Village Manor of Cascadia

Resident 1 was admitted to the facility in 2025, with diagnoses including dementia.-á Resident 1's 7/25/25 Care Plan revealed Resident 1 was a fall risk because of a prior fall and was a one-person max assist for dressing. Resident 1 was care planned for supervision and touch assistance for bathing, used a shower bench or bathtub, and was to wear non-skid footwear when up.-á-á A 7/28/25 FRI indicated Staff 5 (Housekeeping) and Staff 6 (Housekeeping) reported Resident 1 had a fall in the shower room. Staff 5 and 6 found staff to assist Resident 1. The report indicated staff found Resident 1 down in the shower, unattended, and not fully clothed. Resident 1 was transferred to the hospital for evaluation. The FRI indicated Resident 1 sustained multiple complex fractures of the pelvis and was bleeding internally. The FRI indicated the fall occurred due to Resident 1's care plan not being followed. Between 8/11/25 at 11:00 AM to 8/12/25 at 10:00 AM, Staff 2 (CNA), Staff 3 (CNA), Staff 4 (CNA), Staff 5 (Housekeeping) and Staff 6 (Housekeeping) all provided statements, which included Resident 1 was found down in the shower room unattended. Resident 1 was wearing underwear and pants. The resident's pants were not fully up and her/his belt was not buckled. Staff 2, Staff 3, and Staff 4 recalled Resident 1 was not wearing socks or shoes. All staff interviewed did not see a shower bench anywhere near the resident and she/he was found to have been in a shower stall, not a bathtub.-á On 8/11/25 at 10:48 AM, Staff 1 (CNA) indicated she left the shower room when she thought the resident was done with her/his shower and safe. Staff 1 confirmed a shower bench was not used and Resident 1 was left unattended in the shower room.-á On 8/12/25 at 10:00 AM, Staff 8 (LPN) was called for a witness statement. Staff 8 did not answer and did not return the phone call.-á On 8/12/25 at 10:45 AM, Staff 7 (Administrator) confirmed the accident occurred and Resident 1's care plan was not followed.-á

Resident 1 has since passed away. CNA who did not follow the care plan was terminated and reported to the OSBN. All residents are at risk for being impacted by this deficient practice. CNO and Clinical Resource did a full house audit of all shower rooms and provided recommendations to the Facility Services Director to put additional safety measures in place. CNO completed mandatory nursing department in-service on shower safety, fall prevention, and acute change of condition. CNO and Clinical Resource have reviewed the care plan policy. RCM's have reviewed and updated all resident's shower/bathing/dressing care plans and tasks to ensure that appropriate level of assistance needed, if can be left alone, and devices needed to perform the task are care planned and individually tasked. RCM's will review and update all resident's fall care plans to ensure that interventions and tasks meet current resident needs. CNO will conduct an in-service with RCM's to review and enforce the importance of reviewing, updating, and communicating care planned needs in real time and with change in resident condition. CNO or designee will review care plan policy at next all nurse and all CNA in-service to review and enforce the importance of reviewing, updating, and communicating care planned needs in real time and with change in resident condition. RCM or designee will bring results of these audits to QAPI, monthly for 3 months or until deficient practice has been resolved. CNO or designee will audit 10% of MDS' completed each week to ensure that their ADL/fall portion of the care plan and tasks is accurate. CNO or designee will bring results of these audits to QAPI monthly for 3 months or until deficient practice has been resolved.

Based on observation, interview and record review, it was determined the facility failed to maintain a homelike environment for 1 of 1 resident (#9) reviewed for homelike environment. This placed residents at risk for lessened quality of life. Findings include: Resident 9 admitted to the facility in 5/2020 with diagnoses including borderline personality disorder. Resident 9's 2/28/25 care plan found no indication for having a short chain on his/her bedside light. On 5/5/25 at 9:58 AM Resident 9 was observed to have a three to four inch chain on the light on the wall over his/her bed. Resident 9 stated she/he was unable to use it due to the short length and was unable to turn on the light independently. Resident 9 stated she/he became frustrated and had to ring his/her bell to have someone come turn on the light. Resident 9 further stated she/he should be able off her/his own light without assistance. On 5/6/25 at 1:54 PM Staff 30 (CNA) stated she thought Resident 9 was able to turn his/her bedside light on and off with the use of a reacher. On 5/7/25 at 9:36 AM Staff 12 (LPN) stated she did not think Resident 9 was capable of turning the bedside light on or off. However, Resident 9 frequently called for assistance. On 5/7/25 at 10:34 AM Staff 3 (RNCM) stated she was unaware that the bed light was short there was no intentional reason for keeping it short. On 5/7/25 at 11:13 AM Staff 13 (Environmental Services Director) stated the chain was short because Resident 9 had previously pulled on it with his/her body weight to reposition. It was unsafe for him/her to use it that way because it would break and send him/her backwards out of control. Staff 13 was unaware that Resident 9 was not able to turn the light on with the short chain. On 5/7/25 at 2:53 PM Staff 2 (DNS) confirmed Resident 9 should be able to turn on and off the bedside light. She knew it was short, but did not know Resident 9 was unable to turn it on and off without asking for help.

Environmental Services Director fixed the overbed light chain to include a breakaway portion for safety purposes for resident 9. RCM or designee will update the care plan accordingly with the breakaway chain for safety purposes and include a task for care staff to note that the overbed light chain is functional with cares, and to report to the Environmental Services Director or charge nurse if repairs are required. All residents are at risk for being impacted by this deficient practice. RCM or designee will assess each resident's overbed light pull cords and notify the Environmental Services Director or designee of any that require repair, and care plan any that deviate from the basic pull cord for safety or ADL functional needs. Director of Nursing or designee will audit 10% of residents monthly to ensure that the residents with pull cords that are deviated from the basic pull cord are care planned accordingly. Housekeeping staff or designee will ensure that resident overbed light pull cords are fully functional when performing monthly deep cleans of resident rooms, and will notify the Environmental Services Director or designee for any repair needs. Director of Nursing or designee will bring results of this to QAPI quarterly, for 3 cycles or until deficient practice has resolved.

Based on interviews and record review, it was determined the facility failed to protect the resident's right to be free from physical abuse from other residents for 1 of 6 sampled residents (#52) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: Resident 49 was admitted to the facility in 5/2023 with diagnoses including schizoaffective disorder (a mental health condition where a person experiences symptoms of schizophrenia, such as hallucinations and delusions, and a mood disorder, such as mania or depression). Resident 52 was admitted to the facility in 1/2024 with diagnoses including psychosis (a state where a person loses touch with reality, experiencing hallucinations and delusions). On 1/22/25 a Facility Reported Incident (FRI) was received by the State Survey Agency, which alleged Resident 49 slapped Resident 52 on the left side of her/his face. A 1/22/25 Progress Note indicated Resident 49 hit Resident 52 in the face. A 1/27/25 facility investigation revealed on 1/22/25 at 4:30 AM staff heard yelling from room 14 and found Resident 49 standing over Resident 52's bed yelling at her/him. Staff got in between the residents and kept them separated until EMTs arrived. Resident 49 was sent to the hospital. On 5/6/25 at 8:41 AM Resident 52 revealed on 1/22/25 in the middle of the night, she/he was woken up by Resident 49 hitting her/him. Resident 52 stated she/he sat up in bed and kicked Resident 49 away from her/him. Resident 52 stated staff came in and kept Resident 49 away from her/him until Resident 49 left with EMTs. Resident 52 denied injury from the incident and stated Resident 49 was moved to a new room because Resident 52 was not comfortable sleeping in the same room as Resident 49. Resident 49 refused to be interviewed. On 5/8/25 at 1:16 PM Staff 26 (RN) stated Resident 49 had an incident a few months ago where she/he hit Resident 52 while Resident 52 was sleeping. Staff 26 stated Resident 52 had no injuries from the incident. However, Resident 52 expressed feeling scared about sleeping in the same room as Resident 49, so Resident 49 was moved to a new room. On 5/8/25 at 1:24 PM Staff 4 (RNCM) stated there was an incident between Resident 49 and Resident 52 in 1/2025. Staff 4 stated Resident 49 hit Resident 52 in the face while Resident 52 was sleeping. Staff 4 stated after the incident, Resident 49 was placed on a psychiatric hold for medication adjustment and when Resident 49 returned to the facility, she/he was moved to a new room. On 5/9/25 at 11:48 AM Staff 2 (DNS) acknowledged the incident between Resident 49 and Resident 52 occurred and the incident met the definition of abuse.

RCM reviewed and updated Resident 52 care plan to ensure resident safety and to minimize risk to allow him to be free from abuse and neglect. Social Services Director checks in with Resident 52 quarterly and as needed to ensure that he feels safe in his environment and refers to the Mental Health Professional as needed. RCM reviewed and updated Resident 49 care plan to minimize the risk of imposing abuse on other residents. Resident 49 is in the High-Risk Behavior Monitoring group and will be reviewed by the IDT team weekly and with any significant change in condition to determine if further interventions are needed to minimize the risk of abuse to other residents. All residents are at risk for being impacted by this deficient practice. IDT will review all residents daily through the Clinical Stand-up meeting for risk factors in which a resident might or is exhibiting potential for abuse toward another resident and put interventions in place to minimize this risk. The members of the High-Risk Behavior Monitoring group will be reviewed by the IDT team weekly and with any significant change in condition to determine if further interventions are needed to minimize the risk of abuse to other residents. RCM or designee will audit 10% of the residents in the High-Risk Behavior Monitoring group monthly to ensure that interventions are care planned to minimize the risk for potential abuse, as well as refer residents to the Mental Health Professional if there is a change in their health and or behavioral expressions. RCM or designee will bring the results of the audit to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to ensure residents were free from chemical restraints for 1 of 5 sampled residents (#57) reviewed for unnecessary medications. This placed residents at risk for changes to psychosocial well-being. Findings include: Resident #57 was admitted to the facility in 2/2025 with diagnoses including anxiety, hallucinations, and disorientation. A 3/31/25 physician order indicated Resident 57 was prescribed haloperidol Oral Tablet 5 MG (antipsychotic medication) twice daily as needed for 14 days. The Indication for use was hallucinations. A 4/14/25 physician order indicated Resident 57 was prescribed haloperidol Oral Tablet 5 MG twice daily as needed for 14 days. Indications for use were hallucinations or aggression. A 4/21/25 physician order indicated Resident 57 was prescribed haloperidol Oral Tablet 5 MG twice daily as needed for 14 days. Indications for use were hallucinations or aggression. Resident 57's MAR, behavior monitor and progress notes for 4/2025 and 5/2025 indicated she/he received haloperidol with no indication for use on the following days: 4/2/25 and 4/15/25 Resident 57 received two doses of haloperidol. On 4/3/25, 4/4/25, 4/5/25, 4/8/25, 4/11/25 and 4/14/25, 4/27/25, 4/30/25, 5/1/25 and 5/5/25 she/he receceived a single dose of haloperidol. On 5/8/25 11:55 AM Staff 31 (LPN) stated she was unsure why she would have given haloperidol if Resident 57 was not having behaviors on 4/30/25. She further stated she should have documented the specific behaviors in a progress note but did not. On 5/8/25 01:09 PM Staff 9 (LPN) stated she administered haloperidol on on 4/4/25, 4/5/25 and 4/8/25.because Resident 57 would not sleep for long periods of time. Staff 8 stated stated she should have documented the specific behaviors in a progress note but did not. On 5/8/25 at 1:30 PM Staff 22 (LPN) stated he administered haloperidol for agitation and because Resident 57 was difficult to control. Staff 22 could not specifically remember why he administered haloperidol on 4/11/25. Staff 22 further stated he should have documented the specific behaviors in a progress note but did not. On 5/8/25 at 1:54 PM Staff 19 (LPN) stated she administered haloperidol at the instruction of two other nurses because Resident 57 pulled the fire alarm multiple times on 5/4/25. On 5/8/25 at 2:02 PM Staff 32 (LPN) stated she administered haloperidol on 5/1/25 because Resident 57 thought there were people coming in and out of his/her room and wanted to get up. Staff 32 stated she should have documented whether the administration was effective. On 5/8/25 at 3:31 PM Staff 28 (LPN) stated she gave haloperidol when Resident 57 had behaviors and agitation and stated he was not aggressive on 4/3/25. She further stated she should have documented the specific behaviors in a progress note but did not. On 5/9/25 at 9:11 AM Staff 2 (DNS) stated Resident 57 was only to receive haloperidol for aggression or hallucinations. Staff 2 stated nurses should have documented the specific hallucinations or aggressive behaviors, as well as all non-pharmacological interventions attempted with Resident 57 prior to the administration of haloperidol, in a progress note. Staff 2 further stated staff should have documented whether the administration was effective in resolving the behaviors.

Director of Nursing or designee requested that Mental Health Professional review Resident 57 medications and complete an assessment to ensure that he is on the best medications to support his diagnosis while also being free from chemical restraints. RCM or designee has updated resident's orders, behavior monitoring tasks, and care plan to ensure that his triggers, non pharmacological interventions, and behavioral expressions are documented prior to administering any as needed psychoactive medications. All residents are at risk for being impacted by this deficient practice. RCM or designee will audit and update the orders, behavior monitoring tasks, and care plan to ensure that his triggers, non pharmacological interventions, and behavioral expressions are documented prior to administering any as needed psychoactive medications for all residents who have as needed psychoactive medications. Director of Nursing or designee will provide an in-service for all nursing staff to ensure that they understand how and when as needed psychoactive medications should be administered and the proper documentation and follow up for this administration. Director of Nursing or designee will audit all residents who have orders for as needed psychoactive medications weekly to ensure that medications are administered for ordered purpose and proper documentation and follow up is in place when medication has been ordered. CNO or designee will bring the results of the audit to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to report an allegation of abuse to the State Agency (SA) within the mandated timeframe for 1 of 6 sampled residents (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation policy, last revised 8/1/23, indicated the following: -Allegations of verbal, sexual, physical, mental, corporal punishment, involuntary seclusion, and neglect of the resident, as well as mistreatment, injuries of unknown source, exploitation, deprivation of goods and services by staff, and misappropriation of resident property are reported to the administrator immediately and the state agency within two hours if there was alleged abuse or serious bodily injury as a result of an event. Resident 2 was admitted to the facility in 10/2019 with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and history of traumatic brain injury. Resident 59 was admitted to the facility in 4/2025 with diagnoses including dementia and delirium (a disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings). The facility's FRI received on 4/20/25 at 11:14 PM, revealed on 4/20/25 at 4:50 PM, Resident 59 forcefully shoved Resident 2 against the wall, staff intervened, separated the residents and escorted Resident 2 to her/his room. On 5/8/25 at 10:20 AM, Staff 20 (LPN) stated around 4:50 PM, Resident 2 attempted to walk past Resident 59 and Resident 59 "charged" at Resident 2; pushing her/him into the wall. Resident 59 then took her/his hands and "threw" Resident 2 into the wall. Staff 20 stated she was a new nurse and had not previously completed a FRI so she contacted Staff 2 (DNS) who provided assistance and later a night shift nurse also helped with the report. As a result, the FRI was not submitted to the SA within the mandated timeframe. On 5/9/25 at 8:22 AM, Staff 2 (DNS) stated Staff 20 was in contact with her several times regarding the incident on 4/20/25 between Resident 2 and Resident 59. Staff 2 acknowledged the FRI was not completed within the mandated timeframe.

Resident 2/Resident 59 FRI reported late; interventions are in place to prevent any further abuse with Resident 59. All residents are at risk for being impacted by this deficient practice. Administrator will hold an all staff meeting of abuse and neglect and timely reporting. Director of Nursing will hold an all-nursing meeting to review the importance of timely reporting of suspected/actual abuse, and how to properly fill out a FRI for suspected/actual abuse. Director of Nursing or designee will audit all suspected/actual abuse allegations during daily clinical review ensuring that they were/are reported timely. If Director of Nursing or designee notes that the suspected/actual abuse is not reported timely, they will report through the FRI process and follow up with the staff that did not complete the FRI timely for further education and training. Director of nursing or designee will bring the results of the audit to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview, and record review it was determined the facility failed to develop comprehensive care plans that included interventions for the use of psychotropic medication for 1 of 5 sampled resident (#57) reviewed for unnecessary medications. This placed the resident at risk for side effects and unnecessary medication. Findings include: Resident 57 was admitted to the facility in 2/2025 with diagnoses including anxiety, hallucinations and disorientation. A review of Resident 57's physician orders found the following active orders for psychotropic medications: Buspirone HCl oral tablet. Give 15 mg by mouth in the morning for irritability related to anxiety disorder, unspecified and give 15 mg by mouth one time a day for irritability at 4 PM. Do not give at 6 PM per provider. Lamotrigine oral tablet. Give 25 mg by mouth one time a day for mood stabilization related to major depressive disorder, recurrent. Mirtazapine Oral tablet. Give 7.5 mg by mouth one time a day related to insomnia. Duloxetine HCl oral capsule delayed release sprinkle 30 MG. Give 1 capsule by mouth one time a day for mood/depression related to major depressive disorder, recurrent, unspecified. Olanzapine oral tablet disintegrating. Give 15 mg by mouth one time a day related to hallucinations, unspecified. Haloperidol oral tablet. Give 5 mg by mouth as needed for twice daily as needed for hallucinations or aggression for 14 Days. A review of Resident 57's 2/24/25 care plan found no interventions for the use of psychotropic medications. There was no evidence resident-specific interventions for the use of psychotropic medications were developed in Resident 57's health record. On 5/9/25 at 9:11 AM Staff 2 (DNS ) confirmed Resident 57's clinical record lacked interventions for the use of psychotropic medication.

RCM will review and update Resident 57 care plan to include resident specific interventions for use of psychotropic medications. All residents are at risk for being impacted by this deficient practice. RCM or designee will review all residents taking psychoactive medications and ensure that their care plan is updated to include resident specific interventions for use of the psychoactive medications. Clinical Resource or designee will audit 10% of all residents taking psychoactive medications monthly to ensure that their care plans have resident specific interventions for use for psychoactive medications. Director of Nursing or designee will bring the results of the audit to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to timely assess and implement appropriate interventions for a change of condition or accident for 1 of 1 sampled resident (#27). This placed the residents at risk for choking. Findings include: Resident 27 admitted to the facility in 10/2019 with diagnoses including stroke. Resident 27's 4/20/25 comprehensive assessment noted coughing and choking during meals and when swallowing medications. A 4/18/25 physician orders revealed Resident 27 was on a dental/mechanical soft texture, nectar thick liquids consistency. A 5/2/25 progress note found Resident 27 choked during dinner and the Heimlich maneuver was administered successfully by Staff 28 (LPN). A 5/5/25 physician order revealed Resident 27's diet was changed to a pureed texture, three days after Resident 27's choking episode . On 5/8/25 at 3:42 PM Staff 28 stated during dinner on 5/2/25 Resident 27 choked and became very rigid. Staff 28 did the Heimlich maneuver with a CNA and Resident 27 recovered. Staff 28 notified the on-call provider and stated she should have downgraded Resident 27's diet texture to puree at that time but did not. There was no evidence in Resident 27's health record the speech language pathologist was notified after his/her choking episode on 5/2/25. On 5/9/25 at 10:15 AM Staff 30 (Director of Rehabilitation) stated she was not notified until 5/5/25 regarding Resident 27's choking incident, which occurred on 5/2/25 (three days later). She immediately placed orders to downgrade the diet texture to puree and stated she consulted with the speech-language pathologist for safety. Staff 30 stated she would have done so on 5/2/25 if she were notified of the chocking incident. On 5/9/25 at 10:29 AM Staff 2 (DNS) acknowledged Resident 27's diet should have been downgraded immediately after the choking incident on 5/2/25.

SLP was ordered for Resident 27 to determine appropriate diet and interventions to minimize risk for choking during meals. RCM or designee will update orders and care plan accordingly to minimize risk for choking. All residents are at risk for being impacted by this deficient practice. Director of Nursing will hold an all-nursing in-service on proper notification to PCP and administrative nursing staff as well as for requesting SLP and down grading diets as needed to minimize choking. IDT will audit any incident of choking daily through the Clinical meeting to ensure that proper interventions and reporting have been completed to minimize risk for further choking. RCM or designee will bring the results of these audits to QAPI for 3 cycles or until deficient practice has resolved.

Based on observation, interview and record review it was determined the facility failed to provide care planned safety interventions for 1 of 4 sampled residents (#24) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 24 was admitted to the facility in 2018 with diagnoses including Wernicke's encephalopathy (a neurological disorder) and dementia. Resident 24's 4/30/25 Quarterly Smoking Evaluation indicated the resident was to use smoking gloves when smoking. A review of Resident 24's 5/2/25 Quarterly MDS Assessment revealed she/he had moderate cognitive impairment. Resident 24's 8/7/22 Care Plan indicated she/he used smoking materials and was to wear smoking gloves when smoking. On 5/6/25 at 8:33 AM Resident 24 was observed smoking in the facility designated smoking area without smoking gloves on. On 5/6/25 at 8:35 AM Resident 24 stated she/he was not wearing her/his smoking gloves because staff did not offer to provide them to her/him. On 5/6/25 at 8:36 AM Staff 18 (CNA) confirmed Resident 24 was smoking without her/his smoking gloves on and stated she/he should have had them on. On 5/6/25 at 8:39 AM Staff 2 (DNS) stated Resident 24 was care planned to wear smoking gloves to prevent her/his knuckles from burns. Staff 2 acknowledged Staff 18 did not offer Resident 24 her/his smoking gloves.

RCM will review Resident 24 Smoking evaluation and care plan to ensure it continues to be sufficient for safety during smoking pass. All residents are at risk for being impacted by this deficient practice. Director of Nursing or designee will hold an all-nursing in-service to ensure that all staff providing smoke pass are aware of individualized safety interventions for the residents during smoke pass and the importance of following these interventions. RCM or designee will perform weekly audits during smoke pass to ensure that the proper individualized safety interventions are being carried out according to care plan during smoking pass. RCM or designee will bring the results of these audits to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to ensure residents received trauma informed care for 2 of 3 sampled residents (#s 18 and 30) reviewed for behavioral and emotional care needs. This placed residents at risk for re-traumatization. Findings include: The facility's 10/2022 Trauma Informed Care Policy and Procedure revealed the following: -Screen residents for a traumatic event, series of events, or set of circumstances which resulted in actual harm or threat of harm. Determine how the individual perceives the event, as stressful or not. Evaluate how the event adversely impacts the person. -Collaborate with the resident and/or resident advocate to plan for treatment or intervention(s) of resident choice, as indicated and/or appropriate. -Person-centered care planning addresses the following: a. Identify the effects of the trauma on the resident and how that may be manifested in a resident's behavior. b. Address triggers for re-traumatizing and interventions to avoid such an experience, such as loud noises, smells, textures, cold/hot, confinement, invasion of perceived privacy, etc. c. Develop interventions to reduce potential triggers and promote coping techniques. d. Coordinate recovery concepts with counseling and/or therapy, as indicated. 1. Resident 18 was admitted to the facility in 11/2023 with diagnoses including schizophrenia (chronic brain disorder) and PTSD (Post-Traumatic Stress Disorder). Resident 18's 4/7/25 Quarterly MDS indicated the resident was cognitively intact. Resident 18's 4/16/25 Behavior/Psychoactive Quarterly Assessment indicated Resident 18 had auditory hallucinations that bothered her/him and occurred anytime of day. No evidence was found in Resident 18's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers. On 5/7/25 at 8:30 AM Resident 18 stated she/he did not recall if the facility had asked her/him about any triggers she/he had. Resident 18 stated she/he heard voices that would get loud and would cause her/him to scream out for help. On 5/7/25 at 12:55 PM Staff 10 (CNA) and at 1:00 PM Staff 9 (LPN) stated they thought Resident 30 might have PTSD because she/he was a veteran but were unaware if the resident had any triggers. Staff 9 and Staff 10 stated the only behavior Resident 18 displayed was she/he would yell out. On 5/7/25 at 1:50 PM Staff 6 (Social Services) stated resident trauma screenings were to be completed at the time of admission for all residents. Staff 6 stated a care plan had not been developed related to Resident 18's history of trauma or potential triggers. Staff 6 stated she was not aware if Resident 18 had any triggers. On 5/7/25 at 1:58 PM Staff 2 (DNS) and Staff 7 (Clinical Resources) acknowledged Resident 18 had a diagnosis of PTSD and nothing was implemented related to Resident 18's trauma or her/his trauma triggers. 2. Resident 30 was admitted to the facility in 8/2022 with diagnoses including major depressive disorder and PTSD (Post-Traumatic Stress Disorder). Resident 30's 3/1/25 Quarterly MDS indicated the resident was cognitively intact. No evidence was found in Resident 30's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers. On 5/7/25 at 9:52 AM Staff 8 (Activity Director) stated Resident 30 had a few behaviors and could become frustrated with other residents. Staff 8 stated he thought Resident 30 probably had some triggers and could easily become frustrated or lose her/his patience, but was not aware if the resident had any specific triggers. On 5/7/25 at 10:47 AM Resident 30 stated no one at the facility discussed the cause of her/his PTSD or potential triggers for re-traumatization. Resident 30 stated she/he would easily lose her/his patience with others and become frustrated. When asked what triggered her/his behaviors the resident stated "I don't want to talk about it." On 5/7/25 at 12:55 PM, Staff 10 (CNA) and at 1:00 PM Staff 9 (LPN) stated they did not know if Resident 30 had PTSD and were unaware if the resident had any triggers. On 5/7/25 at 1:50 PM Staff 6 (Social Services) stated resident trauma screenings were to be completed at the time of admission for all residents. Staff 6 stated a care plan had not been developed related to Resident 30's history of trauma or potential triggers. Staff 6 stated she was not aware if Resident 30 had any triggers. On 5/7/25 at 1:58 PM Staff 2 (DNS) and Staff 7 (Clinical Resources) acknowledged Resident 30 had a diagnosis of PTSD and nothing was implemented related to Resident 30's trauma or her/his trauma triggers.

Resident 18 will have a Trauma Informed Care evaluation completed by the Social Services Director or designee. Once the evaluation is completed for Resident 18 by the Social Services Director or designee a comprehensive Trauma Informed Care care plan will be completed to address auditory hallucinations, other pertinent diagnosis, potential triggers for prevention of re-traumatization, and other needed interventions. Resident 30 will have a Trauma Informed Care evaluation completed by the Social Services Director or designee. Once the evaluation is completed for Resident 30 by the Social Services Director or designee a comprehensive Trauma Informed Care care plan will be completed to address PTSD, other pertinent diagnosis, potential triggers for prevention of re-traumatization, and other needed interventions. All residents are at risk for being impacted by this deficient practice. Social Services Director or designee will audit all residents who meet criteria for being impacted by Trauma Informed Care and identify if they have a Trauma Informed Care care plan identifying triggers for prevention of re-traumatization and other needed interventions. Social Services Director or designee will then complete the care plans that are identified to be missing from the above audit. Social Services Director or Designee will bring the results of this audit to QAPI. Clinical Resource or designee will audit 10% of all MDS' completed quarterly and ensure that identified residents who meet the criteria for requiring Trauma Informed Care have a sufficient care plan in place identifying triggers for prevention of re-traumatization and other needed interventions. Director of Nursing or designee will bring the results of the audit completed by the Clinical Resource to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to act upon pharmacist recommendations for 1 of 5 sampled residents (#57) reviewed for unnecessary medications. This placed residents at risk for a decrease in their quality of life. Findings include: Resident 57 was admitted to the facility on 2/2025 with diagnoses including anxiety, hallucinations and disorientation. A review of Resident 57's physician orders found an active order for Olanzapine oral tablet disintegrating (an antipsychotic medication). Give 15 mg by mouth one time a day related to hallucinations. A review of pharmacy recommendations for Resident 57 dated 3/19/25 included the following recommendation for the use of Olanzapine: 'If the antipsychotic order is to continue, please update the medical record to include ... a list of symptoms or target behaviors (e.g., hallucinations) including their impact on the resident (e.g., increases distress, presents a danger to the resident or others, interferes with their ability to eat) AND documentation that other causes (e.g., environmental) and medications have been considered, that individualized nonpharmacological interventions are in place and that ongoing monitoring has been ordered.' A review of Resident 57's clinical record lacked specific target behaviors and their impact on the resident, documentation that other causes and medications had been considered and individualize nonpharmacological interventions were in place. There was no evidence in Resident 57's health record that the facility followed up or implemented the pharmacy recommendations. On 5/09/25 at 9:11 AM Staff 2 (DNS) confirmed the pharmacist's recommendation were not followed.

Resident 57 pharmacy recommendations from 3/9/25 were reviewed and followed up on to include: updating the care plan with symptoms of targeted behavior including their impact on the resident, and the intervention for documentation that other causes (e.g., environmental) and medications have been considered, individualized nonpharmacological interventions, and ongoing monitoring. All residents are at risk for being impacted by this deficient practice. Director of Nursing or designee will distribute pharmacist clinical recommendations to the RCMs to process monthly. Director of Nursing will ensure that all pharmacist clinical recommendations are carried out monthly. Clinical Resource or designee will audit pharmacist clinical recommendations for accuracy and completion. Director of Nursing will bring results of this audit completed by the Clinical Resource to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined that the facility failed to ensure residents were free from unnecessary bowel and antihypotensive medications for 2 of 5 sampled resident (#s 20 and 35) reviewed for unnecessary medications. This placed the resident at risk for adverse side effects from medication complications. Findings include: 1. Resident 20 was admitted to the facility in 3/2025 with the diagnosis including hypotension. Resident 20's 3/21/25 through 4/22/25 Physician Orders indicated the resident received midodrine (used to raise blood pressure) three times daily and was to be held for SBP (systolic blood pressure) greater than 120. A review of Resident 20's 3/2025 and 4/2025 MARs revealed Resident 20 received the midodrine on the following dates with the SBP above 120: -3/23/2025 AM dose, SBP was 122. -3/23/2025 AM dose, SBP was 122. -3/24/2025 Mid-day dose, SBP was 121. -3/27/2025 AM dose, SBP was 131. -3/27/2025 Mid-day dose, SBP was 131. -3/27/2025 PM dose, SBP was 130. -3/29/2025 PM dose, SBP was 127. -3/31/2025 PM dose, SBP was 132. -4/11/2025 AM dose, SBP was 146. -4/11/2025 Mid-day dose, SBP was 146. -4/12/2025 PM dose, SBP was 136. -4/14/2025 AM dose, SBP was 145. -4/14/2025 Mid-day dose, SBP was 145. -4/17/2025 AM dose, SBP was 134. -4/17/2025 Mid-day dose, SBP was 134. -4/18/2025 AM dose, SBP was 141. -4/18/2025 Mid-day dose, SBP was 141. -4/19/2025 PM dose, SBP was 140. -4/21/2025 PM dose, SBP 137. Resident 20's 4/23/25 through 5/9/25 Physician Orders indicated the resident received midodrine three times daily and was to be held for SBP greater than 130. A review of Resident 20's 4/2025 and 5/2025 MARs revealed Resident 20 received the midodrine on the following dates with the SBP above 130: -4/25/2025 AM dose, SBP 140. -4/25/2025 PM dose, SBP was 140. -5/1/2025 AM dose, SBP was 132. -5/1/2025 Mid-day dose, SBP was 142. -5/2/2025 AM dose, SBP was 138. On 5/8/25 at 9:11 AM Staff 15 (LPN) stated she administered the midodrine medication to Resident 20 on 5/2/25 when she should not have, as her/his SBP above 130. On 5/8/25 at 1:12 PM Staff 24 (LPN) stated Resident 20's midodrine should have been held when her/his SBP above 130. On 5/8/25 at 1:19 PM Staff 2 (DNS) reviewed Resident 20s's MARs from 3/2025, 4/2025, and 5/2025 and acknowledged the medication was given unnecessarily 24 times when it should have been held. , 2. Resident 35 was admitted to the facility in 5/2022 with diagnoses including bipolar disorder and a hip fracture. A 3/14/25 physician order stated Resident 35 was to receive two 8.6 mg tablets of senna twice a day for constipation and the medication was to be held for loose stools. The medication was scheduled to be received between 6:00 AM and 10:00 AM for the AM dose and between 4:00 PM and 7:00 PM for the PM dose. Review of Resident 35's 4/2025 and 5/2025 MARs revealed Resident 35 received her/his senna medication twice a day every day from 4/1/25 through 5/7/25. Review of Resident 35's 4/8/25 through 5/7/25 Bowel Movement Consistency records revealed the following errors of administration of senna: - On 4/8/25 at 3:17 AM Resident 35 had a type 7 bowel movement (Watery, no solid pieces. Entirely liquid). On 4/8/25 Resident 35 received her/his AM and PM doses of senna. On 4/8/25 at 7:09 PM Resident 35 had bowel movement recorded at type 7. - On 4/10/25 at 7:30 PM Resident 35 had a type 6 bowel movement (Fluffy pieces with ragged edges, a mushy stool). Resident 35 received her/his AM dose of senna on 4/11/25. Resident 35 did not experience a normal consistency bowel movement until 4/11/25 at 1:59 PM. - On 4/13/25 at 9:19 PM Resident 35 had a type 6 bowel movement. On 4/14/25 at 5:59 AM Resident 35 had another type 6 bowel movement. Resident 35 received her/his AM dose of senna on 4/14/25. Resident 35 did not experience a normal consistency bowel movement until 4/14/25 at 1:31 PM. - On 4/17/25 at 12:59 PM Resident 35 had a type 7 bowel movement. On 4/17/25 at 5:04 PM Resident 35 had another type 7 bowel movement. Resident 35 received her/his PM dose of senna on 4/17/25 and her/his AM dose on 4/18/25. Resident 35 did not experience a normal consistency bowel movement until 4/18/25 at 12:59 PM. - On 4/21/25 at 4:36 PM and 6:06 PM Resident 35 had type 6 bowel movements. Resident 35 received her/his 4/21/25 PM and 4/22/25 AM doses of senna, but did experience a normal consistency bowel movement until 4/12/25 at 12:37 PM. - On 4/26/25 at 3:33 PM Resident 35 had a type 7 bowel movement. Resident 35 received her/his PM dose senna on 4/26/25, her/his AM and PM doses of senna on 4/27/25, and her/his AM dose of senna on 4/28/25. Resident 35 did not experience a normal consistency bowel movement until 4/28/25 at 1:35 PM. - On 5/5/25 at 8:36 PM Resident 35 had a type 6 bowel movement. Resident 35 received her/his AM dose of senna on 5/6/25. Resident 35 did not experience a normal consistency bowel movement until 5/6/25 at 1:10 PM. On 5/8/25 at 9:42 AM Staff 27 (CNA) stated she had been instructed to report a loose stool bowel movement, which was at type 6 or type 7, to the CMA and charge nurse. On 5/8/25 at 9:53 AM Staff 4 (RNCM) stated she considered type 6 and type 7 to be loose stool. Staff 4 stated none of the bowel movement consistency ratings included the words "loose stool" which made it challenging to define. Staff 4 confirmed Resident 35's senna medication should have been withheld until her/his stool consistency returned to normal after experiencing loose stool on the dates listed above.

PCP will be notified of medication errors as identified during annual survey for Midodrine by the RCM or designee. PCP will review orders for Midodrine for Resident 20 to ensure that they would like to continue with the current hold parameters. PCP will be notified of medication errors for Senna that were identified during annual survey by the RCM or designee. PCP will review Resident 35 bowel regimen medications to ensure that current medications are best to be continued as ordered, as well as ensure that the hold orders in place are appropriate to manage medical diagnosis. All residents are at risk for being impacted by this deficient practice. Director of Nursing or designee will hold an all-nursing in-service to review the importance of accurately reading and ensuring they are following medication administration with hold orders or parameters. Director of Nursing or designee will review orders to determine which residents have hold orders and or parameters and keep an active list when new orders are written for auditing purposes. RCM or designee will audit weekly to ensure that hold orders and parameters are being followed as ordered and intervene accordingly. RCM or designee will bring the results of these audit to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to provide therapy services for 1 of 3 sampled residents (#28) reviewed for falls. This placed residents at risk for falls. Findings include: Resident 28 was admitted to the facility in 8/2020 with diagnoses including dementia. A review of Resident 28's Physician Orders revealed an 4/8/25 order for PT to evaluate due to frequent falls. On 5/5/25 at 10:15 AM a motion detector alarm was heard going off in Resident 28's room. Resident 28 was observed standing at her/his bedside and turning the alarm off. On 5/8/25 at 10:20 AM Staff 26 (RN) stated Resident 28 had multiple falls in 4/2025, no falls in 3/2025, and two falls in 2/2025. Staff 26 stated Resident 28 had frequent falls related to self-transferring and weakness. On 5/8/25 at 11:06 AM Staff 2 (DNS) stated Resident 28 had eight falls in 4/2025. Staff 2 stated Resident 28's falls were related to Resident 28's impulsiveness and self-transferring. Staff 2 stated Resident 28 was on therapy in 3/2025 and therapy had ordered Resident 28 a wheelchair to help decrease the risk for falls. Staff 2 stated Resident 28 finished PT on 3/15/25. On 5/8/25 at 11:23 AM Staff 4 (RNCM) stated Resident 28 had a lot of falls, mostly in her/his room. Staff 4 stated Resident 28 was impulsive, did not use her/his call light, and would self-transfer which led to falls. Staff 4 stated Resident 28 started PT due to frequent falls. On 5/8/25 at 1:37 PM Staff 4 stated she saw the 4/8/25 order for PT but was unable to see when PT was started. On 5/9/25 at 8:24 AM Staff 29 (Therapy Manager) acknowledged Resident 28's 4/8/25 order for PT. Staff 29 stated she discussed the order for PT with Staff 4 and Staff 29 stated therapy was not appropriate for Resident 28 because she/he was seen by therapy 30 days prior. On 5/9/25 at 10:28 AM Staff 4 stated she emailed Staff 29 on 5/8/25 to request the PT notes for Resident 28. Staff 4 stated she was informed on 5/9/25 by Staff 29, via email, Resident 28's PT evaluation was not completed as ordered on 4/8/25. Staff 4 stated she was informed by Staff 29 Resident 28 was not appropriate for PT because she/he just came off therapy four weeks ago. Staff 4 stated she had not discussed this with Resident 28's provider, because she just became aware of it on 5/9/25. On 5/9/25 at 11:40 AM Staff 2 acknowledged there was an order for Resident 28 to have PT evaluation due to frequent falls on 4/8/25. Staff 2 stated Staff 29 sent an email which stated therapy was not indicated for Resident 28. Staff 2 stated this decision was discussed as an IDT (interdisciplinary team) group on 4/8/25 and she assumed the provider was informed verbally. On 5/9/25 at 12:18 PM Staff 29 stated Resident 28 was at risk for falls due to impulsiveness and poor safety awareness. Staff 29 stated she did not have a discussion with Resident 28's provider related to the appropriateness of Resident 28's 4/8/25 PT order for evaluation. .

RCM or designee received new orders for PT eval and TX for frequent falls for Resident 28. Resident 28 continues to work with PT for fall management, ambulation, and w/c management. All residents are at risk for being impacted by this deficient practice. RCM or designee will complete a full house audit to ensure that any resident with orders for therapy have been carried out. Director of Nursing or designee will ensure that all new orders for therapy are identified and reported to the Director of Therapy daily through the clinical meeting process. Director of Nursing or designee will complete a 10% audit of all residents on therapy to ensure that their therapy services were carried out and timely in initiation. RCM or designee will bring the results of these audits to QAPI for 3 cycles or until deficient practice has resolved. Director of Nursing or designee will bring the results of these audits to QAPI for 3 cycles or until deficient practice has resolved.

********************************* OAR 411-085-0310 Residents' Rights: Generally Refer to F552 and F584 ********************************* OAR 411-085-0360 Abuse Refer to F600 and F609 ********************************* OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F605, F757 ********************************* OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 ********************************* OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ********************************* OAR 411-086-0150 Smoking Refer to F689 ********************************* OAR 411-086-0240 Social Services Refer to F699 ********************************* OAR 411-086-0260 Pharmaceutical Services Refer to F756 ********************************* OAR 411-086-0220 Rehabilitative Services Refer to F825 *********************************

Based on interview and record review it was determined the facility failed to determine if residents had or wished to formulate an advance directive upon admission to the facility for 3 of 3 sampled residents (#s 9, 18 and 56) reviewed for advance directives. This placed residents at risk for not having their health care wishes honored. Findings include: 1. Resident 9 was re-admitted to the facility in 6/2023 with a diagnosis of suicidal ideations. A review of Resident 9's clinical record revealed no evidence the resident had an advance directive or wished to formulate an advance directive upon admission to the facility. On 1/12/24 at 10:57 AM Staff 3 (Social Services Director/Administrator in Training) was asked to provide evidence Resident 9 was asked if she/he had, or wished to formulate, an advance directive on admission to the facility. No additional information was provided. 2. Resident 18 was re-admitted to the facility in 12/2022 with a diagnosis of stroke. A review of Resident 18's clinical record revealed no evidence the resident had an advance directive or wished to formulate an advance directive upon admission to the facility. On 1/12/24 at 10:57 AM Staff 3 (Social Services Director/Administrator in Training) was asked to provide evidence Resident 18 was asked if she/he had, or wished to formulate, an advance directive on admission to the facility. No additional information was provided. 3. Resident 56 was admitted to the facility in 7/2023 with a diagnosis of stroke. A review of Resident 56's clinical record revealed no evidence the resident had an advance directive or wished to formulate an advance directive upon admission to the facility. On 1/12/24 at 10:57 AM Staff 3 (Social Services Director/Administrator in Training) was asked to provide evidence Resident 56 was asked if she/he had, or wished to formulate, an advance directive on admission to the facility. No additional information was provided.

Assistant Administrator or designee will meet with resident 9 and/or resident representative to discuss their wishes to formulate an advance directive, assist as needed with the process, and document and care plan as such. Assistant Administrator or designee will meet with resident 18 and/or resident representative to discuss their wishes to formulate an advance directive, assist as needed with the process, and document and care plan as such. Assistant Administrator or designee will meet with resident 56 and/or resident representative to discuss their wishes to formulate an advance directive, assist as needed with the process, and document and care plan as such. All residents are at risk for being impacted by this deficient practice. Administrator or designee will review the Advance Directive policy with the IDT initially, and then again at least annually. Assistant Administrator or designee will audit all residents' charts for advance directives and if one is not present, discuss the residents' and/or resident representative's wishes to formulate an advance directive, assist as needed with the process, and document and care plan. Assistant Administrator or designee will audit each resident record for advance directives or their wishes on advance directives quarterly, and with with any significant change, assist in the process to complete an advance directive if they wish and document as such. DNS or designee will audit 2 resident records weekly times 4 weeks and then 10% of resident records quarterly, thereafter, ensuring that the resident and or resident representative wishes to have and/or complete an advance directive is present, documented, and care planned. Assistant Administrator or designee will bring results of the audit to QAPI. DNS or designee will bring results of this review to QAPI quarterly, for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 2 of 4 sampled residents (#s 36 and 50) reviewed for hospitalizations. This placed residents at risk of lack of access to an advocate to inform them of their options and rights, and a decreased quality of life. Findings include: 1. Resident 36 was admitted to the facility in 5/2022 with a diagnosis of bipolar schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). A review of Resident 36's 10/11/23 Quarterly MDS Assessment revealed she/he was cognitively intact. A review of Resident 36's nursing progress notes revealed she/he was discharged to the hospital on 6/28/23 due to hypokalemia (low blood potassium level) and was readmitted to the facility on 7/3/23. No evidence was found in Resident 36's health record to indicate a transfer notice with appeal rights was provided in writing to her/him or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. On 1/16/24 at 3:29 PM Staff 2 (DNS) confirmed the facility did not provide residents or their representatives with transfer documents, nor was the Office of the State Long-Term Care Ombudsman notified when they were discharged to the hospital. Staff 2 stated she expected these documents to be provided to residents or their representatives as well as the State Ombudsman's office upon discharge from the facility. 2. Resident 50 was admitted to the facility in 9/2022 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 50's 12/15/23 Quarterly MDS Assessment revealed she/he was cognitively intact. A review of Resident 50's medical records revealed she/he was discharged to the hospital on 11/30/23 due to a bilateral pulmonary embolism (a blood clot in the lungs blocking blood flow) and was readmitted to the facility on 12/3/23. No evidence was found in Resident 50's health record to indicate a transfer notice with appeal rights was provided in writing to her/him or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. On 1/16/24 at 3:29 PM Staff 2 (DNS) confirmed the facility did not provide residents with transfer documents, nor was the Office of the State Long-Term Care Ombudsman notified when they were discharged to the hospital. Staff 2 stated she expected these documents to be provided to residents or their representatives as well as the State Ombudsman's office upon discharge from the facility.

Charge nurse or designee will provide a copy of the bed hold/transfer document for resident 36 for any future transfers/hospitalizations, with Ombudsman notification. Charge nurse or designee will provide a copy of the bed hold/transfer document for resident 50 for any future transfers/hospitalizations, with Ombudsman notification. All residents are at risk for being impacted by this deficient practice. DNS will hold an all-nursing meeting and review the transfer/bed hold policy. DNS will review the transfer/bed hold policy and Ombudsman notification with the IDT team. Charge nurse or designee will notify the Ombudsman of all transfers and discharges weekly. DNS or designee will audit all resident transfers/discharges to ensure that the the transfer document was completed, and that the Ombudsmsan notification was completed, daily in the clinical meeting. DNS or designee will bring the results of the audit to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed-hold policy at the time of transfer to the hospital for 2 of 4 sampled residents (#s 36 and 50) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: The facility's 11/28/17 Bed-Hold Readmission policy indicated "Facilities are required by Federal regulation to have policies addressing holding a resident's bed during periods of absence such as hospitalization or therapeutic leave. Additionally, facilities provide this written information about these policies to residents prior to and upon transfer for such absences." 1. Resident 36 was admitted to the facility in 5/2022 with a diagnosis of bipolar schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). A review of Resident 36's 10/11/23 Quarterly MDS Assessment revealed she/he was cognitively intact. A review of Resident 36's nursing progress notes revealed she/he was discharged to the hospital on 6/28/23 due to hypokalemia (low blood potassium level) and was readmitted to the facility on 7/3/23. On 1/9/24 at 2:22 PM Resident 36 stated she/he was admitted to the hospital in 2023 but was not told by facility staff they would hold her/his room until she/he returned to the facility. No evidence was found in Resident 36's health records to indicate the facility provided her/him with written notification of their bed hold policy. On 1/16/24 at 3:29 PM Staff 2 (DNS) stated the facility did not provide residents with written notification of the facility's bed hold policy at the time they discharged to the hospital. She confirmed she expected these documents to be provided to residents upon discharge from the facility. 2. Resident 50 was admitted to the facility in 9/2022 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 50's 12/15/23 Quarterly MDS Assessment revealed she/he was cognitively intact. On 1/9/24 at 12:55 PM Resident 50 reported she/he was sent to the hospital in 12/2023, but did not recall the details of her/his transfer or if the facility provided documentation of their bed hold policy. A review of Resident 50's medical records revealed she/he was discharged to the hospital on 11/30/23 due to a bilateral pulmonary embolism (a blood clot in the lungs blocking blood flow) and was readmitted to the facility on 12/3/23. No evidence was found in Resident 50's health records to indicate the facility provided her/him with written notification of their bed hold policy. On 1/16/24 at 3:29 PM Staff 2 (DNS) stated the facility did not provide residents with written notification of the facility's bed hold policy at the time they discharged to the hospital. She confirmed she expected these documents to be provided to residents upon discharge from the facility.

Charge nurse or designee will provide a copy of the bed hold/transfer document for resident 36 for any future transfers/hospitalizations/therapeutic leave. Charge nurse or designee will provide a copy of the bed hold/transfer document for resident 50 for any future transfers/hospitalizations/therapeutic leave. All residents are at risk for being impacted by this deficient practice. DNS will hold an all-nursing meeting and review the transfer/bed hold policy. DNS will review the transfer/bed hold policy with the IDT team. Charge nurse or designee will notify the Ombudsman of all transfers and discharges weekly. DNS or designee will audit all resident transfers or therapeutic leaves to ensure that the the transfer document was completed. DNS or designee will bring the results of the audit to QAPI for 3 cycles or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 1 sampled resident (#59) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 59 was admitted to the facility in 6/2023 with a diagnosis of schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). The resident was discharged from the facility on 10/18/23 as a resident initiated discharge. A review of Resident 59's medical record indicated there was no discharge summary documentation. On 1/12/24 at 3:29 PM Staff 2 (DNS) was not able to provide documentation of a discharge summary for Resident 59. Staff 2 stated the facility did not discharge residents often and did not have a great discharge process in place.

Resident 59 has discharged. All residents are at risk for being impacted by this deficient practice. DNS will hold an all-nursing meeting to review the discharge process, and the importance of completing a discharge summary that is provided with the resident when they discharge. DNS or designee will audit all resident's records who are discharging, prior to discharge through the daily clinical meeting to ensure that the discharge transfer forms are completed prior to discharge. If not completed within 24 hours of discharge, will instruct to do so. DNS or designee will bring the results of the audit to QAPI for 3 cycles or until deficient practices has resolved.

Based on interview and record review it was determined the facility failed to ensure resident's records were complete and accurate for 1 of 1 sampled resident (#56) reviewed for change of condition. This placed residents at risk for incomplete clinical records. Findings include: Resident 56 was admitted to the facility in 7/2023 with a diagnosis of dementia. A Progress Note dated 12/19/23 indicated the resident was referred for hospice services but it was unclear if the referral was completed. A review of Resident 56's clinical record revealed no documentation of a hospice evaluation and determination. On 1/12/24 at 11:04 AM Staff 2 (DNS) verified the hospice services evaluation was not in Resident 56's clinical record.

Assistant Administrator or designee will request a copy of the Hospice referral and denial for resident 56 to be placed in the record. DNS or designee will complete a summary note of reasoning for referral and denial, and update care plan accordingly as needed. All residents are at risk for being impacted by this deficient practice. DNS will hold an all-nursing meeting to review change of conditions and outside provider referrals with follow up and proper documentation. DNS or designee will audit residents with changes of condition or outside referrals through the daily clinical meeting to ensure that follow up and documentation is in the resident record. If not, will follow up accordingly. DNS or designee will bring the results of the audit to QAPI for 3 cycles or until deficient practices has resolved.

Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 3 of 3 sampled residents (#s 42, 55 and 58) reviewed for binding arbitration agreement. This placed residents at risk of being uninformed regarding their legal rights. Findings include: The facility's undated Admission Agreement included the following: "The Resident and/or Legal Representative understands that his Arbitration Agreement may be rescinded by giving written notice to the Facility within 10 days of its execution, this Arbitration of its execution. If not rescinded within 10 days of its execution, this Arbitration Agreement shall remain in effect for all claims arising out of the Resident's stay at the Facility. If the acts underlying the dispute are committed prior to the revocation date, this Arbitration Agreement shall be binding with respect to said acts." "THE UNDERSIGNED ACKNOWLEDGE THAT EACH OF THEM HAS READ THIS ARBITRATION AGREEMENT AND UNDERSTANDS THAT BY SIGNING THIS ARBITRATION AGREEMENT EACH HAS WAIVED HIS/HER RIGHT TO A TRIAL, BEFORE A JUDGE OR JURY, AND THAT EACH OF THEM VOLUNTARILY CONSENTS TO ALL OF THE TERMS OF THE ARBITRATION AGREEMENT." 1. Resident 42 was admitted to the facility in 10/2023 with a diagnosis of schizophrenia (a mental health disorder). Resident 42's 11/1/23 Admission MDS indicated the resident was moderately cognitively impaired. On 1/16/23 at 1:58 PM Resident 42 stated she/he could not recall signing paperwork and did not know what the arbitration agreement was. As of 1/17/23 there was no signed arbitration agreement in Resident 42's chart. On 1/16/23 at 2:30 PM Staff 3 (Social Services Director/Administrator in Training) stated she was responsible for reviewing and explaining the facility binding arbitration agreement with the residents. Staff 3 stated the Arbitration Agreement was hard to explain to residents, so she simplified the information so residents could understand the arbitration process. When asked about the resident's right to withdraw the Arbitration Agreement within 30 days of signature, Staff 13 stated she was not familiar with that information and thought it was 10 days like the Admission Agreement stated. 2. Resident 55 was admitted to the facility in 5/2023 with a diagnosis of schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). Resident 55's 8/10/23 Quarterly MDS indicated the resident was moderately cognitively impaired. On 1/16/23 at 2:06 PM Resident 55 stated she/he could not remember anything about an arbitration agreement or signing one. As of 1/17/23 there was no signed arbitration agreement in Resident 55's chart. On 1/16/23 at 2:30 PM Staff 3 (Social Services Director/Administrator in Training) stated she was responsible for reviewing and explaining the facility binding arbitration agreement with the residents. Staff 3 stated the Arbitration Agreement was hard to explain to residents, so she simplified the information so residents could understand the arbitration process. When asked about the resident's right to withdraw the Arbitration Agreement within 30 days of signature, Staff 13 stated she was not familiar with that information and thought it was 10 days like the Admission Agreement stated. 3. Resident 58 was admitted to the facility in 8/2023 with a diagnosis of frontotemporal neurocognitive disorder (brain damage). Resident 58's 8/29/23 Admission MDS indicated the resident was cognitively intact. On 1/16/23 at 2:15 PM Resident 58 stated the facility asked her/him about "a lot of stuff", but could not remember anything about an arbitration agreement. As of 1/17/23 there was no signed arbitration agreement in Resident 58's chart. On 1/16/23 at 2:30 PM Staff 3 (Social Services Director/Administrator in Training) stated she was responsible for reviewing and explaining the facility binding arbitration agreement with the residents. Staff 3 stated the Arbitration Agreement was hard to explain to residents, so she simplified the information so residents could understand the arbitration process. When asked about the resident's right to withdraw the Arbitration Agreement within 30 days of signature, Staff 13 stated she was not familiar with that information and thought it was 10 days like the Admission Agreement stated.

Assistant Administrator or designee will review arbitration agreement with resident 42 and/or resident representative for understanding and signature. Assistant Administrator or designee will review arbitration agreement with resident 55 and/or resident representative for understanding and signature. Assistant Administrator or designee will review arbitration agreement with resident 58 and/or resident representative for understanding and signature. All residents are impacted by this deficient practice. RN Consultant or designee will review Arbitration policy and agreement with the IDT to include Assistant Administrator. Assistant Administrator or designee will complete a full house audit of all residents to ensure all residents have a signed arbitration agreement and if not, complete these agreements with all residents and or resident's representatives impacted. Administrator or designee will do a 10% audit monthly of all current in-house residents as well as audit 100% of all new admits as admitted, to ensure arbitration agreements are in place. Assistant Administrator or designee will bring results of the audit for QAPI. Administrator or designee will bring the results of the audit to QAPI for 3 cycles or until deficient practices have resolved.

Based on interview and record review it was determined the facility failed to complete reference checks for 2 of 5 sampled staff (#s 4 and 5) reviewed for reference checks. This placed residents at risk for abuse. Findings include: A review of the facility's new hires from 9/10/23 through 1/15/24 revealed the following: -Staff 4 (CNA) was employed on 12/27/23. -Staff 5 (CNA) was employed on 10/15/23. No evidence was found to verify reference checks were completed for Staff 4 and Staff 5 prior to employment. On 1/16/24 at 12:40 PM Staff 9 (HR/Payroll Coordinator) acknowledged the absence of completed reference checks for Staff 4 and Staff 5. Staff 9 confirmed reference checks were to be completed prior to employment.

All residents are at risk for being impacted by this deficient practice. HR Director/designee will ensure that all prospective employees provide references that can be contacted and reached. If unable to reach provided references, the HR Director will ask the prospective employee to provide new references that can be contacted and reached. HR Director/designee will ensure that reference checks are completed and documented for all prospective employees prior to employment. HR Director will audit all newly hired employees records weekly to ensure that reference checks have been completed. HR Director/designee will bring the results of the audit to QAPI for 3 cycles or until deficient practices have been resolved.

********************************* OAR 411-086-0040 Admission of Residents Refer to F578 ********************************* OAR 411-088-0080 Notice Requirements Refer to F623 ********************************* OAR 411-088-0050 Right to Return from Hospital Refer to F625 ********************************* OAR 411-086-0160 Nursing Services: Discharge Summary Refer to F661 ********************************* OAR 411-086-0300 Clinical Records Refer to F842 ********************************* OAR 411-086-0110 Administrator Refer to F847 *********************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/07/2023 and 08/13/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/08/2023 and 05/14/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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

Based on observations, interview and record review it was determined the facility failed to ensure residents were free from abuse for 2 of 4 sampled residents (#s 11 and 41) reviewed for abuse. This placed residents at risk for physical abuse by other residents. Findings include: 1. The facility's Preventing Abuse Policy and Procedure revised on 7/13/18 revealed the facility had a process to prevent abuse which included monitoring residents with behaviors. Resident 41 was admitted to the facility in 11/2021 with diagnoses including Parkinson's disease and schizophrenia. Resident 41's 9/2022 Quarterly MDS assessment revealed she/he had a BIMS of 15 (cognitively intact). Resident 42 was admitted to the facility in 1/2021 with diagnoses including aphasia (a loss of ability to understand or express speech) after having a stroke. Resident 42's 7/2022 Annual MDS assessment revealed she/he had a BIMS of 15 (cognitively intact). The facility's 10/15/22 Resident to Resident Event Assessment revealed on 10/15/22 at 4:46 PM Resident 41 reported to staff she/he was hit by Resident 42 and her/his head hurt. Resident 42 indicated she/he hit Resident 41 because she/he did not want Resident 41 to sit by her/him. A 10/15/22 progress note written at 5:37 PM by Staff 5 (LPN) revealed staff informed her of an altercation in the dining hall between Residents 41 and 42. Resident 41 stated her/his head hurt and pointed to the left side of her/his head. Staff 5 noted a red abrasion/scratch approximately 0.5 x 0.2 x 0 cm. On 11/29/22 at 1:31 PM Resident 41 was observed sitting at a table in the dining hall and stated "Yea I've been hit. Staff helped. I didn't need to go to the hospital but it hurt like heck. He hit me right on the head." On 11/30/22 at 9:40 AM Resident 42 was observed laying in bed and refused to be interviewed. On 11/30/22 at 4:09 PM Staff 2 (DNS) stated Resident 42 didn't use her/his words and hit Resident 41 instead. Staff 2 stated it was her expectation residents were free from abuse. On 12/1/22 at 2:35 PM Staff 3 (CNA) stated Resident 41 informed him Resident 42 hit her/him in the head. Staff 3 stated Resident 41 pointed to an area just to the side and above her/his ear. Staff 3 stated he asked Resident 42 if she/he hit Resident 41. Resident 42 said "Yea. I don't want him to sit by me." On 12/1/22 at 4:40 PM Staff 5 (LPN) stated a CNA reported Residents' 41 and 42 had a fight. She stated she assessed Resident 41 and found she/he did not have an injury. Staff 5 stated Resident 42 admitted she/he hit Resident 41. 12/2/22 3:45 PM Staff 1 (Administrator) was informed of the findings and had no additional information to provide. 2. Resident 11 was admitted to the facility in 4/2022 with diagnoses including schizophrenia and bipolar disorder. Resident 11's 9/14/22 Significant Change MDS assessment revealed she/he was not assessed for BIMS due to being rarely or never understood. Resident 29 was admitted to the facility in 11/2021 with diagnoses including dementia with behavioral disturbance. Resident 29's 9/23/22 Quarterly MDS assessment revealed she/he had a BIMS of 06 (severe cognitive impairment). A 10/26/22 progress note revealed Resident 29 hit Resident 11 on the head with a closed fist and tried to pull Resident 11's hair. The facility's 10/28/22 Resident to Resident Event Assessment revealed Residents 11 and 29 were in the day area. Resident 29 attempted to "get by" Resident 11. Resident 11 refused to move. Resident 29 hit Resident 11 on the side of the head with a closed fist and attempted to pull Resident 11's hair. Resident 29 indicated Resident 11 was in her/his way and would not move. The assessment revealed Resident 29 had a history of altercations with Resident 11. Resident 29 was quick to react when frustrated and would verbally and physically strike out at others. On 11/30/22 and 12/1/22 Resident 11 was in her/his bed and refused to be interviewed. On 11/30/22 at 4:09 PM Staff 2 (DNS) stated Resident 29 had a history of aggression towards others and confirmed Resident 11 was hit by Resident 29 on 10/26/22. She stated she expected residents to be free from abuse. On 12/01/22 at 2:35 PM Staff 3 (CNA) stated he witnessed the incident between Resident 29 and Resident 11. Resident 29 and Resident 11's wheelchair wheels meshed together and Resident 29 hit Resident 11. Staff 3 stated he got between the two residents, stepped in and blocked the residents from hitting each other. On 12/01/22 at 4:30 PM Staff 4 (LPN) stated she witnessed Residents' 11 and 29's wheelchairs lock up and then Resident 29 hit Resident 11. She said CNA's ran over to help to separate the residents to prevent further fighting. On 12/2/22 at 4:00 PM Staff 1 (Administrator) was informed of the findings and had no further information to provide.

RCM or designee will ensure that resident #11 care plan is reviewed to ensure proper safety measures. RCM or designee will ensure that resident #41 care plan is reviewed to ensure proper safety measures. All residents are at risk for being impacted by this deficient practice. IDT will review the High-Risk Behavior Management Program and residents on the program for needed changes and or additions. Residents who have altercations with other residents who do not meet the criteria for the High-Risk Behavior Management Program will be monitored monthly for three months by the IDT in order to minimize risk and add additional interventions if needed. This monitoring will be discontinued after the three months if current active interventions are found to be effective. The High-Risk Behavior Management grid will be reviewed in Standup daily by the Assistant Administrator or designee and then any changes will be communicated to the nursing team. If a resident gets involved in a resident to resident altercation the IDT will review the incident and make a referral to the Mental Health Nurse Practitioner for further evaluation and intervention as well as updating the High-Risk Behavior Management Grid accordingly. Assistant Administrator or designee will review the High-Risk Behavior Management Program and importance of increased supervision and oversight in common areas, and dining rooms at All Staff in-service. Assistant Administrator or designee will do a weekly audit to observe dining areas and common areas and identify any potential concerns. Assistant Administrator or designee will bring the results of these audits to QAPI for three months or until deficient practice has resolved.

Based on observation, interview and record review it was determined the facility failed to ensure the environment was free from potential accident hazards for 2 of 2 residents (#s 48 and 51) reviewed for smoking. This placed residents at risk for potential accidents. Findings include: 1. Resident 48 was admitted to the facility in 1/2021 with diagnoses including stroke and dementia. Resident 48's care plan dated 8/1/22 identified the resident to be at risk for non-compliance related to smoking and holding smoking paraphernalia. Interventions included direction to relinquish smoking paraphernalia when Resident 48 was found smoking independently. The care plan further indicated staff were to keep all smoking paraphernalia locked up in a separate storage container for safety and encouraged Resident 48 to smoke during designated smoking times. A Smoking Assessment dated 10/25/22 indicated Resident 48 was a dependent smoker who was unable to safely hold and maintain smoking devices in a designated smoking area and dependent smokers required full staff supervision. An 11/6/22 progress note revealed Resident 48 was found smoking outside of the designated smoke time and refused to relinquish her/his smoking paraphernalia. Observations conducted between 11/29/22 and 12/7/22 revealed posted smoking times of 8:30 AM and 7:00 PM. On 11/30/22 at 9:18 AM Resident 48 stated she/he carried her/his own lighter on her/himself in the facility at all times. On 12/1/22 at 8:52 AM Staff 9 (CNA) stated Resident 48 smoked on a regular basis in the smoking area without staff supervision. Staff 9 stated she was aware Resident 48 carried a lighter in her/his pocket despite it being against facility protocol. Staff 9 stated she and other staff attempted to take the lighter away from her/him but was unsuccessful due to Resident 48's refusal. On 12/1/22 at 10:11 AM Staff 13 (RN) stated staff used their own discretion to determine if a resident could or could not smoke on their own despite this being against facility policy. Staff 13 indicated Resident 48 carried a lighter on her/himself inside the building and would frequently smoke in the smoking area outside the allotted smoke times. On 12/1/22 at 3:28 PM Staff 6 (RNCM) stated Resident 48 was assessed to be unsafe to independently carry smoking paraphernalia. Staff 6 indicated she was aware Resident 48 carried a lighter. Staff 6 stated the facility attempted to confiscate smoking materials from Resident 48 but was unsuccessful due to her/his refusal. On 12/1/22 at 4:07 PM findings were discussed with Staff 1 (Administrator) who provided no additional information. At 5:00 PM Staff 1 stated all lighters and paraphernelia were confiscated from Resident 48. 2. Resident 51 was admitted to the facility in 9/2021 with diagnoses including dementia. A Smoking Assessment dated 10/5/22 indicated Resident 51 was a dependent smoker who was unable to safely hold and maintain smoking devices in a designated smoking area and dependent smokers required full staff supervision. Resident 51's care plan dated 11/16/22 identified the resident required assistance with smoking including lighting and storing smoking paraphernalia. Interventions included direction to relinquish smoking paraphernalia when Resident 51 was found smoking independently. The care plan further indicated staff were to keep all smoking paraphernalia locked up in a separate storage container for safety and encouraged Resident 51 to smoke during designated smoking times. Observations conducted between 11/29/22 and 12/7/22 revealed posted smoking times of 8:30 AM and 7:00 PM. On 11/30/22 at 10:03 AM Resident 51 stated she/he kept a lighter on her/himself so she/he could smoke in the smoking area at her/his own leisure. On 12/1/22 at 8:34 AM Resident 51 was observed outside in the smoking area during the designated smoking time with staff present and lit her/his own cigarette. On 12/1/22 at 10:11 AM Staff 13 (RN) stated staff used their own discretion to determine if a resident could or could not smoke on their own despite this being against facility policy. Staff 13 indicated she was aware Resident 51 had a lighter on her/himself. On 12/1/22 at 4:07 PM findings were discussed with Staff 1 (Administrator) who provided no additional information. At 5:00 PM Staff 1 stated all lighters and paraphernelia were confiscated from Resident 51.

RCM or designee will review the smoking policy/acknowledgement with Resident #48 and have them resign explaining that if they do not comply that their smoking privileges could be suspended. RCM or designee will review the smoking policy/acknowledgement with Resident #51 and have them resign explaining that if they do not comply that their smoking privileges could be suspended. All residents are at risk for being impacted by this deficient practice. IDT will review all smokers to evaluate who may also need to have smoking policy/acknowledgement reviewed and resigned. Administrator or designee will hold an all staff in-service to review the smoking policy and the importance of reporting noncompliance. Administrator or designee will audit a smoke pass weekly for compliance. Administrator or designee will bring the results of these audits to QAPI for three months or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary antibiotics for 1 of 1 sampled resident (#27) reviewed for antibiotic use. This placed residents at risk for adverse medication effects and antibiotic resistance. Findings include: Resident 27 was admitted to the facility on 11/3/22 with diagnoses including schizophrenia. Resident 27's 10/28/22 Admission Orders included an order for Bactrim (antibiotic) 400-80 mg daily for UTI prophylaxis (prevention) for 90 days with a start date of 8/4/22. Resident 27's 11/2022 and 12/2022 signed physician orders revealed orders for Bactrim to start on 11/3/22 and the orders did not include a stop date for the Bactrim. Resident 27's 11/2022 and 12/2022 MARs revealed the resident received Bactrim everyday from 11/3/22 through 12/2/22 for a total of 120 days, which exceeded the prescribed duration by 31 days. On 12/2/22 at 12:16 PM Staff 6 (RNCM) reviewed Resident 27's admission order for Bactrim. Staff 6 confirmed the Bactrim order included "for 90 days with a start date of 8/4/22" and confirmed a stop date was not transcribed to Resident 27's MARs. Staff 6 stated she failed to obtain clarification of the Bactrim order from the provider and the antibiotic was administered beyond the ordered duration. On 12/6/22 at 1:07 PM Staff 2 (DNS) stated new admission orders were checked using a two nurse system. Staff 2 confirmed the stop date was not included on the physician order and MARs and Resident 27 received the Bactrim beyond the prescribed duration.

Resident # 27 antibiotics were discontinued. All residents are at risk for being impacted by this deficient practice. Operational Consultant or designee will hold an in-service with the DNS, RCM, and RCC to review the AB Stewardship Policy as well as the protocol for the 24-hour follow-through process to review all new orders to ensure they are thorough and complete to include stop dates. DNS or designee will audit all new orders for AB TX through standup process to ensure they are thorough and complete to include stop dates. DNS or designee will bring the results of these audits to QAPI for three months or until deficient practice has resolved.

Based on observation, interview and record review it was determined the facility failed to honor food choices for one of two sampled residents (#32) reviewed for choices. This placed residents at risk of not being allowed to make choices related to their food preferences. Findings include: Resident 32 was admitted to the facility in 12/2020 with diagnoses including schizoaffective disorder, bipolar type (a mental health disorder which includes episodes of mania and sometimes major depression). On 11/29/22 at 1:49 PM Resident 32 stated she/he did not like scrambled eggs. She/he stated she/he told caregivers she/he did not like eggs and could not eat them but the kitchen continued to give her/him scrambled eggs. On 12/1/22 at 8:17 AM Resident 32 was observed in her/his room with breakfast. Her/his tray contained scrambled eggs. Resident 32 stated she/he spoke with Staff 8 (Social Service Manager) about her/his food preferences and dislike for eggs. A review of Resident 32's 12/2/22 meal tickets revealed scrambled eggs listed as an item the resident disliked. On 12/2/22 at 1:14 PM Staff 12 (Culinary Manager) stated he used resident information from the resident's health record to create a list of dietary preferences. Staff 12 stated resident dietary preferences were included on each meal ticket so the kitchen staff were aware of them when they prepared each tray and confirmed eggs were listed as food dislikes on Resident 32's meal ticket. Staff 12 stated Resident 32 "absolutely has the right to choose" and her/his breakfasts should not contain eggs.

Resident #32 dietary likes and dislikes will be re-reviewed by the Dietary Manger or designee. Dietary Manger or designee will ensure that dislikes are on the diet tray card and the resident care plan. All residents are at risk for being impacted by this deficient practice. Dietary Manager or designee will hold an in-service with dietary staff on the importance of ensuring that an alternative is provided if a disliked item is served. Dietary Manager or designee will do a 10% audit weekly to ensure diet tray card matches the meal served. Dietary Manager or designee will bring the results of these audits to QAPI for three months or until deficient practice has resolved.

Based on interview and record review it was determined the facility failed to ensure accurate resident medical records for 2 of 2 sampled residents (#s 11 and 46) reviewed for pre-admission screening with serious mental illness. This placed residents with mental health diagnoses at risk for a lack of appropriate mental health services. Findings include: A PASRR (Preadmission Screening and Resident Review) Level I is an assessment completed prior to admission to a Medicaid Certified Nursing Facility to determine if an individual has a mental illness or intellectual disability. 1. Resident 11 was admitted to the facility on 4/21/22 with diagnoses including schizophrenia and bipolar disorder. The signed 4/20/22 Pre-Admission Screening/Resident Review (PASRR) Level 1 form revealed Resident 11 had no serious mental illness indicators. The 4/20/22 Admission MDS assessment revealed Resident 11 was diagnosed with schizophrenia and bipolar disorder diagnoses and she/he received antipsychotics. On 12/1/22 at 5:00 PM Staff 1 (Administrator) stated Resident 11 was admitted to the facility from the Veteran's Administration (VA) hospital. He stated a lot of the time the VA does the PASRR Level 1 paperwork the day the resident was admitting and it may not be accurate. On 12/2/22 at 3:07 PM Staff 8 (Social Services Manager) stated the resident's schizophrenia and bipolar disorder diagnoses were accurate. She confirmed the PASRR Level I form was completed incorrectly. On 12/2/22 at 3:45 PM Staff 1 was informed of the findings. He had no additional information to provide . , 2. Resident 46 was admitted on 5/19/22 with diagnoses including schizoaffective disorder, bipolar type (a condition that causes hallucinations, delusions, mania and depression). Resident 46's PASRR Level I form dated 5/18/22 revealed Resident 46 had no indications of serious mental illness. On 12/5/22 at 11:34 AM Staff 8 (Social Services Manager) confirmed Resident 46's PASRR Level I was not accurrate.

Assistant Administrator or designee will submit a PASRR level 2 screen for resident #11. Assistant Administrator or designee will submit a PASRR level 2 screen for resident #46. All residents are at risk for being impacted by this deficient practice. Assistant Administrator or designee will complete a full house audit to ensure all who need a PASRR level 2 screen will be identified. Assistant Administrator or designee will submit all residents who are identified as needing a PASRR level 2 screen. Assistant Administrator or designee will review PASRR policy and update accordingly. Assistant Administrator or designee will audit each new admit and or residents starting on new psychotropic medications which could trigger an identifiable diagnosis requiring a PASRR level 2 screen. Assistant Administrator or designee will bring the results of these audits to QAPI for three months or until deficient practice has resolved.

Based on observation, interview and record review it was determined the facility failed to ensure staff performed appropriate and adequate hand hygiene during meal delivery for 1 of 2 halls observed during dining. This placed residents at risk for infection. Findings include: The Centers for Disease Control and Prevention (CDC) website section titled, "Hand Hygiene in Healthcare Settings" indicated healthcare personnel should use an alcohol based hand rub (ABHR) or wash with soap and water immediately after touching a patient and the patient's immediate environment. Healthcare facilities should require healthcare personnel to perform hand hygiene in accordance with CDC recommendations. The facility's 2/11/22 Hand Hygiene Policy and Procedure indicated hand hygiene was the single most important procedure for preventing the spread of infection. Hand hygiene consists of either washing with soap and water or ABHR. Opportunities for hand hygiene included before entering a resident room, before preparing food and before handling food. On 11/29/22 from 11:30 AM to 11:38 AM Staff 9 (CNA), Staff 10 (CNA) and Staff 11 (CNA) delivered meal trays to rooms one through eight, for a total of 24 residents. During the meal tray delivery, Staff 9, Staff 10 and Staff 11 touched items within each of the residents' immediate environment and moved items on the residents' overbed tables to clear a space for the meal dishes, utensils and drinkware. Staff 9, Staff 10 and Staff 11 touched the residents' individual privacy curtains, television remotes and other personal items. Upon completion of each resident's meal delivery, Staff 9, Staff 10 and Staff 11 exited the room, opened the meal delivery cart and retrieved the next resident's meal tray. Throughout the meal delivery observation, Staff 9 and Staff 10 performed hand hygiene one time upon exit of a room and Staff 11 did not perform hand hygiene at all. On 11/29/22 at 11:38 AM Staff 9, Staff 10 and Staff 11 confirmed they touched and moved items in each of the resident's immediate environment during the meal delivery. Staff 11 stated she did not perform hand hygiene during the meal delivery and it should have been performed between each resident. Staff 9 and Staff 10 stated they performed hand hygiene once during the meal delivery and acknowledged hand hygiene opportunities were missed between each resident. On 12/7/22 at 9:59 AM Staff 2 (DNS) was informed of Staff 9's, Staff 10's and Staff 11's lack of hand hygiene during the meal delivery and before and after handling items within each of the resident's immediate environment. Staff 2 stated she expected staff to perform hand hygiene during the meal delivery and before and after resident contact.

All residents are at risk for being impacted by this deficient practice. DNS or designee will review Hand Hygiene Policy and update accordingly. DNS or designee will review the Hand Hygiene Policy at the all-staff in-service. Assistant Administrator or designee will complete audits for hand hygiene compliance weekly. Assistant Administrator or designee will bring the results of these audits to QAPI for three months or until deficient practice has resolved.

****************************** OAR 411-085-0360 - Abuse Refer to F600 ****************************** OAR 411-086-0140 - Nursing Services: Problem Resolution & Preventative Care Refer to F689 and F757 ****************************** OAR 411-085-0370 - Confidentiality Refer to F842 ****************************** OAR 411-086-0250 Dietary Services Refer to F806 ****************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ******************************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/25/2022 and 07/31/2022, 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 07/18/2022 and 07/24/2022, 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 observation, interview and record review, it was determined the facility failed to protect 4 out of 9 (#s 2, 3, 8 and 9) residents reviewed for abuse. This placed other residents at risk for abuse. Findings include: The facility's Abuse Prevention policy, revised on 5/2022 stated "...Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation." Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. 1. Resident 8 was admitted to the facility in 4/2015 with diagnoses including dementia with behavioral disturbance and chronic respiratory failure. Resident 8's most recent MDS dated 4/2022 revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident 8's care plan dated 3/21/22 revealed she/he had cognitive deficits including severe memory loss and behaviors which included asking to smoke frequently even though she/he quit smoking several years ago. Resident 7 was admitted to the facility in 7/2021 with diagnoses including dementia with behavioral disturbance and chronic kidney disease. Resident 7's most recent MDS dated 4/2022 revealed a BIMS score of 5, indicating severe cognitive impairment. Resident 7's care plan dated 3/23/22 revealed she/he had cognitive deficits in memory, judgment, decision making and thought processes related to dementia and inappropriate behaviors which included verbal aggression. The 6/19/22 FRI revealed on 6/19/22 at 8:00 PM, Staff 4 (RNCM) received a report from facility staff that Resident 8 was struck on her/his left upper arm by Resident 7 on the smoking patio. Resident 8 was immediately interviewed and told Staff 4 she/he was hit by another resident but she/he did not know who the resident was. Resident 8 was unable to recall what happened immediately prior to the incident due to severe short term memory loss. Other residents on the smoking patio revealed Resident 8 was in her/his wheelchair on the smoking patio and Resident 7 was seen behind her/him trying to "mess" with Resident 8's oxygen tank. Resident 8 turned around, saw Resident 7 and swung her/his arm at Resident 8 but missed. Resident 7 then hit Resident 8 on her/his left arm. Resident 7 was observed to have a reddened area to her/his left upper arm indicative of fresh bruising and she/he reported the area was tender to touch. Observations were made of Resident 8 on 6/28/22 and 6/29/22. She/he was seated in a wheelchair and was observed ambulating throughout the facility and on the facility grounds. Observations were made of Resident 7 on 6/28/22 and 6/29/22. She/he was observed in bed on both days. On 6/29/22 at 1:30 PM, Resident 8 was interviewed and did not recall the incident. On 6/29/22 at 1:50 PM, Resident 7 refused to be interviewed. On 6/29/22 at 2:00 PM, Staff 4 was interviewed and revealed Resident 8 had a "five second memory" and told a CNA someone hit her/him. When Resident 8 was brought upstairs, she/he couldn't remember who hit her/him or why. Staff 4 stated Witness 1 (anonymous) and Witness 2 (anonymous) were in the hallway and told her what happened. Staff 4 and Staff 1 (Administrator) watched the video of the incident and saw Resident 7 doing something on the back of Resident 8's wheelchair. Resident 8 was struck by Resident 7. Staff 4 revealed there was a red circle on Resident 8's arm where she/he was struck which turned into a bruise. On 6/29/22 at 3:27 PM, Witness 1 was interviewed and revealed Resident 8 went to the smoking patio every day because she/he wanted to smoke. The residents who smoked knew Resident 8 couldn't smoke and "shooed" her/him away because they could not smoke until Resident 8 left the patio area. Resident 7 harassed Resident 8 and she/he swung at Resident 7. On 6/29/22 at 3:42 PM, Witness 2 was interviewed and revealed Resident 7 and Resident 8 were seated on the smoking patio. Resident 7 started "messing" with Resident 8's oxygen tank and Resident 8 turned around and swung at Resident 7. Resident 7 then hit Resident 8 on the arm. On 6/29/22 at 3:51 Staff 2 (DNS) confirmed the resident to resident incident occurred, resulting in a bruise to Resident 8's arm. , 2. Resident 2 admitted to the facility in 7/2021 with diagnoses including bipolar disorder (mental condition marked by periods of elation and depression) and dementia with behavioral disturbance. Resident 2's 2/4/22 Quarterly MDS indicated she/he presented with severe impaired cognitive skills, experienced delusions, and physical and verbal behaviors towards others. Resident 8 admitted to the facility in 2017 with diagnoses including dementia with behavioral disturbance and major depression. Resident 8's 1/23/22 Quarterly MDS indicated her/his BIMS score of 9 (moderately impaired), experienced delusions and verbally threatened others daily. Resident 2's progress note on 3/5/22 at 8:22 PM written by Staff 5 (LPN), revealed she heard "Fuck You!" and a "smacking noise" from the hallway. Staff 5 went to assess and observed Staff 10 (CNA) pulled Resident 8 away from Resident 2. Resident 8 jolted forward in her/his wheelchair and smacked Resident 2 with her/his right hand across the neck. Staff 10 reported to Staff 5 that Resident 8 attempted to use the restroom and was told the restroom was occupied. Resident 8 backed up her/his wheelchair into Resident 2's wheelchair on accident. Resident 2 told Resident 8 "Don't do that." Then Resident 8 shouted "Fuck You!" and Resident 2 proceeded to strike Resident 8 on the mouth. Resident 8 then jolted forward to hit Resident 2 on the left side of Resident 2's neck. The residents were separated immediately, Staff 5 assessed both residents to have no injuries and placed both residents on alert for monitoring. Staff 5 initiated 15-minute checks on each resident. On 6/27/22 at 3:03 PM, 6/28/22 at 9:30 AM, 6/29/22 between 1:40 PM and 3:21 PM, Resident 2 was observed in her/his room, in the hallways self-propelling her/his wheelchair, around other staff and residents with no physical behaviors observed. In an interview on 6/28/22 at 9:54 AM, Resident 8 was unable to recall the incident between her/himself and Resident 2. Resident 8 expressed she/he felt safe in the facility and expressed no concerns. On 6/29/22 at 1:40 PM, an attempt was made to interview Resident 2 who was unable to answer questions. On 6/29/22 at 3:15 PM, Resident 8 was observed to self-propel her/his wheelchair in the hallways, while staff and other residents passed by. On 6/29/22 at 2:01 PM, Staff 5 recalled the incident on 3/5/22 between Resident 2 and Resident 8. Staff 5 confirmed the information written in the 3/5/22 progress note and the incident report. No additional information was provided. During an interview on 6/29/22 at 3:55 PM, Staff 2 (DNS) acknowledged the incident between Resident 2 and Resident 8. 3. Resident 2 admitted to the facility in 7/2021 with diagnoses including bipolar disorder (mental condition marked by periods of elation and depression) and dementia with behavioral disturbance. Resident 2's 5/7/22 Quarterly MDS indicated she/he presented with severe impaired cognitive skills, experienced delusions and physical and verbal behaviors towards others. Resident 9's 4/28/22 Admission MDS indicated her/his BIMS score of 15 (cognitively intact). A progress note on 5/14/22 at 7:45 PM by Staff 12 revealed Resident 2 rolled up to Resident 9 and punched her/ him in the chest three times. Resident 2 stated she/he was calling police because Resident 9 was a bad person. The 5/18/22 Resident to Resident Event Assessment form, signed by Staff 2 (DNS), indicated Resident 2 was sitting at the dining room table and rolled up to Resident 9 and hit her/him three times in the chest, unprovoked. Resident 9 was assessed to have no physical injuries and stated she/he was taken by surprise. On 6/27/22 at 3:03 PM, 6/28/22 at 9:30 AM, 6/29/22 between 1:40 PM and 3:21 PM, Resident 2 was observed in her/his room, in the hallways self-propelling her/his wheelchair, around other staff and residents with no physical behaviors observed. On 6/28/22 at 9:46 AM, Resident 9 stated she/he did not recall the incident with Resident 2, felt safe in the facility and did not fear any other people at the facility. On 6/29/22 at 2:42 PM Staff 6 (Personal Care Assistant) stated she witnessed Resident 2 hit Resident 9 three times in the chest. Resident 9 appeared surprised, but not in pain or hurt by the incident. On 6/29/22 at 3:55 PM Staff 2 acknowledged the incident between Resident 2 and Resident 9. 4. Resident 2 admitted to the facility in 7/2021 with diagnoses including bipolar disorder (mental condition marked by periods of elation and depression) and dementia with behavioral disturbance. Resident 2's 5/7/22 Quarterly MDS indicated she/he presented with severe impaired cognitive skills, experienced delusions and physical and verbal behaviors towards others. Resident 3 admitted to the facility in 12/2020 with diagnosis including schizoaffective disorder (mental health condition). Resident 3's 4/17/22 Quarterly MDS indicated her/his BIMS score of 15 (cognitively intact). The 6/9/22 Resident to Resident Event Assessment, signed by Staff 3 (RNCM), revealed on 6/7/22 at 3:00 PM, Resident 2 slapped Resident 3 on the face. On 6/27/22 at 3:03 PM, 6/28/22 at 9:30 AM, 6/29/22 between 1:40 PM and 3:21 PM, Resident 2 was observed in her/his room, in the hallways self-propelling her/his wheelchair, around other staff and residents with no physical behaviors observed. On 6/28/22 at 10:15 AM Resident 3 stated Resident 2 was her/his roommate in 6/2022. Resident 3 recalled Resident 2 pulled back the curtain divider in their room and started going through Resident 3's belongings in the drawers. Resident 3 stated she/he told Resident 2 to "stop, that is my drawer and belongings." Resident 3 recalled Resident 2 said "it was not" and then slapped Resident 3 on the right side of her/his face. Resident 3 stated it hurt but felt better later. Resident 3 was moved to another room. Resident 3 felt safe in the facility and did not think Resident 2 could remember the incident or how to find her/him. On 6/29/22 at 1:50 PM Staff 7 (Activities Assistant) recalled the incident between Resident 2 and Resident 3, confirmed the information was correct in the resident's health records with no additional information was provided. On 6/29/22 at 3:55 PM Staff 2 (DNS) acknowledged the incident between Resident 2 and Resident 3. 5. Resident 1 admitted to the facility in 11/2021 with diagnoses including dementia with behavioral disturbance and Encephalopathy (disease of the brain which alters brain function or structure). Resident 1's 4/5/22 Significant Change of Condition MDS indicated a BIMS score of 6 (severe impairment). Resident 2 admitted to the facility in 7/2021 with diagnoses including bipolar disorder (mental condition marked by periods of elation and depression) and dementia with behavioral disturbance. Resident 2's 5/7/22 Quarterly MDS indicated she/he presented with severe impaired cognitive skills, experienced delusions and physical and verbal behaviors towards others. A 6/7/22 progress by Staff 9 (LPN) revealed at about 6:54 PM she was approached by an aide who brought Resident 2 to nurses' station and stated Resident 1 "threw coffee all over" Resident 2 in the day room. Staff 9 noted Resident 2 was visibly wet on face and clothing. Staff 9 noted coffee all over floor in the middle of the day room. Resident 1 sat in a wheelchair at the far table in day room and looked towards the window. Staff 9 asked, "did you throw coffee at [her/him]?" Resident 1 responded, "yeah well [she/he] was being a bitch." ... Resident stated, "Yeah well if I had a gun I would shoot [her/him] right in the cunt and you as well." ... Resident 1 then responded, "well I served for this country and I can do whatever the hell I want." On 6/27/22 at 3:03 PM, 6/28/22 at 9:30 AM, 6/29/22 between 1:40 PM and 3:21 PM, Resident 2 was observed in her/his room, in the hallways self-propelling her/his wheelchair, around other staff and residents with no physical behaviors observed. On 6/28/22 at 9:34 AM Resident 1 was observed in her/his bed in her/his room. Resident 1 could not recall the event. On 6/29/22 at 2:37 PM Staff 9 confirmed the 6/7/22 progress note of the event between Resident 1 and Resident 2. On 6/29/22 at 4:15 PM Staff 2 (DNS) acknowledged the event between Resident 1 and Resident 2.

Resident 2 has been discharged to another permanent placement setting. Resident 3 care plan will be reviewed and updated accordingly by RCM or designee. Resident 8 care plan will be reviewed and updated accordingly by RCM or designee. Resident 9 care plan will be reviewed and updated accordingly by RCM or designee. All residents are at risk for being impacted by this deficient practice. DNS or designee will review the new Village Manor of Cascadia abuse policy and update as needed. DNS or designee will review, educate, and implement new abuse investigation process with nursing department. Administrator or designee will ensure that all employees now employed by Village Manor of Cascadia have reviewed the new Village Manor of Cascadia abuse policy. Administrator or designee will hold an all staff in-service for increased observation and redirection of residents while sharing common spaces. Interdisciplinary team will complete a full resident review for residents 3,8,and 9 to determine if they meet the criteria for the high risk resident behavior group. Interdisciplinary team will complete a full audit of all residents on the high risk behavior group and review their care plan to minimize risk while adding any needed interventions. Residents who have altercations with other residents who do not meet the criteria for the high risk behavior group will be evaluated monthly for three months by the interdisciplinary team in order to minimize risk and then discontinue from this monitoring if current active interventions are found to be effective. The high risk behavioral grid will be updated by the Assistant Administrator or designee and kept current. The high risk behavioral grid will be brought to stand up daily by the Assistant Administrator or designee and reviewed for any updates or changes needed, and then communicated with the nursing team. Nurses will chart on the residents on the high risk behavioral grid at a minimum of once per shift. If a resident gets involved in a resident to resident altercation the interdisciplinary team will review the incident and make a referral to the Mental Health Nurse Practitioner for further evaluation and intervention as well as updating the high risk behavioral grid accordingly. Social Services Director or designee will audit all residents who have had 2 or more resident to resident altercations in a month for any trends. Social Services Director or designee will bring results of the audit to QAPI monthly for three months or until 100% compliance is reached.

****************************** OAR 411-085-0360 Abuse Refer to F600 ******************************

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 01/24/2022 and 01/30/2022, 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 follow the care plan to prevent falls for 1 of 3 sampled residents (#4) reviewed for accidents. Resident 4 sustained a spinal fracture as a result of a fall. This placed residents at risk for injury. Findings include: Resident 4 admitted to the facility in 2016 with diagnoses including Alzheimer's disease. A 3/18/21 Physical Restraint/Device Record of Informed Consent revealed Resident 4 was to have a floor pressure mat alarm and seat belt alarm in place for fall preventions. A 4/10/21 Fall Assessment revealed the following: - Resident 4 was found on the ground outside on 4/10/21 at 4:00 PM - Resident 4 was to have frequent checks, wear a seatbelt with alarm while in the wheelchair, and have a floor sensor alarm in place - Resident 4 was last seen 30 minutes prior in bed when a staff member helped her/him lay down - Resident 4 was to have a floor mat with an alarm - The alarm on Resident 4's floor mat did not sound when the CNA was in the room 30 minutes before the fall - The alarm on Resident 4's floor mat was unplugged earlier in the day and it was reported but due to a language barrier the staff notified did not understand - Resident 4 got out of bed, the alarm did not sound, she/he walked out of the room, out of the side door to the building, down a ramp and fell at the bottom of the ramp where there were no hand rails - Resident 4 complained about new pain to the back of her/his head following the fall. A 4/10/21 Progress Note revealed Resident 4 fell outside on the west ramp, reported pain in her/his neck and was sent to the emergency room for evaluation. A 4/14/21 Transfer Order revealed Resident 4 returned from the hospital on 4/14/21 with a new diagnosis for a adenoid fracture (spinal fracture). In an interview on 8/5/21 at 11:43 AM Staff 18 (RN) stated he found Resident 4 outside when she/he had fallen on 4/10/21, Staff 14 did not recall if fall interventions were in place at the time of the fall. In an interview on 8/5/21 at 12:40 PM Staff 7 (RN/RCM) stated Resident 4 broke her/his neck during the fall on 4/10/21. Staff 7 stated Resident 4 was to have a floor mat plugged into an alarm, however this was unplugged prior to the fall and the staff did not know how to fix the alarm. Staff 7 stated Resident 4 was in bed at 3:30 PM on 4/10/21, was found on the ground at 4 PM, the floor alarm did not sound. Staff 7 stated Resident 4 was assessed and sent out to the hospital.

Resident 4 has since passed away. All residents are at risk for being impacted by this deficient practice. DNS reviewed and updated the Care Plan Management Policy. DNS or designee will hold a nursing meeting to review the new policy. RCM's will complete a full house audit of alarms being used, and then the IDT will review and determine need. RCM's will complete a full house audit of each resident's fall/safety care plans to ensure they are comprehensive and current. RCM's will complete their daily rounds form each scheduled day ensuring that the devices or safety measures are in place, functioning, and match the care plan interventions. Director of facility services or designee will audit monthly through the TELS system to ensure alarms are fully functioning and replace as needed. The DNS or designee will audit 10% of the residents fall/safety care plans to include ensuring any devices are functioning weekly times 4 weeks, and then monthly. DNS or designee will bring results of the audit to QAPI monthly for three months or until 100% compliance is reached.

********************************** OAR 411-086-0140: Nursing Services: Problem Resolution & Preventive Care Refer to F689 **********************************