oxygen with a flow rate of 1.5 liters. On 5/29/24 at 8:03 AM Resident 21 was observed to use an oxygen concentrator with a flow rate of 2.5 liters. The external filter on the oxygen concentrator was also observed to have a thick layer of dust. On 5/29/24 at 8:21 AM Staff 7 (LPN) observed the resident and her/his equipment. Staff 7 acknowledged the physician's order was not followed regarding the oxygen flow rate and the external filter of the oxygen concentrator was not clean. On 5/29/24 at 8:56 AM Staff 2 (DNS) stated it was her expectation the oxygen levels were checked at the beginning of each shift and external filters were cleaned once a month.

F695 Respiratory/Tracheostomy Care and Suctioning 1. R4 concentrator filter was immediately cleaned and R21oxygen flow rate was corrected per physician order and vent/filter was cleaned. 2. Residents with oxygen therapy needs have the potential to be affected by alleged deficiency. An audit was conducted by Unit Manager/Designee on residents with oxygen therapy orders to ensure correct flow rate was being delivered per order, vent/filter on oxygen concentrators is cleaned, and order place for vent/filter cleaning monthly and as needed. 3. DON/Designee delivered education to Nurse Managers, Nurses and Direct care staff on facility policy F695 Respiratory Care, importance of per shift validation of resident Oxygen flow rate as ordered by provider and order/procedure for monthly and as needed oxygen concentrator vent/filter cleaning for proper maintenance of oxygen delivery methods. 4. A continued audit will be conducted by Unit Manager/Designee weekly x 4 weeks and then Monthly x 2 months on residents with oxygen therapy orders to ensure correct flow rate set on oxygen concentrator and vent/filter cleaned. Any identified deficiencies noted in the audit will be corrected promptly to ensure compliance. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

Based on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 2 facility kitchens (dining room kitchenette) reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include: On 5/28/24 at 11:34 AM during the initial tour of the dining room kitchenette, the following was observed: Refrigerator: -One piece of cake with whipping cream not covered, labeled or dated. -One small plastic container of an unknown substance not labeled or dated. -One covered plate with a pork chop, baked potato and corn not labeled or dated. -One tray with multiple covered juice drinks not labeled or dated. -One opened container of prune juice on the top shelf that spilled to the lower shelves and out onto the floor. Freezer: -Seven small plastic containers with unknown substances not labeled or dated. -Two individual strawberry yogurt containers with a use by date of 5/20/24. -Two opened one pint ice cream containers with resident names not dated. -One opened gallon of chocolate ice cream without a secure lid and not dated. -Three small plastic containers of fish snack crackers on top of the refrigerator not labeled or dated. On 5/28/24 at 11:43 AM Staff 1 (Administrator) confirmed the identified items were not appropriately stored.

F812 Food Procurement, Store/Prepare/Serve-Sanitary 1. Food stored with improper label/date in dining room kitchenette was immediately corrected by removal upon identification of state survey and Dietary manager educated on facility process of labeling, dating and removal of expired items. 2. Residents residing in the facility have the potential to be affected by alleged deficient practice. An audit was conducted by Administrator/Designee of dining Kitchenette Fridge/Freezer of labels and dates with item removal of any identified deficiencies. 3. Administrator provided education to Dietary manager on facility policy F812 related to proper labeling, dating and removal of items that are past used by date on daily schedule. Dietary Manager educated Dietary team members on facility policy F812 and the process of proper labels, dates and removal requirements of foods/drinks stored in Fridge/Freezer of Dining room Kitchenette. 4. A continued audit will be conducted by Administrator/Designee weekly x 4 weeks and then Monthly x 2 months on Dining room Kitchenette Fridge/Freezer to ensure follow through on proper label, dating and removal of item compliance. Any identified deficiencies noted in the audit will be corrected promptly to ensure compliance. Results of audit will be brought to Dietary Manager for review and correction with findings presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

Based on observation, interview and record review it was determined the facility failed to accurately document wound care being provided which followed physician's orders for 1 of 1 resident (# 241) reviewed for wound care. This placed residents at risk of unmet care needs. Findings include: Resident 241 was initially admitted to the facility in 1/2018 with diagnoses including lymphedemia (swelling of the extremities) and erythmia (skin redness caused by swelling or irritation). A cognitive assessment from 1/18/24 indicated Resident 241 had normal cognitive function. A Physician Order from 4/3/24 instructed staff to apply ACE wraps to both lower extremities in the morning before Resident 241 got out of bed and to take them off at night. Review of the 5/2024 TAR revealed ACE wraps were documented as being off of Resident 241's lower extremities on the following dates: - 5/20/24, - 5/21/24, - 5/22/24, - 5/23/24, - 5/24/24, - 5/25/24, - 5/26/24, - 5/28/24, - 5/29/24, - 5/30/24 and - 5/31/24. On 5/28/24 at 1:13 PM Resident 241 was observed wearing ACE wraps which appeared ragged and nearly falling off. Resident 241 stated she/he had worn the same ACE wraps for a week with the wraps never being taken off during the night. On 5/31/24 at 11:08 AM Staff 3 (LPN RCM) confirmed Resident 241's records regarding ACE wraps being on or off were not accurately documented.

F842 Resident Records  Identifiable Information 1. R241 ACE wraps were removed and reapplied per provider order. Order in resident record was corrected to reflect proper ordered time of application and removal for accurate documentation. 2. Residents with orders for ACE wrap applications have the potential to be affected by alleged deficient practice. An audit was conducted by DON/Designee on orders to ensure residents with ACE wrap orders are correctly inputted and that treatments delivered per provider order and reflect documentation of application and removal accurately. 3. DON/Designee provided education to Nurse Managers and Nursing staff on proper entering of ACE wrap orders, and proper time documentation of application/removal of ACE wraps. When ACE wrap orders are received, the Nurse Manager is to review administration time entered to ensure proper documentation of application and removal occurs in resident record per providers' order and care delivery is reaching patient per documentation entered. 4. A continued monitoring Audit will be conducted by DON/Designee weekly x 4 weeks and then Monthly x 2 months with observation on all residents with ACE wrap orders to ensure accurate administration times entered in order and proper documentation on application/removal is occurring and matching care delivery. Any identified deficiencies noted in the audit will be corrected promptly to ensure compliance. Results of audit will be brought to Administrator for review and presented to QAPI committee monthly x 3 months. Person responsible for date of compliance: Administrator Date of compliance: 07/11/24

****************************** OAR 411-086-0360 - Residents Furnishings: Equipment Refer to F558 ****************************** OAR 411-086-0040 - Admission of Residents Refer to F578 ****************************** OAR 411-086-0130 - Nursing Services: Notification Refer to F580 ****************************** OAR 411-087-0100 - Physical Environment: Generally Refer to F584 ****************************** OAR 411-085-0360 - Abuse Refer to F600 ****************************** OAR 411-086-0040 - Admission of Residents Refer to F655 ****************************** OAR 411-086-0060 - Comprehensive Assessment and Care Plan Refer to F656 ****************************** OAR 411-086-0110 - Nursing Services: Resident Care Refer to F684 ****************************** OAR 411-086-0140 - Nursing Services: Problem Resolution & Preventive Care Refer to F689 ****************************** OAR 411-085-0110 - Nursing Services: Resident Care Refer to F695 ****************************** OAR 411-086-0250 - Dietary Services Refer to F812 ****************************** OAR 411-085-0370 - Confidentiality Refer to F842 ******************************

Based on interview and record review it was determined the facility failed to ensure a psychotropic medication consent was provided for 1 of 5 sampled residents (#30) reviewed for unnecessary medications. This placed residents at risk for not being informed of risks and benefits of medications. Findings include: Resident 30 was admitted to the facility in 2019 with diagnoses including Parkinson's disease (a central nervous system disorder that affects movement), depression, and anxiety disorder. Resident 30's Admission Record dated 3/8/23 indicated her/his family member was the resident's responsible party. Resident 30's 11/29/22 Quarterly MDS indicated the resident had severe cognitive impairment. Resident 30's physician orders dated 12/11/22 indicated the resident had orders for the following scheduled medications: - Seroquel (antipsychotic medication) twice daily for psychotic disorder with hallucinations. - Zoloft (psychotropic medication used to treat depression) once daily for depression related to anxiety disorder. - mirtazapine (psychotropic medication used to treat depression) once daily for depression. - Nuplazid (used to treat Parkinson's disease psychosis) once daily for psychotic disorder with hallucinations related to Parkinson's disease. Resident 30's 2/2023 and 3/2023 MARs revealed the resident received these medications as ordered. Resident 30's health record did not contain a consent for the use of these psychotropic medications. On 3/14/23 at 9:42 AM Staff 1 (Administrator) confirmed there was no documentation to demonstrate the resident or their responsible party were informed of the risks and benefits of the psychotropic medications.

000 Preparation and execution of the Plan of Correction does not constitute admission or agreement by Avalon Care Center Portland of the truth of the facts alleged or the conclusions set forth in this statement of deficiencies. Immediate Action: Psychotropic consent for Seroquel, Zoloft, mirtazapine and Nuplazid was obtained for resident 30 on 3/15/2023. Identify others at risk: Current residents who take psychotropic medications are at risk. Current residents who are prescribed psychotropic medications will be audited by DON/designee/interdisciplinary team by 4/12/23 to validate psychotropic consents are in place. Systemic Changes: Licensed nurses will be reeducated by DON/designee about the use of psychotropic consents by 4/12/23. Psychotropic consents will be reviewed during monthly psychotropic committee meeting. Monitor: DON/Designee to audit 5 random residents who receive psychotropic medications to ensure consent is present.¿Audits will be completed weekly X4 weeks then monthly X2 months.¿ Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is¿deemed¿appropriate.¿ Responsible Party:¿Director of Nursing Date of Compliance:¿¿4/12/23

Based on interview and record review it was determined the facility failed to ensure residents were provided information related to the formulation of an Advance Directive for 3 of 3 sampled residents (#10, #23, #32) reviewed for Advance Directives. This placed residents at risk for not having their treatment decisions honored. Findings include: 1. Resident 10 was admitted to the facility in 2018 with diagnoses including multiple sclerosis (degenerative neurological disease). Resident 10's Admission Record dated 3/6/23 indicated the resident was her/his own responsible party. Resident 10'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 3/9/23 at 10:37 AM Staff 1 (Administrator) stated there was no documentation Resident 10 was provided written information concerning her/his right to formulate an Advanced Directive. , 2. Resident 23 was admitted to the facility in 2023 with diagnoses including stroke. A review of Resident 23's digital and physical clinical record revealed no documentation that Advance Directive information or the right to formulate one was provided to Resident 23 or her/his responsible party. On 3/7/23 at 11:11 AM Staff 2 (DNS) stated if Advance Directive information was not in the clinical record it did not exist. On 3/14/23 at 12:30 PM Staff 1 (Administrator) confirmed there was inadequate documentation that Advance Directive information was provided to residents. , 3. Resident 32 was admitted to the facility in 11/2022 with diagnoses including stroke. Resident 32's Admission Record dated 3/14/23 indicated the resident was her/his own responsible party. Resident 32'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 3/14/23 at 9:53 AM Staff 1 (Administrator) confirmed Resident 32 was not informed or provided written information concerning her/his right to formulate an Advance Directive.

Immediate Action: Resident 10 was given information on the formulation of an Advance Directive on 3/29/2023. Resident 23 will be given information on the formulation of an Advance Directive by 4/12/23. Resident 32 was given information on the formulation of an Advance Directive on 3/29/2023. Identify others at risk: Current residents are at risk. Social services/designee will review current residents to ensure they have received information about advanced directives by 4/12/23. Systemic Changes: Admin/designee will educate the IDT team about advance directives by 4/12/23. Residents will have their advance directives reviewed on admission and quarterly by SSD/designee. Monitor: Social Services/designee will review 5 residents to validate they were given information regarding advanced directives. Audits will be completed weekly x4 then monthly by x2 to verify they were given information regarding advanced directives. Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is deemed appropriate.¿ Responsible Party: Administrator Date of Compliance:¿¿4/12/23

Based on interview and record review it was determined the facility failed to ensure resident grievances were documented and resolved in a timely manner for 1 of 1 sampled resident (#5) reviewed for personal property. This placed residents at risk for unaddressed concerns and unmet care needs. Findings include: Resident 5 admitted to the facility in 2022 with diagnoses including major depressive disorder. On 3/6/23 at 12:15 PM Resident 5 stated an unknown CNA broke her/his watch band more than a month ago and the facility had not replaced it. On 3/9/23 at 10:47 AM Staff 1 (Administrator) stated he offered to replace Resident 5's watch band. Staff 1 stated he received the watch and was researching a new band for the resident. Staff 1 reported the resident asked for her/his watch back and the item was returned to the resident and was not repaired. On 3/9/23 at 11:06 AM Staff 1 reported there was no documentation regarding this grievance. On 3/14/23 at 9:24 AM Staff 5 (Social Service Director) stated grievances were documented on a grievance log including documentation detailing the concern and resolution. Staff 5 stated there was usually a progress note in the resident's chart to document the grievance and resolution. Staff 5 confirmed there was no grievance log entry, or a progress note regarding this concern.

Immediate Action: Grievance for resident #5s watch was completed on 3/22/22 and watch was replaced. Identify others at risk: Current residents are at risk.¿Administrator/designee will review Grievance binder by 4/12/23.¿Any current outstanding grievances¿filed will be addressed. Activities director/designee will reeducate residents during resident council about the grievance process and inquire about outstanding grievances by 4/12/23. Systemic Changes: Administrator/designee will reeducate current staff on the grievance process, grievance process, the grievance officer,¿and¿filing a grievance by 4/12/23. Monitor: NHA/Designee will complete three resident interviews related to grievances to verify that residents are having their concerns addressed. Grievance binder will be reviewed for appropriate follow-up related to grievances. Audits will be completed weekly¿X4 weeks then monthly X2 months.¿ Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is deemed appropriate.¿ ¿¿ Responsible Party:¿Administrator Date of Compliance:¿4/12/23

Based on interview and record review it was determined the facility failed to thoroughly investigate accidents for 1 of 1 sampled resident (# 21) reviewed for skin conditions. This placed residents at risk for abuse. Findings include: 1. Resident 21 was admitted to the facility in 2023 with diagnoses including diabetes. On 3/6/23 at 10:20 AM Resident 21 stated her/his leg was pinched in a mechanical lift on 12/30/22. An incident report dated 12/30/22 indicated Resident 21 informed staff there was an accident earlier in the day on 12/30/22 involving a mechanical lift transfer. On 3/9/23 at 11:54 AM Staff 2 (DNS) confirmed an accident occurred causing a bruise and small cut to Resident 21's toe. Staff 2 further confirmed an incident report should have been completed. 2. Resident 21 was admitted to the facility in 2023 with diagnoses including diabetes. An incident report dated 12/30/22 indicated Resident 21 had an unwitnessed accident with her/his power chair where she/he was found "against the closet door." The incident report indicated Resident 21 believed she/he may have run into the closet door with her/his power chair. There was no further information regarding the incident. On 3/9/23 at 11:54 AM Staff 2 (DNS) stated Staff 20 (LPN/Unit Manager) and Staff 21 (LPN) heard the incident and responded promptly. Staff 2 further indicated the facility contacted the physician and received an order for ice packs and an X-ray. On 3/12/23 Staff 2 requested Resident 21 be sent to the hospital for evaluation due to increased pain and worsening skin injury. Staff 2 confirmed this information was not documented in the incident report. On 3/9/23 at 12:05 PM Staff 20 stated she heard a loud noise and went into Resident 21's room and observed Resident 21's chair against the closet door. The resident stated she/he hit her/his leg. Staff 20 stated Resident 21 had cellulitis at the time, which likely contributed to her/his worsening condition. Staff 20 recalled coming into work the morning of 1/2/23 and the overnight nurse asked her to a look at Resident 21's leg. Staff 20 stated that is when she and Staff 2 decided the resident should be sent out to the hospital for evaluation. Staff 2 confirmed this information was not documented in the incident report. On 3/13/23 at 12:18 PM Staff 2 confirmed the investigation was not thorough and accurate.

Immediate Action: An incident report was created for resident #21 on 3/9/22 Identify others at risk: Current residents of Avalon Care Center Portland are at risk. DON/designee will complete a review of March 2023 incidents by 4/12/23 to validate that incidents were investigated thoroughly. Systemic Changes: DON/designee will reeducate licensed nurses on when to complete an Incident Report by 4/12/23. RNC/designee will reeducate DON and Administrator by 14/12/23 about investigating incidents Monitor: The DON/Designee will review incidents during clinical meeting to validate incidents were investigated properly. Audits will be completed weekly for x4 weeks then monthly X2 months. Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is deemed appropriate.¿¿ Responsible Party:¿Administrator Date of Compliance:¿¿4/12/23

Based on observation, interview and record review it was determined the facility failed to administer oxygen and medications according to physician's orders for 2 of 6 sampled residents (#s 10 and 30) reviewed for medications and oxygen administration. This placed residents at risk for pain and unnecessary oxygen administration. Findings include: 1. Resident 10 was admitted to the facility in 2018 with diagnoses including multiple sclerosis (degenerative neurological disease). a. Resident 10's current physician's orders as of 3/6/23 indicated the resident had an order for oxygen at three liters per minute PRN to keep O2 sats above 90%. On 3/6/23 at 9:45 AM and 3/7/23 at 10:23 AM Resident 10 was observed in bed receiving oxygen at three liters per minute continuously. Resident 10's TAR, Progress Notes and O2 Sats Summary for 3/6/23 and 3/7/23 revealed no documentation to indicate which staff had initiated the oxygen administration, an assessment to indicate the need for oxygen administration or resident O2 sats below 90%. On 3/7/23 at 11:53 AM Staff 10 (LPN) stated he did not administer the oxygen to Resident 10 because it was already in place and he had not assessed the resident to determine if the resident needed the oxygen. On 3/8/23 at 10:30 AM Staff 2 (DNS) verified the resident's PRN oxygen order and the treatment was not signed for on the TAR. She stated for PRN orders the resident should be assessed prior to administering the intervention and reassessed later for effectiveness. b. Resident 10's 3/2023 MAR and current physician's orders as of 3/6/23 indicated the resident had orders for the following scheduled medications: - Gabapentin (used to treat convulsions and nerve pain) BID for muscle spasms, scheduled for 8:00 AM and 5:00 PM daily. - Baclofen (muscle relaxant) TID for muscle spasms, scheduled for 7:00 AM, 3:00 PM and 9:00 PM daily. - Methadone (used to treat moderate to severe pain) TID for multiple sclerosis, scheduled for 8:00 AM, 12:00 PM and 4:00 PM daily. On 3/6/23 at 9:45 AM Resident 10 stated her/his morning medications were administered late at least six times in the last couple of months and her/his pain increased when they were late. A review of untitled medication administration time reports from 1/31/23 through 3/7/23 revealed the following number of instances when medications were administered over an hour later than their scheduled administration times: Baclofen - 11 times Gabapentin - 4 times Methadone - 6 times On 3/8/23 at 10:30 AM Staff 2 (DNS) verified the late medication administrations and stated the expectation was for medications to be administered within one hour of their scheduled administration times. , 2. Resident 30 was admitted to the facility in 2019 with diagnoses including Parkinson's disease (a central nervous system disorder that affects movement). Resident 30's current physician orders revealed the following medications: - Senna Plus BID for constipation. The medication was to be held for loose stools. - Imodium A-D (treats diarrhea) PRN for diarrhea after each loose stool. Bowel elimination records from 2/8/23 through 3/8/23 revealed Resident 30 had loose stools or diarrhea documented on 17 of 30 days for a total of 22 occurrences. Resident 30's 2/2023 and 3/2023 MARs indicated the resident's scheduled Senna Plus was administered routinely BID and was not held as ordered when the resident had loose stools. The PRN Imodium also was not administered when the resident had diarrhea or loose stools. On 3/10/23 at 11:20 AM Staff 10 (LPN) stated Resident 30 received the Senna Plus and it should have been held on the days the resident had loose stools. He confirmed the PRN Imodium was not administered. On 3/10/23 at 1:23 PM Staff 11 (CMA) stated she administered the scheduled Senna Plus to Resident 30 and did not administer the PRN Imodium because she was not aware the resident had loose stools. On 3/14/23 at 10:00 AM Staff 2 (DNS) verified Resident 30's medication orders for the scheduled Senna Plus and PRN Imodium were not followed. She stated her expectation was for medications to be administered according to the physician's orders.

Immediate Action: The oxygen order for Resident #10 was updated on 3/8/2023. The physician will review Resident #30 orders for Senna Plus and Imodium by 4/12/23. The physician will review Resident #10 orders for Baclofen, Gabapentin, and Methadone by 4/12/23 Identify others at risk: Current residents on oxygen are at risk. DON/designee will review oxygen orders by 4/12/23 for current residents on oxygen to validate appropriate orders. Current residents are at risk. DON/Designee will complete a 14 day review current resident Medication Administration Records for late pain medication administration and bowel protocol orders by 4/12/23. Systemic Changes: DON/designee will reeducate current licensed nurses/CMAs on oxygen orders by 4/12/23 DON/designee will reeducate current Licensed Nurses/CMAs on the 8 rights of medication by 4/12/23. Monitor: The DON/Designee will conduct random audits of residents who have oxygen orders to validate they are being implemented according to how they are prescribed. Audits will be completed on 5 residents weekly x4 weeks then x2 monthly. Audits will be reviewed at QAPI committee monthly x2 months or until a lesser frequency is deemed appropriate. The DON/Designee will conduct random audits of residents medication administration times to validate they are being given according to how they are prescribed. Audits will be completed on 5 residents weekly x4 weeks then x2 monthly. Audits will be reviewed at QAPI committee monthly x2 months or until a lesser frequency is deemed appropriate.

Based on observation, interview and record review it was determined the facility failed to ensure adequate supervision for 1 of 1 sampled resident (#30) reviewed for accidents. This failure placed residents at increased risk for falls. Findings include: Resident 30 was admitted to the facility in 2019 with diagnoses including Parkinson's disease (a central nervous system disorder that affects movement) and Alzheimer's disease (brain disorder). Resident 30's 11/29/22 Quarterly MDS indicated the resident had severe cognitive impairment. The resident required extensive assistance of two or more staff for bed mobility and transfers. The MDS indicated the resident was not steady to transfer between the bed and her/his wheelchair and was only able to stabilize with staff assistance. Resident 30's Fall Risk Assessment dated 3/1/23 indicated she/he was at risk for falls due to multiple chronic diagnoses, decreased muscular coordination and non-ambulatory status. Resident 30's Care Plan dated 12/3/22 contained a fall risk focus due to a history of falls, poor balance and gait, unawareness of safety needs, and cognitive and physical impairment. The Care Plan had an intervention initiated on 8/25/22 which indicated in all capital letters, "DO NOT LEAVE RESIDENT UNATTENDED IN THE WHEELCHAIR." On 3/7/23 at 9:15 AM Staff 12 (CNA) brought Resident 30 to her/his room in a wheelchair. Staff 12 exited the room and left the resident unattended in the wheelchair. On 3/10/23 at 9:11 AM Staff 12 returned Resident 30 to her/his room in a wheelchair and informed the resident she would get assistance to help her/him back to bed. The resident was left unattended in the wheelchair and was observed to wheel around her/his room in the wheelchair. At 9:16 AM Staff 12 returned to the resident's room with a mechanical lift and another staff member. The two staff assisted the resident into bed. On 3/10/23 at 9:26 AM Staff 12 stated she did not know Resident 30 was not to be left alone in the wheelchair and thought this was only necessary when the resident was in the bathroom. On 3/14/23 at 10:00 AM Staff 2 (DNS) confirmed Resident 30's Care Plan indicated not to leave the resident unattended in the wheelchair. She stated her expectation was for staff to follow the plan of care.

Immediate Action: Care plan for resident #30 was reviewed and updated on 3/28/2023 and care is being provided per current plan of care. Identify others at risk: Current residents who are falls risk are at risk. IDT team will review care plans for current residents who are at risk for falls by 4/12/23 and ensure Kardex is updated. Systemic Changes: DON/designee will reeducate current clinical staff on residents who are at risk for falls by 4/12/23. DON/designee will educate current clinical staff on where to find the Kardex by 4/12/23. Monitor: The DON/designee will randomly question three staff members on their knowledge of residents who are at risk for falling and where to find the information. Audits will be completed weekly X4 weeks then monthly X2 months.¿ Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is¿deemed¿appropriate.¿ Responsible Party:¿Director of Nursing Date of Compliance:¿¿4/12/23

Based on observation, interview and record review it was determined the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 sampled resident (#28) reviewed for respiratory care. This placed residents at risk for infection. Findings include: Resident 28 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease. Resident 28's current physician orders indicated her/his oxygen tubing was to be changed weekly on Mondays. On 3/6/23 at 10:10 AM Staff 19 (LPN) confirmed the date on Resident 28's nasal canula read 2/21/23. On 3/6/23 at 12:30 PM Staff 19 stated she did not know who was responsible for changing the oxygen tubing. On 3/9/23 at 2:28 PM Staff 2 (DNS) confirmed Resident 28's oxygen tubing read 2/21/23 and should have been changed weekly for resident health.

Immediate Action: Residents #30s nasal canula was changed on 3/6/23. Identify others at risk: Current residents who are prescribed oxygen are at risk. DON/Designee will review current oxygen tubing in use to validate it was changed according to orders by 4/12/23. Systemic Changes: DON/designee will reeducate Licensed Nurses and CMAs about changing oxygen tubing/cannulas by 4/12/23. Monitor: DON/Designee will audit 5 random residents for proper changing of oxygen tubing/cannulas.¿Audits will be completed weekly X4 weeks then monthly X2 months.¿ Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is¿deemed¿appropriate.¿ Responsible Party:¿Director of Nursing Date of Compliance:¿¿4/12/23

Based on interview and record review it was determined the facility failed to ensure RN coverage for 8 consecutive hours per day 7 days per week for 30 out of 127 days reviewed for staffing. This placed residents at risk for lack of timely assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 7/1/22 through 9/30/22 and 2/1/23 through 3/7/23 revealed there was no RN coverage for eight consecutive hours on: -7/17, 7/31, 8/1, 8/7, 8/8, 8/9, 8/10, 8/14, 8/15, 8/16, 8/19, 8/20, 8/24, 8/31, 9/6, 9/9, 9/13, 9/20, 9/22, 9/27, 9/29, 9/30; -2/4, 2/11, 2/12, 2/13, 2/18, 2/20, 2/28, 3/6. On 3/8/23 at 9:46 AM Staff 1 (Administrator) was notified of the findings of this investigation. Staff 1 stated the facility had struggled to hire RN's.

Immediate Action: Current schedule was reviewed by scheduler/designee to validate that RN coverage was in place for the upcoming schedule on 3/17/2023. Identify others at risk: Current residents are at risk. Current schedule will be reviewed by DON/designee by 4/12/23 to validate RN coverage was in place for the upcoming week. Systemic Changes: Administrator/designee will reeducate the staffing Director, DON and Unit manager on 8 hours of consecutive RN coverage 7 days a week by 4/12/23. Monitor: Staffing Director to audit review schedule for RN coverage 3 times a week x4 weeks then monthly for x2 months. Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is¿deemed¿appropriate.¿ Responsible Party:¿Director of Nursing Date of Compliance:¿¿4/12/23

Based on interview and record review it was determined the facility failed to ensure there was appropriate evaluation and monitoring of psychotropic medications for 1 of 5 sampled resident (#21) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications. Findings include: Resident 21 was admitted to the facility in 2023 with diagnoses including heart failure. A review of Resident 21's clinical record revealed the resident had orders for the following psychotropic medications: - Sertraline (Anti-depressant) - Abilify (Antipsychotic) - Buspirone (Anti-anxiety) The most recent Abnormal Involuntary Movement Scale (AIMS) in Resident 21's record was dated 8/27/22. The most recent Psychotropic medication review in Resident 21's record was dated 9/28/22. On 3/13/23 at 12:18 PM staff 2 (DNS) confirmed the AIMS should have been completed at least every 3-6 months, and psychotropic review should have been completed at least monthly.

Immediate Action: Resident #21 will be reviewed by psychotropic committee by 4/12/23. Resident #21 had the AIMS completed on 3/13/23. Identify others at risk: Current residents who take psychotropic medications are at risk. DON/Designee will review current residents on psychotropic medications by 4/12/23 to ensure they have been reviewed by the psychotropic committee meeting. Any residents who need to be reviewed will be placed on the roster to be reviewed at the next scheduled psychotropic meeting. DON/Designee will review current residents on psychotropic medications to ensure AIMs have been completed by 4/12/23 Systemic Changes: RNC/designee will educate SSD, DON, Licensed Nurses, and Unit Manager on the completion of AIMs and monthly psychotropic meetings by 4/12/23. Residents on antipsychotics will be reviewed during the psychotropic committee meeting to validate the AIMS have been completed per schedule. Monitor: DON/Designee to audit 5 random residents who receive psychotropic medications to ensure AIMs and psychotropic meeting are completed.¿Audits will be completed weekly X4 weeks then monthly X2 months.¿ Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is¿deemed¿appropriate.¿ Responsible Party:¿Director of Nursing Date of Compliance:¿¿4/12/23

Based on observation, interview and record review it was determined the facility failed to provide palatable meals for 1 of 3 sampled residents (#10) reviewed for food. This placed residents at risk for impaired nutrition. Findings include: Resident 10 was admitted to the facility in 2018 with diagnoses including multiple sclerosis (degenerative neurological disease). On 3/6/23 at 9:45 AM Resident 10 stated the facility's food was cold, tough and "nasty". The resident stated she/he did not eat the usually prepared lunch and only wanted a grilled cheese or egg salad sandwich and soup. On 3/6/23 at 12:21 PM a lunch tray cart was observed in the hall outside room 19. Staff were delivering lunch trays to residents who were eating in their rooms. The door to the cart was left open as staff delivered trays and moved the cart further down the hall. Resident 10 received her/his lunch tray at 12:50 PM. The resident's grilled cheese sandwich and tomato soup were luke warm. On 3/9/23 at 12:43 PM a lunch meal tray was sampled which included stir fried beef, fried rice, chopped asparagus, chocolate pudding with cherry pie filling, and a grilled cheese sandwich. All of the foods which were supposed to be served hot were only luke warm. The beef was very dry and tough. The rice was over cooked. The asparagus was initially mistaken for mushy over cooked green beans.

Immediate Action: Resident #10s food was taken back to the kitchen and replaced on 3/6/2023. Identify others at risk: Residents that reside at Avalon Care Center Portland are at risk. Dietary Manager/Designee will gather dietary preferences from current residents by 4/12/23 Systemic Changes: Dietary Manager/Designee will audit food temperatures monthly. Activities Director/designee will ask residents about dietary concerns during monthly Resident Council Meetings. Administrator/Designee will have a test tray monthly. Dietitian will provide education to dietary manager about palatable meals by 4/12/23. Monitor: Dietary Manager/Designee will audit and test 3 meals to validate palatability. Audits will be completed weekly X4 weeks then monthly X2 months. Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is deemed appropriate. Dietary Manager/Designee will check hall tray food temps. Audits will be completed weekly X4 weeks then monthly X2 months. Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is deemed appropriate. Responsible Party: Administrator Date of Compliance: 4/12/22

Based on observation, interview and record review it was determined the facility failed to handle, label and store food in a sanitary manner for 1 of 1 kitchen and 1 of 1 dining room reviewed for sanitary food handling and serving practices. This placed residents at risk of cross contamination and foodborne illness. Findings include: 1. On 3/8/23 at 10:23 AM a tray in the main dining room refrigerator was observed to contain 12 individually-covered beverages. Ten of the 12 beverages were not labeled or dated. A tray that contained nine uncovered puddings and two uncovered fruit cups was observed on the counter adjacent to the refrigerator. On 3/8/23 between 11:00 AM and 11:35 AM six residents were observed participating in a chair yoga activity with Staff 18 (Activities Assistant) in the area immediately adjacent to the counter and tray of uncovered puddings and fruit cups. On 3/8/23 at 1:00 PM one remaining cup of uncovered pudding was observed on the counter. Staff 4 (Dietary Manager) verified the temperature of the pudding was 62 degrees F and stated these items should have been covered and dated in the refrigerator to maintain a safe temperature and minimize the potential for cross contamination. 2. On 3/8/23 at 12:10 PM Staff 13 (Cook) was observed in the kitchen plating dishes for lunch service. He wore gloves as he handled the serving utensils, dishes, and food. Between 12:14 PM and 12:20 PM he was observed to touch stove knobs, refrigerator handles, his personal beverage cup, a cheese sandwich, and a bacon-wrapped chicken breast without changing his gloves. He was also observed to adjust his face mask and beard restraint while wearing the same gloves. On 3/8/23 at 1:25 PM Staff 13 and Staff 4 (Dietary Manager) confirmed Staff 13 should have changed his gloves prior to touching residents' food after he touched service items, handles, and personal items to minimize the potential for cross contamination. 3. On 3/8/23 at 12:20 PM Staff 13 (Cook) was observed in the kitchen plating residents' meals for lunch service. He reheated a bowl of soup in the microwave oven and was observed to use a Super Sani Cloth (germicidal disposable wipe) to sanitize an instant-read thermometer prior to inserting it into the soup. He then sanitized the thermometer again with the same sanitizing wipe, discarded the wipe, and passed the bowl of soup to Staff 14 (Cook) who placed it on a tray to be delivered to a resident as part of the lunch meal. The directions for use on the label of the Super Sani Cloth indicated it could be used to disinfect nonfood contact surfaces only. The label also indicated, "Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco, or using restroom." On 3/8/23 at 12:48 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed kitchen staff should not have used the Super Sani Cloth to sanitize items that came into direct contact with food.

Immediate Action: Dietary Manager/designee labeled and dated the 12 beverage containers, threw out uncovered food, and threw out food that wasnt properly stored on 3/8/23. Dietary manager/designee educated staff 13, 14, and 4 on food handling and hand hygiene. Food that came in contact with Sani Cloth cleaned utensils was thrown out on 3/8/23. Identify Others: Current residents are at risk. Full kitchen audit will be completed by dietary manager and administrator by 4/12/23. Systemic Changes: Dietary Manager/designee will reeducate current dietary staff about labeling of food, storage of food, food handling, hand hygiene, and thermometer cleaning by 4/12/23. Monitor: Dietary Manager/Designee will complete a full kitchen audit. Audits will be completed weekly X4 weeks then monthly X2 months. Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is deemed appropriate. Responsible Party: Administrator Date of Compliance: 4/12/22

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 30 of 127 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident care and services. Findings include: Review of the Direct Care Staff Daily Reports from 7/1/22 through 9/30/22 and 2/1/23 through 3/7/23 revealed for 30 of 127 days there was no designated RN charge nurse who worked for eight consecutive hours in the facility between the start of day shift and the end of evening shift. On 3/8/23 at 9:46 AM Staff 1 (Administrator) was notified of the findings of this investigation. Staff 1 stated the facility had struggled to hire RN's.

Immediate Action: Current schedule was reviewed by scheduler/designee to validate that RN coverage was in place for the upcoming schedule on 3/17/2023. Identify others at risk: Current residents are at risk. Current schedule will be reviewed by DON/designee by 4/12/23 to validate RN coverage was in place for the upcoming week. Systemic Changes: Administrator/designee will reeducate the staffing Director, DON and Unit manager on 8 hours of consecutive RN coverage 7 days a week by 4/12/23. Monitor: Staffing Director to audit review schedule for RN coverage 3 times a week x4 weeks then monthly for x2 months. Audits will be reviewed at QAPI committee monthly X2 months, or until a lesser frequency is deemed appropriate. Responsible Party: Director of Nursing Date of Compliance: 4/12/23

************************ OAR 411-085-0310 Residents' Rights: Generally Refer to F552 and F585 ************************ OAR 411-086-0040 Admission of Residents (Advanced Directives) Refer to F578 ************************ OAR 411-085-0360 Abuse Refer to F610 ************************ OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 and F695 ************************ OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care Refer to F689 and F758 ************************ OAR 411-086-0100 Nursing Services: Staffing Refer to F727 ************************ OAR 411-086-0250 Dietary Services Refer to F804 and F812

Based on interview and record review the facility failed to provide bathing services for 2 of 3 residents (#'s 1 and 2) reviewed for bathing. This placed residents at risk for poor hygiene. Findings include: 1. Resident 2 was admitted to the facility in 7/2021 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease (breathing difficulty) and obesity. Review of Resident 2's Kardex (CNA care instructions) from 7/12/22 included instructions for Resident 2 to be fully assisted by two CNAs with bathing on Tuesday and Friday evenings. Review of Resident 2's bathing records from 6/1/22 through 7/11/22 revealed Resident 2 did not receive bathing care assistance on the following dates: 6/7, 6/10, 6/17, 6/21 and 6/24. On 7/13/22 at 1:05 PM Staff 24 (CNA) stated bathing care was unable to be provided to residents as scheduled during 6/2022 due to staffing shortages. Staff 24 stated she was so busy during this period that she was unable to document missed showers to be made up on a future date. On 7/13/22 at 1:22 PM Staff 4 (RCM) and Staff 7 (RCM) confirmed bathing care was not provided to or rescheduled for Resident 2 on the listed dates. On 7/13/22 at 1:49 PM Staff 1 (Administrator) was notified of the findings. No additional information was provided. 2. Resident 1 was admitted to the facility in 1/2021 with diagnoses including osteoporosis. Review of Resident 1's MDS from 6/2022 revealed Resident 1 had a BIMS of 15 indicating normal cognitive function. Review of Resident 1's Kardex (CNA care instructions) from 7/12/22 included instructions for Resident 1 to receive assistance from one CNA with bathing on Monday and Thursday evenings. Review of Resident 1's bathing records from 6/1/22 through 7/11/22 revealed Resident 1 did not receive bathing care assistance on the following dates: 6/9, 6/13 and 6/23. On 7/11/22 at 4:05 PM Resident 1 stated the facility experienced CNA shortages during 6/2022 and 7/2022 which resulted in bathing assistance not being provided as scheduled. Resident 1 stated she/he had only refused one shower during 6/2022 and 7/2022. Resident 1 stated bathing assistance was not provided on 6/9, 6/13 and 6/23. On 7/13/22 at 1:05 PM Staff 24 (CNA) stated bathing care was unable to be provided to residents as scheduled during 6/2022 and 7/2022 due to staffing shortages. Staff 24 stated she was so busy during this period that she was unable to document missed showers to be made up on a future date. On 7/13/22 at 1:22 PM Staff 4 (RCM) and Staff 7 (RCM) confirmed bathing care was not provided to or rescheduled for Resident 1 on the listed dates. On 7/13/22 at 1:49 PM Staff 1 (Administrator) was notified of the findings. No additional information was provided.

Resident # 1 is receiving showers per schedule. Resident # 2 is receiving showers per schedule. Residents who require assist with showers are at risk DON/Designee completed baseline audit of current residents to verify residents are receiving showers as scheduled. Newly identified issues will be addressed. DON/Designee re-educated nursing staff on 7/20/22 related to providing residents showers according to schedule, including documentation and interventions for refusals. DON/Designee will conduct audit of 10 residents weekly to verify showers are being provided per plan of care and documentation is complete. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed ensure sufficient staffing to meet the needs of 2 of 3 sampled residents (#s 1 and 2) who were reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 2 was admitted to the facility in 7/2021 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease (breathing difficulty) and obesity. A review of the 6/1/22 through 7/11/22 Direct Care Staff Daily Reports indicated the facility did not provide adequate CNA staffing to meet minimum CNA staffing ratios for 25 out of 41 days. Review of Resident 2's Kardex (CNA care instructions) from 7/12/22 included instructions for Resident 2 to be assisted by two staff members for bathing on Tuesday and Friday evenings. Review of Resident 2's bathing care task records from 6/1/22 through 7/11/22 revealed Resident 2 did not receive bathing care on the following scheduled dates: 6/7, 6/10, 6/17, 6/21 and 6/24. On 7/13/22 at 1:05 PM Staff 24 (CNA) stated bathing care was unable to be provided for residents as scheduled during 6/2022 due to CNA staffing shortages. On 7/13/22 at 1:22 PM Staff 4 (RCM) and Staff 7 (RCM) confirmed bathing care was not provided to Resident 2 on the listed dates due to CNA staffing shortages. On 7/13/22 at 1:49 PM Staff 1 (Administrator) was notified of the findings. No additional information was provided. 2. Resident 1 was admitted to the facility in 1/2021 with diagnoses including osteoporosis. A review of the 6/1/22 through 7/11/22 Direct Care Staff Daily Reports indicated the facility did not provide adequate CNA staffing to meet minimum CNA staffing ratios for 25 out of 41 days. Review of Resident 1's MDS from 6/2022 revealed Resident 1 had a BIMS of 15 indicating normal cognitive function. Review of Resident 1's Kardex (CNA care instructions) from 7/12/22 included instructions for Resident 1 to be assisted with bathing on Monday and Thursday evenings. Review of Resident 1's bathing care task records from 6/1/22 through 7/11/22 revealed Resident 1 did not receive bathing care assistance on the following dates: 6/9, 6/13 and 6/23. On 7/11/22 at 4:05 PM Resident 1 stated bathing assistance had not been provided as scheduled. Resident 1 stated she/he had only refused one shower during 6/2022 and 7/2022. Resident stated bathing assistance was not provided on 6/9, 6/13 and 6/23. On 7/13/22 at 1:05 PM Staff 24 (CNA) stated bathing care was unable to be provided for residents as scheduled during 6/2022 due to CNA staffing shortages. On 7/13/22 at 1:22 PM Staff 4 (RCM) and Staff 7 (RCM) confirmed bathing care was not provided to Resident 1 due to CNA staffing shortages. On 7/13/22 at 1:49 PM Staff 1 (Administrator) was notified of the findings. No additional information was provided. Refer to F677.

Additional agency contracts have been acquired to assist with meeting needed staffing levels. Residents residing in the facility are at risk. NHA/Designee completed baseline audit of current schedule to verify required number of CNAs are scheduled and direct care ratios on staffing sheets are met. Newly identified issues will be addressed. NHA/Designee re-educated clinical nurse managers 7/20/22 related to maintaining direct care staffing levels per guidelines and documentation of staffing interventions on exception report when ratios unmet. A staffing meeting will be held Monday thru Friday to verify sufficient staff is scheduled. Weekend staffing will be reviewed during the Friday meeting. NHA/Designee will audit staffing sheets to validate adequate staffing Audits will be conducted daily for 2 weeks, weekly x4 then monthly x2. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

1.

Based on observations, interviews and record review it was determined the facility failed to maintain appropriate infection control practices to prevent the potential spread of the COVID-19 virus and other infectious diseases for 1 of 3 hallways and 1 of 1 screening areas. This placed residents at risk for exposure and contraction of the COVID-19 virus and other infectious diseases. Findings include: a. CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", last updated 2/2/22, instructed facilities to ensure environmental cleaning and disinfection procedures were followed consistently and correctly. The facility policy, "Procedures for a COVID-19 Outbreak Based on Contingency Criteria", undated, indicated the following: -Between each resident use, care staff should disinfect any shared resident equipment with a designated disinfectant-nursing equipment, resident body lifts, shower chairs, dining room tables, etc. On 7/12/22 at 12:20 PM Staff 18 (CNA) was observed taking a body lift from room 10 directly into room 7. Staff 18 then left the room. Staff 18 reported she did not disinfect body lifts between residents unless she was taking the body lift from a resident's room that was COVID-19 positive to a resident's room who was on precautions. Staff 18 confirmed she did not disinfect the body lift between residents in room 10 and room 7. On 7/13/22 at 10:55 AM Staff 8 (CNA) took a body lift from room 9 directly to room 4 and used the body lift with the resident in room 4. Staff 8 then took the body lift from room 4 to room 10. At 11:05 AM Staff 8 stated she was supposed to disinfect the body lift between residents but did not because there were no disinfecting wipes to use. On 7/13/22 at 1:49 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 10 (Regional Nurse Consultant) were notified of the findings of this investigation. No additional information was received. b. The CMS 3/2022 QSO-20-39-NH Nursing Home Visitation Guidance emphasized the importance of maintaining infection prevention practices, given the continued risk of COVID-19 transmission and included the following Core Principle of COVID-19 Infection Prevention which should be adhered to at all times: - Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observations of signs or symptoms. During this survey, from 7/11/22 through 7/13/22, a notification was posted on the facility's front door indicating the facility was under enhanced infection control protocols due to confirmed COVID-19. The notification was in effect as of 7/8/22. On 7/12/22 at 2:31 PM the employee Staff and Essential Visitor COVID-19 screening log located at the main nurse's station (employee screening area) indicated on 7/12/22, Staff 20 (Dietary) completed the employee screening log and answered "yes" to the question, "Do you currently have any of the COVID-19 symptoms listed at the bottom of the screening clipboard?". Staff 20's temperature was documented as 97.6 and the "reviewing" RN section was initialed by Staff 19 (LPN). On 7/12/22 at 2:36 PM Staff 20 stated she completed the employee screening log around 5:30 AM and checked the box marked "yes" indicating she had COVID-19 symptoms because she was not sure if she had allergies or not and reported she felt "fine". Staff 20 reported she was unaware of what to do if she marked "yes" to having COVID-19 symptoms, she did not notify anyone and no one asked her about her "yes" response. Staff 20 stated she was working in the kitchen with her N95 mask and face shield on all day. Staff 20 denied that she went into any resident care areas. On 7/12/22 at 3:13 PM Staff 3 (Infection Preventionist) stated staff self-screened by completing their temperatures and answering the questions on the Staff and Essential Visitor COVID-19 Screening log when they came on shift. Staff 3 stated staff were not monitored during the screening process by another staff or nurse but the charge nurse was responsible for reviewing the log and if a staff member marked "yes" the expectation was the nurse would further question the staff member, circle the "yes" and write a brief assessment and then that staff would be tested. Staff 2 (DNS) and Staff 3 confirmed Staff 20 marked "yes" on the screening log, there was no documentation on the log that additional questions were asked of Staff 20 and Staff 2 and Staff 3 were not aware Staff 20 had answered "yes" to having COVID-19 symptoms. Staff 2 and Staff 3 reported Staff 20 participated in routine COVID-19 testing around 1:30 PM and was negative for COVID-19. On 7/12/22 at 4:52 PM Staff 19 (LPN) stated she worked night shift and reviewed the 7/12/22 staff screening log and initialed the entry for Staff 20. Staff 19 stated she did not notice Staff 20 marked "yes" for currently having COVID-19 symptoms and Staff 20 did not mention that she was experiencing symptoms. Staff 19 stated if someone marked "yes" she would send them home or have them wait outside in the parking lot until an RN arrived because only RN's completed COVID-19 testing. Staff 19 stated if there was not an RN coming for a while, she would send the staff member home because, "we do not want this stuff in the building". On 7/13/22 at 1:49 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 10 (Regional Nurse Consultant) were notified of the findings of this investigation. 2. Based on interview and record review it was determined the facility failed to review and update Infection Prevention and Control Policies and Procedures at least annually. On 7/12/22 at 1:46 PM Staff 3 (Infection Control Preventionist) was asked to provide documentation indicating when the facility's Policy and Procedure manual for Infection Control was last reviewed and on 7/13/22 at 9:50 AM Staff 10 (Regional Nurse Consultant) was asked to provide documentation when the facility's Policy and Procedure manual for Infection Control was last reviewed. Neither Staff 3 or Staff 10 were able to provide the requested documentation. On 7/13/22 at 1:49 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 10 (Regional Nurse Consultant) were notified of the findings of this investigation.

Covid-19 screening sheets for last 14 days have been reviewed with follow up on yes responses to exposure/symptoms from staff. Designated staff are being assigned to review screening forms prior to individuals exiting screening area. Shared resident equipment is being disinfected between residents Infection Control policies have been reviewed through QAPI process Residents residing in the facility are at risk DON/Designee completed baseline audit of current month screening sheets to verify follow up has been conducted on staff reported yes responses to Covid-19 symptoms/exposures. Newly identified issues will be addressed. DON/Designee completed baseline observation to verify shared resident equipment is being disinfected between use. Newly identified issues will be addressed. DON/Designee re-educated screening staff on 7/20/22 related to employee screening process and response to reported symptoms and exposure. DON/Designee re-educated staff on 7/20/22 related to disinfecting resident care equipment between residents. NHA/Designee re-educated QAPI team on 7/20/22 related to updates and yearly review of Infection Control policies. Specific staff have been assigned to review screening forms prior to individual leaving screening area. Training has been given related to follow-up of yes responses. DON/Designee will conduct audit of staff Covid-19 screening sheets to verify Yes responses to exposure/symptoms were reviewed prior to staff leaving screening area, daily x2 weeks then weekly x3 months DON/Designee will complete 10 observations weekly x4 weeks then monthly x2 to verify shared resident equipment is being disinfected between residents. NHA/Designee will monitor for needed updates to infection control policies and submit for review as needed. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

Based on interview and record review it was determined the facility failed to inform residents, resident representatives and families by 5:00 PM the next calendar day following the occurrence of a suspected or confirmed COVID-19 infection and failed to include mitigating actions taken by the facility to prevent or reduce the risk of transmission for 1 of 1 facility. This placed residents at risk for not being informed of the facility's COVID-19 outbreak status. Findings include: During this survey, from 7/11/22 through 7/13/22, a notification was posted on the facility's front door indicating the facility was under enhanced infection control protocols due to confirmed COVID-19. The notification was in effect as of 7/8/22. On 7/12/22 at 4:09 PM a facility staff provided the surveyor a copy of a hand-written note dated 7/12/22 that was given to the residents on 7/12/22 regarding a confirmed COVID-19 infection which occurred on 7/8/22. On 7/12/22 at 4:14 PM Resident 8 stated she was handed a copy of a hand-written note dated 7/12/22 which indicated the facility had confirmed COVID-19 on 7/8/22. Resident 8 stated she had just received the note a few minutes earlier. On 7/12/22 at 4:10 PM Staff 1 (Administrator) stated the facility had confirmed COVID-19 on 7/8/22 and she was aware the residents, the resident representatives and families needed to be notified by 5:00 PM the next calendar day following 7/8/22 but it did not get done until 7/12/22. The note did not include mitigating actions taken by the facility to prevent or reduce the risk of transmission. On 7/1322 at 1:49 PM Staff 1, Staff 2 (DNS) and Staff 10 (Regional Nurse Consultant) were provided with the findings of this investigation. Staff 1 indicated she was aware the information needed to include mitigating actions taken by the facility to prevent or reduce the risk of COVID-19 transmission.

Residents, Representatives, and families have been notified of facilitys current Covid-19 status. Residents residing in the facility are at risk NHA/Designee completed baseline audit of current residents to verify the resident, their representative and families have been notified of facilitys current Covid-19 status. Newly identified issues will be addressed. NHA/Designee initiated further education to DON, Infection Preventionist and Social Services Director on 7/20/22 related to notifying residents, representatives and families by 5 PM on the following calendar day each time a confirmed COVID-19 case is identified or whenever three (3) or more residents or staff are identified with new onset of respiratory symptoms occurring within 72-hours of each other. NHA/Designee will conduct audit of notifications to verify residents, representatives and families were notified by 5pm next day of qualifying Covid-19 status changes in the facility. Audits will be conducted weekly for 4 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.

******************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677 ******************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F725 ******************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880, F885 ********************************

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 06/27/2022 and 07/03/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/20/2022 and 06/26/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/13/2022 and 06/19/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to develop additional precautions intended to mitigate the transmission and spread of COVID-19 for 8 of 9 unvaccinated staff (#s 2, 8, 10, 15, 16, 17, 18 and 19) reviewed for COVID-19 staff vaccinations. This placed residents at risk for potential exposure of the COVID-19 virus. Findings include: The facility's 10/2021 COVID-19 Vaccine Maintenance Plan indicated "A non-vaccinated staff, with an approved exemption, will be subject to all of the existing accommodation protocols of a non-vaccinated employee, (including but not limited to, increased COVID-19 test)." The facility's COVID-19 Staff Vaccination Status for Providers identified nine staff members who where unvaccinated due to non-medical exemptions. In an interview on 2/18/22 at 9:08 AM, when asked what the source control and contingency plan was for unvaccinated staff, Staff 3 (Assistant DNS) and Staff 5 (RNCM) confirmed the only requirement for unvaccinated staff was testing two times a week. There was no documented evidence the facility's COVID-19 Staff Vaccination policy addressed additional precautions intended to mitigate the spread of COVID-19 for unvaccinated staff. Additional measures could include, reassigning staff to non-patient care areas, adhering to universal source control and physical distancing measures in areas that are restricted from patient access, and require the use of a NIOSH (National Institute for Occupational Safety and Health) approved N95 mask or equivalent or higher-level respirator or source control regardless if unvaccinated staff are providing direct care.

Cornerstone Care Option shall continue to develop, implement, monitor, and evaluate effective strategies to mitigate the transmission and spread of COVID-19, for all residents and staff By 3/17/22, the Cornerstone Care Option infection control leadership team shall review the previous 90 days of all CMS, CDC, OHA, and DHS guidelines specifically involving the Contingency planning for staff who are not fully vaccinated for COVID-19. Based on this guidance review, this team shall then revise all appropriately targeted Cornerstone infection control and Covid-19 policies and procedures to ensure the inclusion of all of the core elements thus identified, regarding the contingency planning for staff who are not fully vaccinated. By 4/04/22, Cornerstone will then implement, monitor, and track precautions intended to mitigate the spread of Covid-19 for all staff who are not fully vaccinated. These precautions shall include, but not be limited to, the required routine use of an approved N-95 mask for all staff who are not fully vaccinated. Therefore, by 4/04/22, the infection control leadership team shall in-service all staff regarding the newly revised Cornerstone policies and procedures regarding the contingency plan for staff who are not fully vaccinated. This in-servicing shall additionally include the proper use of N95 masks specifically used by those staff who are not fully vaccinated, (and/or used by other staff as identified in the Cornerstone Covid-19 outbreak procedure). The Cornerstone infection control leadership team shall continue to promptly review guidance updates for necessary action, as made available by CMS, CDC, OHA, and DHS. As necessary, Cornerstone shall make future policy and procedure revisions, based on this appropriate updated guidance. On no less than a quarterly basis, the QAPI Committee shall consider Covid-19 regulation updates with existing Cornerstone Covid-19 policies, for any additional suggestions and/or needed policy revisions.

*************************** OAR 411-086-0330 - Infection Control and Universal Precautions Refer to F888 ***************************