Gracelen Care Center

Resident 1 admitted to the facility on 4/30/26 with diagnosis including monoplegia of upper limb following nontraumatic intracerebral hemorrhage (stroke) affecting left dominant side. On 5/13/26 at 12:16 PM, Resident 1 was observed to ambulate independently without an assistive device. Resident 1's care plan initiated on 4/30/26 documented Resident 1: -Had an alteration in neurological status related to monoplegia of the upper limb following a nontraumatic intracranial hemorrhage affecting left dominant side; -Was independent for ambulation and transfers and did not use an assistive device; and -Was alert and oriented times three.-á Resident 1's 4/29/26 hospital Occupational Therapy Note indicated ""with independent activities of daily living tasks in unfamiliar/novel environments, [Resident 1] struggles much more. For example, during a basic tea-making task, [Resident 1] needed mod-max direct verbal cues for safety, sequencing and decision-making."" Resident 1's 4/30/26 Elopement Assessment completed by Staff 6 (RN) documented Resident 1:-á -Was not cognitively impaired with poor decision-making skills; -Did not ambulate independently with or without the use of assistive device; and -Did not have a diagnosis of dementia, cognitive impairment or a diagnosis impacting gait and mobility. Resident 1's 5/7/26 Admission MDS documented Resident 1 was independent for mobility without an assistive device. The facility's elopement assessment incorrectly documented Resident 1 as non-ambulatory, no deficits in gait, mobility or decision-making, which was inconsistent with Resident 1's care plan, Occupation Therapy Notes and comprehensive MDS assessment. On 5/13/26 at 12:38 PM, Staff 6 stated she inaccurately documented Resident 1's 4/30/26 elopement assessment. On 5/13/26 at 2:18 PM, Staff 2 (DNS) stated Resident 1's 4/30/26 elopement assessment was inaccurate.

Resident 1 remains in facility. Resident 1’s elopement assessment was updated accurately on 5/8/26 and confirmed to be accurate on 5/13/26. Since 5/8/26 Resident 1 has had no further elopement incidents. Potential for effect to all residents. All residents will have their most recent elopement assessments reviewed for accuracy with updates made as needed. Staff 6 was provided corrective education on the appropriate assessment process for elopement assessments. All Nursing Staff will be in-serviced on the facility policy and process of accurate elopement assessments. An initial audit will be performed of all residents’ most recent elopement assessment for accuracy. An audit of 5 elopement assessments will be assesed for accuracy weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Resident 6 was admitted to the facility in 11/2024 with diagnoses including major depressive disorder. Resident 7 was admitted to the facility in 1/2026 with diagnoses including senile degeneration of the brain with anxiety and agitation. On 2/14/26 at 6:27 PM, a FRI was submitted which indicated on 2/14/26 at 10:00 AM, Resident 7 struck Resident 6 with her/his reader stick after Resident 6 wandered into Resident 7GÇÖs room looking for her/his items. -á A Progress Note on 2/14/26 at 12:28 PM, indicated Staff 7 (Social Services Director) noticed Resident 7 received assistance with a bandage to her/his knee. When asked, Resident 7 stated she/he was hit by another resident after she/he entered Resident 7GÇÖs room and approached her/him. On 3/10/26 at 12:26 PM, Staff 2 (DNS) stated she was aware of the incident of potential abuse between Resident 6 and Resident 7 and acknowledged allegations needed to be reported within 2 hours of the incident occurring. Staff 2 acknowledged the incident of potential abuse was not reported within the 2-hour time frame.-á On 3/10/26 at 2:40 PM, Staff 7 stated she wrote the incident report involving Resident 6 and Resident 7 and informed both Staff 1 (Facility Administrator) and Staff 2 of the incident on 2/14/26 after completing the incident report at approximately 12:00 PM.-á

Resident 6 remains in facility; no verbalized or observed signs of abuse were noted. Resident 7 has expired; record review shows no signs of abuse from the reported incident. Potential for effect to all residents. All residents will be interviewed about abuse from other residents and concerns addressed. The DNS will be in-serviced on the facility policy andn regulatory requirment for timely reporting of allegations of abuse. All Staff will be in-serviced on the facility policy for timely reporting allegations of abuse. An initial audit will be performed of all incident reports for allegations of abuse x30 days to determine timely reporting occured. An audit of 5 incident reports that are allegations of abuse will be assesed for timely reporting weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to ensure a residentGÇÖs change of condition was assessed in a timely manner for 1 of 1 sampled resident (#7) reviewed for accidents. This placed residents at risk for a delay of care and unmet treatment needs. Findngs include: Resident 7 was admitted to the facility in 11/2024 with diagnoses including end stage kidney disease and diabetes. Provider Notes dated 11/15/24 and 11/29/24 indicated Resident 7 was alert but tired on exam. Resident 7 was able to answer questions appropriately.-á Resident 7GÇÖs 11/29/24 Admission MDS indicated the resident had moderate cognitive impairment. A CMA Medication Administration Note dated 12/8/24 at 8:42 AM Staff 26 (CMA) indicated the following: -Resident 7 was unable to stay awake long enough to drink fluids despite cueing and redirection. -Staff 43 (RN) completed an assessment and directed Staff 26 to wait 20 minutes before reattempting medication administration. -Upon the second attempt, Resident 7 continued to fall asleep. -Medications could not be administered, and Staff 43 was notified for reassessment.-á Review of Resident 7GÇÖs medical record on 12/8/24 between 8:42 AM and 1:51 PM revealed no documentation Staff 43 performed a reassessment, checked blood sugars, or contacted the on-call provider. -áA blood pressure reading was recorded at 1:51 PM and no other vital signs were recorded. In a 12/8/24 at 2:27 PM Nursing Note the charge nurse documented Resident 7 was sent out to the hospital at 2:20 PM per the familyGÇÖs request. A 1/4/25 Hospitalist Progress Note, revealed Resident 7 had been admitted to the hospital on 12/8/24 with sepsis (a bodyGÇÖs extreme reaction to infection) due to a urinary tract infection. On 10/14/25 at 9:14 AM Witness 3 (Family Member) stated they visited Resident 7 on 12/8/24, were alarmed by the residentGÇÖs appearance and requested the resident be sent to the hospital.-á On 10/16/25 at 10:02 AM Staff 26 stated they observed Resident 7 to be lethargic and difficult to rouse on 12/8/24 at approximately 8:00 AM. Staff 26 reported their concerns to Staff 43 because Resident 7 was not at baseline for mental alertness, and they requested a reassessment after the resident was unable to take her/his medications. Staff 26 stated Staff 43 GÇ£only lookedGÇ¥ at the resident but did not perform a physical assessment, speak to the resident, take vital signs, a blood sugar check, or contact the on-call provider. Staff 26 stated Resident 7GÇÖs changed mental status persisted through the morning and despite their multiple reports of concern, Staff 43 did not take further action. On 10/17/25 at 10:39 AM Staff 24 (CNA) stated they were assigned to Resident 7 during the day shift on 12/8/24. Staff 24 stated the resident was GÇ£usually pretty alert"", but throughout the day she/he was difficult to rouse and minimally responsive. Staff 24 stated they expressed their concerns to Staff 43 several times throughout the morning.-á Staff 43 was unavailable for interview. On 10/17/25 at 1:05 PM Staff 7 (LPN) stated if staff reported signs of altered mental status, such as inability to stay awake or follow direction, the resident should be assessed right away as it may indicate a change of condition. Staff 7 stated they would perform a head-to-toe assessment, take a full set of vital signs and check blood sugar levels if the resident was diabetic. Staff 7 stated depending on the findings they would contact the on-call provider for further direction. On 10/17/25 at 1:20 PM Staff 41 (NP) stated they rounded on Resident 7, who was normally alert, and they would expect an GÇ£immediateGÇ¥ call if there were a change in the resident's mentation such as not able to be aroused or the inability to follow direction and take medications. Staff 41 stated they expected an assessment by the licensed nurse and blood sugar levels checked. On 10/20/25 at 9:27 AM Staff 42 (NP) stated they were on-call on 12/8/24 and did not receive a notification of Resident 7GÇÖs change of change in mental status. On 10/20/25 Staff 4 (LPN Resident Care Manager) stated they expected the nurse to assess the resident, obtain a set of vital signs, and based on findings contact the on-call provider when a change of condition was reported to them. Staff 4 reviewed Resident 7GÇÖs medical record and acknowledged there was no documentation by Staff 43 of an assessment, vital signs, blood sugar checks or communication with the on-call provider on 12/8/24.-á On 10/20/25 Staff 2 (DNS) stated if staff expressed concerns to the charge nurse about a residentGÇÖs change of condition, such as signs of altered mental status, they expected the nurse to perform a full assessment, take vital signs, if appropriate check blood sugar levels, and contact the on-call provider. Staff 2 acknowledged there was no documentation to indicate an assessment was performed, vital signs taken, blood sugar levels were checked, or the on-call provider was notified for Resident 7 on 12/8/24 by Staff 43 after they were notified of the residentGÇÖs change of condition. -á

F684 Quality of Care Resident 7 no longer resides in the facility Potential for effect to all residents. All Nurses and RCM’s will be in-serviced on the facility policy for a resident that has an acute change in condition. Clinical management is required to have a thorough review and return demonstration of skills  prior to new nursing staff working the floor. An initial audit will be performed of all residents with an acute change in condition to ensure appropriate care was provided x30 days. An audit of 5 residents with acute change in condition will be performed weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to assess, monitor, and treat pressure ulcers for 1 of 1 sampled resident (#7) reviewed for wound care. This placed residents at risk for unassessed wounds, unmet treatment needs and worsening pressure ulcers. Findings include: The 2019 National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide indicated the following recommendations regarding pressure ulcer assessment: - Assess the pressure ulcer initially and re-assess it at least weekly to monitor progress towards healing; - Document the results of all wound assessments; - Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor;-á -á- Select a uniform, consistent method for measuring wound length, width, depth or wound area to facilitate meaningful comparisons of wound measurements across time;-á - Ensure pressure ulcers are correctly differentiated from other skin injuries, particularly incontinence associated dermatitis or skin tears. Resident 7 was admitted to the facility in 11/2024 with diagnoses including end stage kidney disease and diabetes. Resident 7GÇÖs 11/13/24 Nursing Admission Database completed by Staff 23 (LPN) indicated the resident had an unstageable sacral (a bone at the base of the spine) wound; no further description, measurements or staging of the wound was provided. Resident 7GÇÖs 11/29/24 Admission MDS indicated the resident had moderate cognitive impairment and was at risk for pressure injury development related to decreased mobility, end stage kidney disease, incontinence and diabetes. Review of Resident 7GÇÖs medical record revealed there was no comprehensive assessment conducted of the residentGÇÖs wound to capture characteristics such as location, stage, measurements, tissue type(s), color, wound edges, undermining or tunneling, draining or odor, or documentation of notification to the facility provider the resident had a sacral wound. No evidence was found that wound care or treatment was provided to the resident between 11/13/24 through 11/19/24 (six days). Resident 7 was hospitalized 11/19/24 through 11/23/24 with hypoglycemia (low blood sugar).-á Resident 7GÇÖs 11/23/24 Hospital After Visit Summary directed the resident to receive the following daily wound care orders: 1. Sacrum: -Cleanse the sacrum with normal saline; -Apply Venelex ointment (a medicated treatment for wounds) over the entire wound bed; -Cover with a sacral foam dressing; -Change daily.-á 2. Left and right heels: -Paint with betadine swab (a medicated applicator) daily for antimicrobial (to reduce germs) and to keep dry. Review of Resident 7GÇÖs 11/2024 TAR revealed Resident 7 did not receive sacral wound care treatment from 11/23/24 through 11/27/24 (five days) and did not receive left heel wound care from 11/23/24 through 12/5/24 (13 days). There was no evidence found that treatment for the right heel wound was ever initiated.-á On 10/14/25 at 9:14 AM Witness 3 (Family Member) stated Resident 7 admitted to the facility with a sacral wound, which worsened during her/his stay.-á On 10/15/25 at 1:12 PM Staff 41 (Former NP) stated facility staff were expected to notify them of all wounds so treatment orders could be initiated as soon as possible. Witness 41 did not recall being notified of Resident 7GÇÖs sacral wound. On 10/16/25 at 2:46 PM Staff 23 (LPN) stated they completed Resident 7GÇÖs initial skin assessment upon admission which noted a sacral wound. Staff 23 stated they were responsible for entering wound care orders into the residentGÇÖs record, and they believed Staff 4 then took photos and a wound care provider was to round on the resident. Staff 23 stated residentGÇÖs wound did not improve while at the facility. -á On 10/20/25 at 9:39 AM Staff 29 (LPN) stated when a resident was admitted to the facility with wounds but without treatment orders, they would promptly notify the Resident Care Manager, who was responsible for assessment and the initiation of care. Staff 29 stated when a resident was admitted with wound treatment orders the admitting nurse and their counterpart were responsible for verifying and entering the orders into the residentGÇÖs record.-á On 10/20/25 at 10:30 AM Staff 4 (LPN Resident Care Manager) stated they expected the admitting nurse to thoroughly assess and photograph all wounds within the first eight hours of admission and make a referral to the wound clinic. Staff 4 stated they expected wound care orders to be implemented the same day as receipt. Staff 4 acknowledged no assessment of Resident 7GÇÖs wound was performed upon admission on 11/13/24 and there was no documentation in the TAR or progress notes of wound care treatment provided between 11/13/24 and 11/19/24. Staff 4 acknowledged Resident 7 was readmitted to the facility on 11/23/24 with treatment orders for wounds to the sacrum and both heels. Staff 4 acknowledged treatment for the sacral wound was not initiated until 11/28/24, treatment for the left heel was not initiated until 12/6/24 and there was no record of treatment provided for the right heel.

F686 Treatment and Services to Prevent/Heal Pressure Ulcer Resident 7 no longer resides in the facility Potential for effect to all residents. The facility has purchased an additional iPhone device to increase availability of the tools for nursing staff to document and assess wounds All Nurses and RCM’s will be in-serviced on the facility policy for assessing and documenting new wounds as well as wounds present on admission or re-admission. All Nurses and RCM’s will be in serviced on the facility policy of entering and obtaining wound care orders upon admission or re-admission. RCM’s will be in serviced on the facility policy of Admission and Readmission review process. An initial audit will be performed of all admissions and readmissions x30 days to determine appropriate assessment, orders and documentation of wounds are present. All residents will be audited for current wounds to ensure appropriate assessment, orders and documentation is in place x30 days. An audit of 5 residents with wounds will be performed weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Resident 1 admitted to the facility in 2023 with diagnosis including movement disorder and chronic incomplete quadriparesis (form of paralysis affecting all four limbs with some motor function and sensation preserved). -á Resident 1GÇÖs 8/23/24 Annual MDS revealed the resident was cognitively intact and was dependent on staff for bathing. -á A FRI was submitted to the State Agency on 11/11/25 at 9:43 AM to report Resident 1 experienced a fall in the shower at 7:50 AM. -á A 1/11/25 at 10:09 AM Progress Note by Staff 2 (LPN) revealed Resident 1 fell in the shower, 911 was called and the resident was sent to the hospital. At 5:38 PM the hospital called the facility and Resident 1 was admitted to the hospital with a left hip fracture. -á A care plan dated 1/11/25 indicated Resident 1 was dependent on one staff member for assistance during showers. -á A 1/17/25 facility investigation revealed on 1/11/25 Staff 3 (CNA) provided Resident 1 with a routine shower in the facilityGÇÖs shower room. The investigation determined the staff failed to ensure the shower gurney was properly locked for safety which caused Resident 1GÇÿs head to lower and fall to the floor. Resident 1 re-admitted to the facility on 1/17/25 with a diagnosis including a post-surgical repair of the left hip. On 8/28/25 at 9:35 AM Resident 1 recalled her/his 1/11/25 fall in the shower in detail and believed the fall was a GÇ£freakGÇ¥ accident. Resident 1 stated Staff 3 followed her/his care plan and tried to make her/his head more comfortable when the shower gurney head went down. Resident 1 stated she/he did not experience pain at the time of the incident. -á On 8/28/25 at 10:34 AM Staff 3 stated she provided Resident 1 a shower on 1/11/25 which resulted in a fall. Staff 3 recalled she tried to put a towel under Resident 1GÇÖs head, the head of the shower gurney (a specialized piece of medical equipment designed to bathe individuals who are unable to stand or sit upright during a shower) fell backwards and the resident fell to the floor. Staff 3 reported the shower gurney was a new piece of equipment and believed it appeared and felt safe when she transported Resident 1 to the shower room. After the fall Staff 3 stated she learned the gurney had a safety clip that should have been in secured however, she was not trained on how to use the equipment prior to its use. -á On 8/28/25 at 11:00 AM Staff 2 stated she was called to the shower room after Resident 1 had fallen to the floor. She recalled when she arrived at the shower room, the head and lower part of the leg section of the shower gurney had fallen down and Resident 1 was on the floor. Staff 2 called 911, the resident was sent to the hospital and had surgery for a hip fracture. -á On 8/28/25 at 11:09 AM Staff 4 (Maintenance Director) stated the shower gurney used in Resident 1GÇÖs 1/11/25 fall was a new piece of equipment and was different from the other shower chairs used in the facility. He stated he inspected the shower gurney after the incident and observed the medal pin was not locked in the pin bar which was necessary for safety. Staff 4 immediately removed the shower gurney from the facility, education was provided, and he was unaware of any other falls from equipment in disrepair or misused. -á Observations were made of the facility's shower chairs and gurneys on 8/28/25 at 11:14 AM with Staff 4. Staff 4 demonstrated the shower equipment movements and how to place them in locked position. No shower equipment was found in disrepair. -á On 8/28/25 at 11:40 AM Staff 2 (DNS) confirmed Resident 1GÇÖs 1/11/25 fall in the shower resulted in hospitalization and hip surgery. Staff 2 confirmed she completed the 1/17/25 investigation which concluded the fall was due to staff not properly securing the shower gurney. She expected all staff to use the shower equipment properly and all parts should be locked while providing a shower. -á On 1/17/25, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined staff was not trained for the proper use of the new shower gurney. The Plan of Correction included: 1. Staff educated on shower equipment use. 2. The new shower gurney was removed from the facility until staff were trained and competency was demonstrated. 3. The Maintenance Director inspected all the shower equipment to ensure safety. 4. If new shower equipment was purchased, which was different than current shower equipment used, the Maintenance Director would conduct training prior to the use of the new equipment. 5. The Maintenance Director conducts monthly inspection of all shower equipment. -á The facility's implementation of corrective actions was verified through the survey process. Observations conducted throughout the facility on 8/28/25 revealed no concerns with use of shower equipment.

The facilityGÇÖs 6/12/18 Abuse Prevention Policy and Procedure revealed it was the policy of the facility that all suspected or alleged cases of abuse shall be reported according to State and Federal regulations. -á On 7/21/25 at 6:55 PM Witness 3 (Family Member) stated Resident 1 moved rooms because her/his former roommate, Resident 8, shoved her/him into a wall. Witness 3 reported the physical altercations to facility staff immediately. -á On 7/25/25 at 10:18 AM Staff 21 (RN) stated she did not contact the State Agency to report the allegation of abuse. Staff 21 stated the incident occurred prior to the start of her shift at 6:00 PM and the information was reported to her during shift change. Staff 21 stated she called Staff 1 (Administrator) and Staff 2 (DNS) to report the allegation more than two hours after she was aware of the allegation. -á On 7/25/25 at 11:32 AM Staff 1 confirmed no report of an allegation of abuse was made to the State Agency which involved Resident 1 and Resident 8. Staff 1 expected all allegations of abuse to be reported to the State Agency within the required two-hour time frame.

The resident-to-resident allegation incident was reported to the FRI investigation unit. Resident 1 was monitored for s/sx abuse and none noted. Resident 8 was monitored for s/sx physical aggression towards others, and no incidence was noted. Potential for effect to all residents. All residents will be interviewed about abuse from other residents and concerns addressed. The Administrator and DNS will be in-serviced on the facility policy for reporting allegations of abuse. All Nurses will be in-serviced on the facility policy for reporting allegations of abuse. An initial audit will be performed of all incident reports for allegations of abuse x30 days to determine timely reporting occured. An audit of 5 incident reports for allegations of abuse and timely reporting weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

The facilityGÇÖs 6/12/18 Abuse Prevention Policy and Procedure revealed all suspected or alleged cases of abuse shall be thoroughly and completely investigated. The procedure directed staff as soon as a report of alleged or suspected abuse was received, the investigation would begin and be completed within five days. -á Resident 1's 7/18/25 progress note revealed she/he had been moved to a new room following an altercation with her/his former roommate. -á On 7/21/25 at 6:55 PM Witness 3 (Family Member) stated Resident 1 moved rooms because her/his former roommate, Resident 8, shoved her/him into a wall. Witness 3 reported the altercation to staff immediately. -á On 7/25/25 at 10:18 AM Staff 21 (RN) stated staff told her of an incident which occurred prior to the start of her shift at 6:00 PM, between Resident 1 and Resident 8. Staff 21 spoke to Witness 3 who indicated Resident 8 shoved Resident 1 into a wall.-á -á On 7/25/25 at 11:32 AM Staff 1 (Administrator) confirmed a thorough investigation had not been completed for the 7/18/25 allegation of possible abuse between Resident 1 and Resident 8 timely. Staff 1 expected all allegations of abuse to be thoroughly investigated.-á

The resident-to-resident allegation incident was investigated and completed. Resident 1 was monitored for s/sx abuse and none noted; careplan updated accordingly. Resident 8 was monitored for s/sx physical aggression towards others, and no incidence was noted; careplan updated accordingly. Potential for effect to all residents. An initial audit will be performed of all incident reports for allegations of abuse x30 days to determine investigations were completed thoroughly and timely. The Administrator and DNS will be in-serviced on the facility policy for completing thorough and timely investigations. An audit of 5 incident reports for thorough and timely completion weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

2. Resident 3 was admitted to the facility in 7/2023 with diagnoses including dementia and stroke. Resident 3GÇÖs 7/2/25 care plan revealed she/he was a fall risk with interventions including placement of a fall mat when she/he was in bed. On 7/23/25 at 3:22 PM and 7/25/25 at 9:51 AM, Resident 3 was observed in bed sleeping with no fall mat on the floor. -á On 7/25/25 at 10:12 AM, Staff 11 (CNA) was not sure of the fall interventions for Resident 3. On 7/25/25 at 10:17 AM, Staff 13 (CNA) acknowledged Resident 3 was a fall risk but did not know about her/his fall interventions. On 7/25/25 at 10:38 AM, Staff 3 (Resident Care Manager-LPN) stated Resident 3 was a fall risk, had a history of falling, and expected CNA staff to place a fall mat by Resident 3GÇÖs bed when she/he was in bed. Staff 3 observed Resident 3 in bed and acknowledged the absence of a fall mat on the floor and was unable to locate a fall mat in Resident 3's room.-á -á , -á 1. Resident 59 was admitted to the facility in 10/2024 with diagnoses including stroke and anxiety. -á A Fall Risk Assessment dated 5/7/25 determined Resident 59 was at high risk for falling. -á The 5/21/25 Care Plan identified Resident 59 a high fall risk for falls. Interventions included a fall mat to be placed at bedside when the resident was in bed.-á -á On 7/24/25 at 8:32 AM Resident 59 was observed asleep in bed without a fall mat in place.-á -á On 7/24/25 at 8:34 AM Staff 7 (CNA) stated Resident 59 was at risk for falls but did not have any fall interventions in place. -á On 7/24/25 at 8:59 AM Staff 3 (Resident Care Manager-LPN) stated Resident 59's Care Plan included having a fall mat in place when the resident was in bed. Staff 3 confirmed Resident 59's care plan were not being implemented, and all CNAs were expected to implement and follow the care plan.-á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á -á

Resident 59 had their fall mat placed in their room and sign posted for reminder to staff use Resident 3 had their fall mat placed in their room and sign posted for reminder to staff use Potential for effect to all residents. All residents will be audited to determine that fall risk interventions are in use and in place, follow-up completed. All CNA’s and Nurses will be inserviced on the facility fall risk policy and careplan policy. An audit will be performed of 5 fall risk residents to ensure their care plan interventions are in use weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Resident 48 admitted on 1/2025 with diagnoses including fibromyalgia (health condition which causes pain and tenderness throughout the body). The Quarterly MDS dated 3/26/25 indicated Resident 48 was cognitively impaired and she/he had a history of falls. The Quarterly MDS dated 4/29/25 indicated Resident 48 used a FWW (front wheel walker) and wheelchair to assist with ambulation. A review of Resident 48's medical record revealed the resident fell on 1/27/25, 5/11/25, 5/20/25 and 6/4/25. The 5/19/25 care plan indicated Resident 48 was to have a GÇ£call donGÇÖt fallGÇ¥ sign within eyesight of the resident and was to have a FWW. On 7/21/25 at 9:55 AM and 1:03 PM, Resident 48 was observed leaning behind her/his wheelchair and used it to ambulate to the restroom. Resident 48 stated she/he was not offered a FWW to use. -á Random observations of Resident 48GÇÖs room from 7/21/25 through 7/24/25 revealed no visual sign in her/his room and no FWW. On 7/24/25 at 1:59 PM, Staff 17 (CNA) stated there used to be a sign in Resident 48's room, but it was not currently posted. The sign was to remind Resident 48 to use her/his call light before getting out of bed. Staff 17 stated Resident 48 pushed her/his wheelchair and used it to ambulate. Staff 17 stated she/he was not given a FWW.-á On 7/25/25 at 10:14 AM, Staff 18 (CNA) stated there was no sign in Resident 48GÇÖs room to remind the resident to utilize her/his call light prior to getting out of bed. On 7/25/25 at 10:38 AM, Staff 5 (LPN) stated Resident 48 walked behind the wheelchair to ambulate. Staff 5 stated she/he was not offered a FWW. On 7/25/25 at 10:44 AM, Staff 3 (Resident Care Manager- LPN) acknowledged the care plan indicated there was supposed to be a sign to remind Resident 48 to utilize the call light prior to getting out of bed.-áStaff 3 stated Resident 48 used a FWW to ambulate and was unaware Resident 48 used her/his wheelchair to ambulate. -á -á -á -á -á -á -á -á

Resident 48 had their fall sign posted as well as their fall risk care plan re-assessed with appropriate interventions updated and appropriate DME placed in room. Potential for effect to all residents. All residents will be audited to determine that fall risk interventions are in use and in place, follow-up completed. All CNA’s and Nurses will be inserviced on the facility fall risk policy and careplan policy. An audit will be performed of 5 fall risk residents to ensure their care plan interventions are in use weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

A review of the Direct Care Staff Daily Reports for 7/1/24 through 7/31/24 and 6/19/25 through 7/24/25 revealed there were eight days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period: -7/7/24 -7/13/24 -7/14/24 -7/21/24 -7/22/24 -7/28/24 -7/29/24 -7/13/25 On 7/25/25 at 9:12 AM Staff 16 (Staffing Coordinator) acknowledged the facility did not have adequate RN coverage on the above dates and understood the need to staff the facility with an RN in order to provide residents with care and assessments they needed.-á On 7/25/25 9:44 AM Staff 1 (Administrator) stated she expected the facility to be staffed appropriately with RN coverage to ensure residents received appropriate care and services.-á

No specific residents were cited Potential for effect to all residents. An audit of each resident on the dates of missed RN hours was performed to determine if care needs were met. The facility recruitment team will focus efforts on recruiting RN canadidates to staff for open RN positions that meet the RN hour requirement of the facility The Administrator and Staffing Coordinator will be in-serviced on the facility policy for scheduling RN hours for the facility An audit will be performed daily for use of RN hours in the facility weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

The 2019 Insulin Lispro Solostar Pen Manufacturer Instructions for Use and the 2022 How to Use Lantus Pen Manufacturer Instructions specified the following: - to inject your dose, clean site with an alcohol swab, keep the pen straight, insert the needle into your skin, use the thumb to press the injection button all the way down. When the number in the dose window returns to zero as you inject, slowly count to 10 before removing (counting to 10 will makes sure residents received the full insulin dose), release the button and remove the needle from your skin. The facilityGÇÖs 3/2025 Insulin Administration Policy specified the following: -Depress the plunger and remove the needle after approximately five seconds. The 2024 What Happens If I Take CREON Without Food Manufacturer Instructions specified the following: -Creon needs to be taken with every meal and snack to work as expected. The digestive enzymes in CREON need to mix with food and enter the stomach and the small intestine at the same time. The facility's 4/2019 Administering Medications Policy specified the following: - Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1.Resident 3 was admitted to the facility in 2/2024 with diagnoses including type 2 diabetes mellitus (impaired insulin production). Resident 3's 7/2025 MAR included the following: - Insulin lispro injection solution, inject five units subcutaneously with meals. - Insulin glargine solution pen-injector, inject 46 units subcutaneously in the morning. On 7/23/25 at 7:36 AM, Staff 8 (LPN) was observed during Resident 3 and 52GÇÖs medication administration. Staff 8 prepared five units of lispro insulin and injected Resident 3GÇÿs arm and immediately removed the needle from the skin. Staff 8 did not perform the safety steps as indicated in the manufacturer's instructions. On 7/25/25 at 11:25 AM, Staff 2 (DNS) was informed about Resident 3 insulin administration and the improper use of the insulin pens, which were not held for 10 seconds before needle removal from the residentGÇÖs skin, and the safety steps were not followed prior to administration. Staff 2 stated she expected staff to follow the safety steps for administering insulin.-á 2. Resident 52 was admitted to the facility in 12/2022 with diagnoses including type 2 diabetes mellitus (impaired insulin production). Resident 52's 7/2025 MAR included the following: - Insulin glargine solution pen-injector, inject 19 units subcutaneously two times a day. On 7/23/25 at 7:36 AM, Staff 8 (LPN) was observed during Resident 52GÇÖs medication administration. Staff 8 prepared 19 units of glargine insulin and injected Resident 52GÇÖs arm and immediately removed the needle from the skin. Staff 8 did not perform the safety steps as indicated in the manufacturer's instructions. On 7/25/25 at 11:25 AM, Staff 2 (DNS) was informed about Resident 52's insulin administration and the improper use of the insulin pens, which were not held for 10 seconds before needle removal from the residentGÇÖs skin, and the safety steps were not followed prior to administration. Staff 2 stated she expected staff to follow the safety steps for administering insulin.-á 3. Resident 60 admitted to the facility in 11/2024 with diagnoses including type 2 diabetes mellitus (impaired insulin production). Resident 60's 7/2025 Physician Orders included the following: - Creon delayed release capsule, give one capsule by mouth with meals for digestion. On 7/24/25 at 11:48 AM, Staff 19 (CMA) was observed during Resident 60GÇÖs medication administration. Staff 19 administered the scheduled medication without offering a snack or meal, and no food was observed in the residentGÇÖs room. Staff 19 stated it was difficult to coordinate scheduled medications with meals or when meal trays arrived. She mentioned having one hour before and after the scheduled medication times to administer medications. On 7/25/25 at 11:25 AM, Staff 2 (DNS) was informed about Resident 60GÇÖs Creon not administered with a snack or meal. Staff 2 stated she expected staff to implement and follow physician orders. -á -á -á

Resident 3 was evaluated for the incorrect safety step administration of insulin pen dose with no ill effect noted. Resident 52 was evaluated for the incorrect safety step administration of insulin pen dose with no ill effect noted. Resident 60 was evaluated for incorrect administration of creon dose with no ill effect noted. Potential for effect to all residents. All residents receiving insulin via insulin pen use will have the special instructions of the order updated to include safety steps. All residents with orders to administer their medication with food will have this instruction updated in their special instructions section of the order. All nurses will be inserviced on the safety steps for administration of insulin pen orders, medications that require adminstration with food and medication administration policy A random audit of 5 residents receiving insulin and 5 residents with medications to be taken with food will be performed weekly x4 weeks and then monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

2. On 7/24/25 at 8:19 AM, the East Hall treatment cart was unlocked. Staff and residents were observed to be walking by the treatment cart.-á On 7/24/25 at 8:32 AM, Staff 4 (LPN) acknowledged the unlocked treatment cart. The contents inside of the cart included insulin, insulin pens, needles, and resident prescribed oral medications. Staff 4 stated he was supposed to lock the treatment cart before walking away from the treatment cart. 3. On 7/25/25 at 8:30 AM, the West Hall treatment cart was unlocked. The treatment cart contained insulin supplies, dressings, creams, and resident tube feeding medications.-á On 7/25/25 at 8:38 AM, Staff 6 (RN) stated the West Hall treatment cart was supposed to locked when unattended.-á On 7/25/25 at 10:15 AM, Staff 2 (DNS) stated she expected medication and treatment carts to be locked when staff were not in view of them. 4. On 7/25/25 at 12:27 PM, the East Hall treatment cart was unlocked. The contents in the cart included insulin, insulin pens, needles, lubricants, and resident prescribed oral medications. Residents and staff were observed walking past the unlocked treatment cart.-á On 7/25/25 at 12:43 PM, Staff 5 (LPN) and Staff 2 (DNS) acknowledged the East Hall treatment cart was unlocked. Both stated treatment carts should not be unlocked when left unattended. , The facility's 11/2020 Storage of Medications Policy specified the following: - Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs-áor biologicals are returned to the dispensing pharmacy or destroyed. 1.On 7/25/25 at 11:15 AM, one open, vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) dated 6/6/25 was observed inside the refrigerator located in the medication storage room. On 7/25/25 at 11:35 PM, Staff 2 (DNS) acknowledged the vial of tuberculin was expired and expected staff to discard tuberculin vial within 30 days of opening. -á -á -á

No specific residents were cited Potential for effect to all residents. Residents admitted to facility 7/6/25 onward with potential to have been administered the expired Tuberculin vial have had their PPD series re-started with a new current vial of Tuberculin. All Nurses will be inserviced on appropriate storage of the Tuberculin vial and facility policy on Drug storage including importance of keeping medication and treatment carts locked. A random audit for proper Drug Storage in facility medication/treatement carts will be performed 5x weekly x4 weeks and then monthly x2 months. An audit of the expiration date for facility Tubercullin vials open in use will be performed weekly x4 weeks and then monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Resident 11 was admitted to the facility in 2025 with diagnoses including quadriplegia (partial or complete paralysis of all four limbs). The 2024 CDC Clinical Safety: Hand Hygiene for Health care workers specified the following: -Clean your hands immediately after glove removal to prevent the spread of germs and potential infections. A review of Resident 11GÇÖs Quarterly MDS dated 2/6/25 indicated the resident was admitted with four pressure ulcers. A review of Resident 11GÇÖs Annual MDS dated 5/7/25 indicated the resident acquired an in-facility pressure ulcer. A review of Resident 11GÇÖs 7/2025 MAR indicated daily wound care to the sacrum (a bone at the base of the spine) and the right ischium (a bone forming the lower and back part of the hip bone) pressure ulcers. On 7/23/25 at 11:01 AM, During wound care to the ischium wound, Staff 8 (LPN) was observed to perform peri-care, removed gloves and donned new gloves. Staff 8 proceeded to cleanse wound, removed gloves and donned new gloves. Staff 8 proceeded to apply dressing, removed gloves and donned new gloves. No hand hygiene was observed in between donning and doffing of gloves. On 7/23/25 at 11:10 AM, During wound care to the sacral wound, Staff 8 was observed to cleanse wound, removed gloves and donned new gloves. No hand hygiene was observed in between donning and doffing of gloves. On 7/23/25 at 11:15 AM, Staff 8 stated he performed hand hygiene before and after care the wound care treatments. He acknowledged the lack of hand hygiene after removing gloves during wound care.-á -á On 7/25/25 at 11:25 AM, Staff 2 (DNS) stated she expected staff to perform hand hygiene after removal of gloves when performing wound care. -á -á -á -á -á -á

Resident 11 had their wounds evaluated by the Wound care NP resulting no ill effect noted. Potential for effect to all residents. All residents with open wounds will be evaluated for s/sx infection and follow-up done with appropriate provider. All nurses will be inserviced on facility wound care administration policy as it realtes to proper hand hygiene An audit of nursing staff performing wound care for 5 residents with open wounds will be performed weekly x4 weeks and then monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

A review of the Direct Care Staff Daily Reports for 7/1/24 through 7/31/24 and 6/19/25 through 7/24/25 revealed the following 38 days without an RN working in the facility as charge nurse for eight consecutive hours between the start of day shift and the end of evening shift: -7/1/24 -7/2/24 - 7/3/24 - 7/4/24 - 7/6/24 - 7/7/24 - 7/8/24 - 7/9/24 - 7/10/24 - 7/11/24- - 7/12/24 - 7/13/25 - 7/14/24 - 7/15/24 - 7/18/24 - 7/19/24 - 7/20/24 - 7/21/24 - 7/22/24 - 7/23/24 -7/25/24 - 7/28/24 - 7/29/24 - 6/19/25 - 6/25/25 - 6/26/25 - 6/30/25 - 7/2/25 - 7/9/25 - 7/10/25 - 7/13/25 - 7/15/25 - 7/16/25 - 7/17/25 - 7/20/25 - 7/23/25 - 7/24/25. On 7/25/25 at 9:12 AM Staff 16 (Staffing Coordinator) acknowledged the facility did not have adequate RN coverage on the above dates and stated she understood the need to staff the facility with an RN in order to provide residents with care and assessments they needed.-á On 7/25/25 at 9:44 AM Staff 1 (Administrator) stated she expected the facility to be staffed appropriately with RN coverage to ensure residents received appropriate care and services.

No specific residents were cited Potential for effect to all residents. An audit of each resident on the dates of missed RN hours was performed to determine if care needs were met. The facility recruitment team will focus efforts on recruiting RN canadidates to staff for open RN positions that meet the RN hour requirement of the facility The Administrator and Staffing Coordinator will be in-serviced on the facility policy for scheduling RN hours for the facility An audit will be performed daily for use of RN hours in the facility weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on observation, interview, and record review it was determined the facility failed to protect a resident's right to be free from mental abuse by staff for 1 of 5 sampled residents (#8) reviewed for abuse. This placed residents at risk for further mental abuse. Findings include: On 9/5/24 the State Survey Agency received a public complaint which alleged Resident 8 was spoken to rudely and threatened by a CNA. Resident 8 was admitted to the facility in 9/2024, with diagnoses including vascular dementia and a hip fracture. Resident 8's 9/9/24 Admission MDS indicated she/he was cognitively intact. On 12/17/24 at 9:00 AM, Staff 5 (CNA) stated Staff 3 (CNA) stated to her and Staff 4 (CNA) "tell Resident 8 that you will put them in a room by herself/himself with the door closed and no call light" if Resident 8 was "on the call light too much." Staff 5 stated Staff 3 informed them she knew Resident 8 from the hospital and saying those things worked there. Staff 5 stated they immediately reported to management. On 12/19/24 @ 8:03 AM, Staff 4 (CNA) stated Staff 3 (CNA) stated to her and staff 5 (CNA) "tell Resident 8 that you will put them in a room by herself/himself with the door closed and no call light" if Resident 8 was "on the call light too much." Staff 4 stated Staff 3 informed them she knew Resident 8 from the hospital and saying those things worked there. Staff 4 stated her, and Staff 5 reported the incident immediately to management. On 12/19/24 at 9:51 AM, this surveyor attempted to reach Staff 3 via phone. Staff 3 refused to speak to this surveyor. On 12/19/24 at 10:40 AM, Resident 8 stated she/he recalled being threatened by a staff member for using the call light too much. Resident 8 stated "they told me if I used the call light too much I would have been put in a room by myself and would not receive any help no matter how much I called." Resident 8 stated Staff 3 (CNA) did also turn off the lights one time. Resident 8 screamed and Staff 3 turned the lights back on. Resident 8 stated "it was a terrifying few moments." On 12/13/24 at 2:49 PM, Staff 1 (DNS) and Staff 2 (Administrator) confirmed the incident occurred.

F600 Free from Abuse and Neglect Resident 8 remains in the facility and continues to verbalize and demonstrate no negative impact from the inappropriate statements of the staff member. Staff 5 is no longer employed with the facility since the original investigation. Staff were in-serviced at a facility All staff meeting on Elder abuse and steps to reduce occurrence on 9/26/24. This has the potential to affect all residents. All staff will be in-serviced on abuse policy and procedures. All CNA staff will be in-serviced on appropriate response to resident behavior management. All interview able residents will be interviewed about abuse from staff and concerns addressed. Facility will interview 5 residents weekly about abuse from staff and their concerns addressed weekly x4 weeks and then monthly x2months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to document the basis for transfer and failed to include code and health status to the receiving provider for 1 of 3 sampled residents (#7) reviewed for hospitalization. This placed residents at risk for inaccurate health care. Findings include: Resident 7 was admitted to the facility in 8/2024, with diagnoses including traumatic brain injury and delirium. Resident 7's 10/3/24 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 7's medical record revealed no documentation to indicate the basis for the transfer and if appropriate information was communicated to the receiving hospital. There was no information demonstrating why the facility could not meet the resident's needs and whether the discharge was initiated by the resident or the facility. On 12/19/24 at 10:40 AM, Staff 1 (DNS) was informed of the findings of this investigation and acknowledged the discharge information was not documented in Resident 7's medical record.

F622 Transfer and Discharge Requirements Resident 7 has been discharged from the facility. This has the potential to affect all residents. All Nurses will be in-serviced on Resident change in condition hospital transfer requirements. All Resident change of condition hospital transfers of the last 30days will be reviewed for appropriate transfer documentation being sent with the Resident. An audit of up to 5 Residents with changes in condition requiring a transfer out to the hospital will be reviewed for appropriate transfer procedures and documents sent weekly x4 weeks and then monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

********************* OAR 411-085-0360: Abuse Refer to F600 ********************* OAR 411-088-0020: Basis for Involuntary Transfer Refer to F622 **********************

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity related to dining needs for 1 of 2 sampled dining rooms reviewed for dining. This placed residents at risk for lack of a dignity. Findings include: The facility's 3/2022 Assistance with Meals Policy indicated residents would receive assistance with meals in a manner that met the individual needs of each resident. Residents unable to feed themselves would be fed with attention to safety, comfort and dignity including "not standing over residents while assisting them with meals." On 4/2/24 between the hours of 11:55 AM and 12:30 PM, during the lunch meal in the East dining room, the following observations were made: -The East dining room consisted of four tables with two to three residents placed at each table, one resident placed at a bedside table and another resident sitting in a wheelchair. -Staff 8 (CNA) provided assisted with the lunch meal at a table with three males, standing over one resident as she provided eating assistance. While Staff 8 stood, she also assisted a second resident, alternating eating assistance between the two residents. -Staff 22 (RN) arrived at the table and assisted the third resident with eating assistance while standing over the resident. Both Staff 8 and Staff 22 stood while assisting the residents with their meals. On 4/2/24 at 12:30 PM Staff 8 stated CNAs were not supposed to stand over residents while assisting them at meals because it was not "dignified." Staff 8 stated there were not enough stools for all of the CNAs so she had to stand. On 4/2/24 at 12:30 PM Staff 22 stated staff were not supposed to stand while assisting residents during meals. Staff 22 stated staff were to sit and be face-to-face with residents when assisting them. Staff 22 stated there were not enough stools to allow each staff to sit when assisting residents during meals. On 4/8/24 at 10:33 AM Staff 2 (DNS) stated staff were not supposed to stand while providing eating assistance to residents as this was considered a lack of dignity and she expected staff to sit when assisting residents with their meals.

No specific resident was cited. Potential for effect to all residents. The facility purchased an additional sufficient amount of stools for staff use during meal assistance. All staff that assist with meals will be in-serviced about providing a dignified dining experience for residents. An audit of 5 residents that require assistance with meals will be monitored for a dignified dining experience in which staff are seated during meal service weekly x4 weeks and then monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to ensure consent was obtained prior to administering psychotropic and antiviral medications to 2 of 5 sampled residents (#s 12 and 29) reviewed for medications. This placed residents at risk for being uninformed about their medications. Findings include: 1. Resident 29 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease. Resident 29's Profile Information Sheet indicated the resident's spouse was the resident's responsible party. Resident 29's 12/2023, 1/2024, 2/2024, 3/2024 and 4/2024 Physician Orders included mirtazapine (antidepressant) and quetiapine (antipsychotic). Resident 29's 12/2023, 1/2024, 2/2024, 3/2024 and 4/2024 MARs revealed the resident received mirtazapine 15 mg daily and quetiapine 25 mg - 50 mg daily. Review of Resident 29's health record revealed no documentation to indicate the resident or her/his representative was informed of the risks, benefits and potential side effects of mirtazapine and quetiapine and no evidence the resident consented to receive the medications. On 4/5/24 at 1:00 PM Staff 12 (LPN Resident Care Manager) reviewed Resident 29's health record and was unable to locate evidence the resident or the resident's representative was informed of the risks, benefits and potential side effects of mirtazapine and quetiapine and was unable to provide documentation the resident's representative consented to the medications prior to administration. On 4/5/24 at 1:32 PM Staff 2 (DNS) was notified of the findings of this investigation and acknowledged the lack of evidence regarding medication information and consent. , 2. Resident 12 was admitted to the facility in 2024 with diagnoses including anxiety disorders and depression. a. Resident 12's 3/19/24 Physician Order indicated the resident was prescribed clonazepam (anti-seizure) for anxiety and restlessness. Resident 12's 3/2024 and 4/2024 MARs revealed the resident received clonazepam daily. Review of Resident 12's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of clonazepam. b. Resident 12's 3/29/24 Physician Order indicated the resident was prescribed Celexa (anti-depressant) for depression. Resident 12's 3/2024 and 4/2024 MARs revealed the resident received Celexa daily. Review of Resident 12's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of Celexa. c. Resident 12's 3/30/24 Physician Order indicated the resident was prescribed asenapine (antipsychotic) for psychotic symptoms. Resident 12's 3/2024 and 4/2024 MARs revealed the resident received asenapine daily. Review of Resident 12's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of asenapine. On 4/4/24 at 12:40 PM Staff 3 (LPN Resident Care Manager) reviewed Resident 12's health record, acknowledged there was no documentation to indicate the resident was informed of the risks and benefits of asenapine, clonazepam and Celexa. Staff 3 confirmed consent was not obtained from Resident 12 prior to the resident starting the medications.

Resident 12 had a consent for psychotropic medication completed and reviewed with their POA. Resident 29 had a consent for psychotropic medication completed and reviewed with their POA. Other resident receiving psychotropic medications are at risk for this deficiency. The assigned RCM will be given performance improvement education on the facility policy for psychotropic medication. All Nurses and RCMs will be in-serviced on resident rights to be informed and facility policy for psychotropic medication use. Potential for effect to all residents. All residents receiving psychotropic medication will have the chart reviewed for appropriate consents. An audit of 5 residents with new psychotropic orders will be reviewed for appropriate consent of use weekly x4 weeks and then monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on observation, interview and record review it was determined the facility failed to provide reasonable accommodations for 1 of 1 sampled resident (#37) reviewed for wheelchair accommodations. This placed residents at risk for unmet needs. Findings include: Resident 37 admitted to the facility in 4/2021 with diagnoses including Parkinson's disease (a disorder affecting movements). Observation on 4/3/24 at 12:21 PM revealed Resident 37 was sitting in her/his wheelchair with her/his calves pressed against the back of exposed metal on her/his chair and the left arm rest pad was missing, leaving a metal bar exposed for her/his arm to rest on. On 4/5/24 at 10:08 AM Resident 37 stated the back of her/his legs hurt. On 4/5/24 at 10:34 AM Staff 10 (CNA) stated she reported the missing arm rest pad to maintenance "a while ago." On 4/5/24 at 11:22 AM Staff 3 (LPN Resident Care Manager) stated she was not aware of Resident 37's missing arm rest pad or and that her/his legs were resting against exposed metal. Staff 3 observed the back of Resident 37's calves and stated there were "bad indentations" because of the exposed metal. Staff 3 stated Resident 37 needed a cushion or wedge to keep her/his legs from resting on the metal. On 4/5/24 at 1:01 PM Staff 7 (Maintenance Director) stated he was not aware of Resident 37's missing arm rest pad or the metal being exposed on the seat of the wheelchair.

Resident 37s wheelchair was repaired on 4-8-24. Resident 37 had a skin check completed as well and no impairments were noted. Residents residing at the facility have the potential to be impacted by the alleged deficient practice. An audit was conducted of residents who ambulate using a wheelchair to assure they are in proper working order and not in disrepair. Any identified repair needs will be corrected. The Maintenance Director will be provided with training regarding the need to ensure residents wheelchairs are in good repair. Staff will be provided with education on how to notify the maintenance director of items in need of repair, including wheelchairs. Administrator/Designee will complete weekly audit for 4 weeks, then monthly audits for 2 months to ensure all residents wheelchairs are in good repair. Identified items during audits will be repaired/replaced as indicated. Any issues identified through these audits will be brought to QAPI and a process improvement plan will be developed as necessary.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 4/2/24 through 4/8/24 identified the following issues: -Room 21 had a section of missing cove base behind the door, scrapes of missing paint along the wall under the window, gouges of missing wood on the window sill and the bedside table base was covered with paint chips. -Floor mats in multiple resident rooms were torn and tattered. -West hall sitting area across from the DNS office had an approximate 12 inch piece of wall covering peeling from underneath the window sill, a long crack in the wall with missing paint above the hand hygiene dispenser, and four large screws sticking out of the wall below the flag quilt. -The west dining room had an area on the north wall with missing paint and brackets were sticking out. On 4/8/24 at 11:31 AM Staff 7 (Maintenance Director) acknowledged these issues created an unkempt environment.

No specific resident(s) was identified. Room 21 had missing cove base replaced, paint touched up to identified areas, window sill repaired and bedside table repainted. The wall in the west hall sitting area was repaired and the wall had touch up paint applied. The screws were also resolved. West dining room had touch up paint and brackets resolved. An audit was conducted of fall mats and those identified with tears or in disrepair were replaced. Residents residing at the facility have the potential to be impacted by the alleged deficient practice. An audit of the building was conducted to review fall mats, touch up painting needs, bedside tables that could improve the facilitys home like environment. Identified items will be added to the maintenance repair tasks to resolve. The Maintenance Director will be provided with education on maintaining a home-like environment. A monthly schedule for touch up painting will be created as a part of preventative maintenance program. Staff will also be provided with education on how to notify the maintenance department of items in need of repair and painting. Administrator/Designee will complete a weekly audit for 4 weeks, then monthly audits for 2 to ensure that resident environment is home like. Any issue identified through the audits will be brought to QAPI and a process improvement plan will be developed as necessary.

Based on observation, interview and record review it was determined the facility failed to protect the residents' rights to be free from physical abuse by Residents (#s 3, 18, 26 and 46) for 4 of 4 sampled residents (#s 3, 4, 18, and 46) reviewed for physical abuse. This placed residents at risk for physical abuse. Findings include: 1. Resident 26 was admitted to the facility in 11/2022 with diagnoses including dementia and behavioral disturbance. Resident 26's 3/8/24 Quarterly MDS indicated a BIMS score of 6 (severe cognitive impairment) and no behaviors. Resident 4 was admitted to the facility in 2/2024 with diagnoses including dementia. Resident 4's 2/8/24 5 Day MDS indicated a BIMS score of 15 (cognitively intact) and no behaviors. On 3/14/24 the facility submitted a FRI which indicated Resident 26 punched Resident 4 on the right shoulder once and twice to the right side of the face. On 4/4/24 at 5:15 PM Staff 13 (LPN) stated he witnessed Resident 26 hit Resident 4 pretty hard on the right shoulder and the right side of her/his face twice. On 4/8/24 at 10:35 PM Staff 1 (Administrator) confirmed the 3/14/24 incident between Resident 26 and Resident 4 occurred. , 2. Resident 3 was admitted to the facility in 12/2020 with diagnoses including dementia with agitation. Resident 3's 11/9/23 MDS indicated a BIMS of 1 which indicated severe cognitive impairment. Resident 18 was admitted to the facility in 12/2020 with diagnoses including dementia with behavior disturbance and delusional disorder. Resident 18's 10/2/23 Aggression/Violence Risk Assessment indicated a moderate risk for aggressive/violent behavior. On 7/25/22 the facility submitted a FRI which indicated Resident 18 and Resident 3 were overheard yelling at each other. When Staff 32 (CNA) went to check on the residents, they were observed hitting each other and staff intervened to separate Resident 18 and Resident 3. On 4/2/24 to 4/8/24 from 8:00 AM through 5:00 PM Resident 3 was observed walking throughout the facility without supervision and Resident 18 was observed sitting in her/his wheelchair around other residents during dining and activities. On 4/2/24 interviews were attempted with Resident 3 and Resident 18. Both residents were determined to be not interviewable. On 4/4/24 at 9:20 AM Staff 32 recalled the incident and stated she had to "rush in" to intervene when Resident 3 and Resident 18 were hitting each other. On 4/5/24 at 1:36 PM Staff 1 (Administrator) confirmed the incident of abuse between Resident 3 and Resident 18 occurred. 3. Resident 3 was admitted to the facility in 12/2020 with diagnoses including dementia with agitation. Resident 3's 11/9/23 MDS indicated a BIMS of 1 which indicated severe cognitive impairment. Resident 46 was admitted to the facility in 12/2023 with diagnoses including alcohol dependence with alcohol-induced persisting dementia. Resident 46's 1/3/24 MDS indicated a BIMS of 3 which indicated severe cognitive impairment. A 3/10/24 FRI indicated Resident 3 punched Resident 46 on his back after Resident 46 sat on Resident 3's bed. In response, Resident 46 punched Resident 3 in the stomach. Staff intervened to separate the residents. On 4/2/24 to 4/8/24 from 8:00 AM through 5:00 PM Resident 3 was observed walking throughout the facility without supervision and Resident 46 was observed sitting in her/his room with the door open across the hall from Resident 3's room. On 4/2/24 interviews were attempted with Resident 3 and Resident 18. Both residents were determined to be not interviewable. On 4/5/24 at 9:27 AM Staff 31 (Housekeeping) stated she witnessed the incident. Staff 31 stated she saw Resident 46 walk with a cup and attempted to set the cup down on Resident 3's bed. Resident 3 observed this, "got upset" and started hitting Resident 46. Resident 46 immediately responded by hitting Resident 3. Staff 31 stated she had to get assistance from another staff member to intervene with the incident. On 4/5/24 at 1:36 PM Staff 1 (Administrator) confirmed the incident of abuse between Resident 3 and Resident 46 occurred.

Resident 18 Remains in the facility and had no ill effect from the incident. Resident will be reviewed for potential discharge to an appropriate facility. Resident 3 remains in the facility and had no ill effect from the incident. Resident 4 remains in the facility and had no ill effect from the incident. Resident 46 remains in the facility and had no ill effect from the incident. Potential for effect to all residents. All residents will be interviewed about abuse from other residents and concerns addressed. All staff will be in-serviced on Abuse and steps to reduce occurrence. An audit will be performed of all incident reports for incidence of abuse x30 days and appropriate follow-up. An audit of all incidents reports for abuse and appropriate follow-up weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 4 sampled residents (#5) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 5 was admitted to the facility in 2/2024 with diagnoses including post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Resident 5's 3/5/24 Admission MDS indicated the resident was moderately cognitively impaired. Resident 4 was admitted to the facility in 3/2024 with diagnoses including alcohol-induced dementia. Resident 4's 3/22/24 Admission MDS indicated the resident was moderately cognitively impaired. Resident 4's 5/16/24 Care Plan revealed the following: -The resident was involved in an incident which involved physical aggression on 5/8/24 with another resident and on 5/14/24 with a staff member. -The resident's behaviors included wandering, exit-seeking, verbal aggression and physical aggression. A 5/21/24 FRI indicated Resident 4 was agitated after dinner and was found with her/his hands around the neck of Resident 5. The residents were separated, and Resident 5 did not sustain any injuries. The FRI also indicated Resident 4 had been involved in a similar incident prior to this event. A 5/21/24 Witness Statement completed by Staff 8 (CNA) revealed Resident 4 had been verbally aggressive towards other residents, shouting and swearing at them, prior to the incident that occurred between Residents 4 and 5. A 5/21/24 Witness Statement completed by Staff 5 (CNA) revealed Staff 5 witnessed Resident 4 exhibit "violent behavior" against Resident 5 in the facility's dining room. The Witness Statement indicated a nurse intervened at the time of this altercation, and Resident 4 was known to experience continuous "aggressive changes in behavior." On 5/23/24 at 11:55 AM Resident 4 was observed in her/his room in bed. Staff 4 (CNA) sat in the hallway just outside of the resident's room. Resident 4 stated everything at the facility was good and she/he did not recall any verbal or physical altercations with other residents or staff. On 5/23/24 at 11:59 AM Staff 4 stated Resident 4 required one-to-one supervision because she/he "tried to choke Resident 5." On 5/23/24 at 1:06 PM Staff 8 stated Resident 4 had become "very aggressive" after a fall about a month ago. Staff 8 stated since the fall, Resident 4 became "upset easily if a lot was going on and it had to be quiet in the dining room." Staff 8 further stated Resident 4 would often tell other residents to "shut up." Staff 8 stated on 5/21/24 Resident 4 was in the dining room prior to the incident that occurred with Resident 5 and was extremely agitated. Staff 8 stated Resident 4 yelled at other residents to shut up and leave her/him alone prior to dinner. Staff 8 stated she did not witness the incident on 5/21/24 between Residents 4 and 5 but was told by Staff 6 (LPN) that Resident 4 put her/his hands around Resident 5's neck. Staff 8 stated Resident 5 was confused after the incident and told her she/he would punch Resident 4 if the resident tried to choke her/him again. On 5/23/24 at 1:21 PM Staff 6 stated he was the nurse on 5/21/24 when the incident between Residents 4 and 5 occurred. Staff 6 stated Resident 4 was "agitated at baseline" but was extra agitated on this particular day. Staff 6 stated he was in the dining room shortly after dinner on 5/21/24 when he observed Resident 4 place her/his hands around Resident 5's neck. Staff 6 stated he was able to immediately intervene and separate the residents. Staff 6 stated he assessed Resident 5 for injuries and there were none. On 5/23/24 at 1:55 PM Resident 5 was observed in her/his room in bed. Resident 5 stated Resident 4 tried to choke her/him the other night and it "hurt when [she/he] did it but hasn't hurt since." Resident 5 stated she/he was worried Resident 4 was going to try and choke her/him again, but she/he was not afraid of the resident. On 5/23/24 at 2:30 PM Staff 7 (CNA) stated Resident 5 reported she/he could not sleep the night following the incident because she/he was concerned about Resident 4. On 5/23/24 at 2:37 PM Staff 5 stated Resident 4 has been "physically violent towards staff and has made body motions to indicate physical violence towards residents" prior to the incident on 5/21/24. Staff 5 further stated Resident 4's behavior on 5/21/24 had been "very violent" even prior to the incident. On 5/24/24 at 11:19 AM Staff 2 (DNS) acknowledged Resident 4 experienced both verbal and physically aggressive behaviors, and the resident had her/his hands around Resident 5's neck on 5/21/24.

F600 Free from Abuse and Neglect Resident #4 remains in the facility and had no ill effect from the incident. They remain on 1:1 staff supervision. The Resident will be reviewed for potential discharge to an appropriate facility. Resident #5 remains in the facility and had no ill effect from the incident. All staff will be in-serviced on behavioral interventions that may reduce occurrence of resident-to-resident abuse. An audit will be performed of all residents behavioral history for incidence of violence or abuse towards others. Residents with this history will have an informative order inplace for nursing to monitor and they will be added to the facilitys LCSW treatment. An audit of all new admits for history of violence or abuse towards others and appropriate order in place will be performed weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on observation, interview and record review it was determined the facility failed to obtain consent, assess, monitor and reevaluate for use of a restraint for 1 of 1 sampled resident (#5) reviewed for restraints. This placed residents at risk for inappropriate use of a restraint. Findings include: The facility's 4/2017 Use of Restraints Policy stated the following: -Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. -Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. - Resident and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. Resident 5 was admitted to the facility in 8/2007 with diagnoses including schizophrenia and dementia with behavioral disturbances. A 7/12/23 Annual MDS reported Resident 5 had a severe cognitive impairment. On 4/3/24 at 9:27 AM Resident 5 was observed laying in bed with four bolster pillows (long tube-shaped pillows) at the left and right sides of the bed. Two pillows were placed on either side of Resident 5's upper body and two pillows were placed on either side of Resident 5's lower body. Review of Resident 5's records revealed consent was not obtained regarding the use of the bolster pillows. Assessment, monitoring and reevaluation of the continued use of the bolster pillows was not performed for the use of bolster pillows. On 4/8/24 at 9:19 AM Staff 3 (LPN Resident Care Manager) stated Resident 5 was able to move in bed and the bolster pillows were there to prevent her/him from falling out of bed. Staff 3 confirmed consent was not obtained from Resident 5's representative for the use of bolster pillows. Staff 3 confirmed no assessment, monitoring or reevaluation was performed for the use of bolster pillows for Resident 5.

Resident 5 received a nursing assessment, POA consent and MD order for use of the bolstered/perimeter mattress. Potential for effect to all residents. All residents will be observed to determine whether they are using a potentially restraining device and will have appropriate orders and assessments put in place. The assigned RCM will be given performance improvement education on the facility policy for restraints and assistive devices for resident use. All Nurses and RCMs will be in-serviced on the facility policy for restraints and assistive devices for resident use. An audit of 5 new residents and/or new assistive device orders will be performed weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to report an incident of suspected abuse in a timely manner for 2 of 4 sampled residents (#s 3 and 18) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 3 was admitted to the facility in 12/2020 with diagnoses including dementia with agitation. Resident 18 was admitted to the facility in 12/2020 with diagnoses including dementia with behavior disturbance and delusional disorder. On 7/25/22 at 11:53 AM a FRI was submitted which indicated on 7/22/22 at 6:17 PM Resident 18 and Resident 3 were overheard yelling at each other and then observed hitting each other. On 4/5/24 at 1:36 PM Staff 1 (Administrator) confirmed the incident of abuse between Resident 3 and Resident 18 occurred and there was a delay in reporting the incident within the required two hour reporting timeframe.

Resident 18 Remains in the facility and had no ill effect from the incident. Resident will be reviewed for potential discharge to an appropriate facility. Resident 3 remains in the facility and had no ill effect from the incident. Potential for effect to all residents. All residents will be interviewed if abuse from other residents was received, and concerns addressed. All staff will be in-serviced on Abuse and timely reporting. An audit will be performed of all incident reports for incidence of abuse x30 days and appropriate reporting. An audit of all incidents reports for abuse and appropriate reporting weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed

Based on observation, interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 1 of 2 sampled residents (#8) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 8 was admitted to the facility in 12/2023 with diagnoses including schizoaffective disorder (a mental health condition), bipolar disorder (a mental health condition) and stroke. Resident 8's current care plan indicated the following: -Resident 8 required extensive assistance of one person for toileting. -Resident 8 required extensive assistance of one person for dressing and personal hygiene. -Resident 8 required extensive assistance of one person for ambulation while using a front wheeled walker. -Resident 8 required extensive assistance of one person for bed mobility and transfers. Multiple observations from 4/2/24 through 4/8/24 between the hours of 8:00 AM and 3:30 PM revealed Resident 8 independently moved in her/his bed, transferred from the bed to standing and/or to her/his wheelchair without assistance, dressed herself/himself and ambulated independently around her/his room without an assistive device. The resident was also observed walking down the east hallway with her/his walker without staff assistance. On 4/4/24 at 10:16 AM Staff 36 (CNA) reported Resident 8 completed most of her/his ADL care on her/his own and she checked on her/him occasionally to see if the resident needed any help. Staff 36 reported Resident 8 used a urinal and CNA staff emptied it for her/him. Staff 36 stated Resident 8 toileted, transferred and fed herself/himself without assistance. On 4/5/24 at 10:24 Staff 19 (CNA) stated Resident 8 did "everything" on her/his own. Staff 19 stated the resident changed her/his own brief independently and ambulated with a walker outside frequently to feed the squirrels. On 4/5/24 at 1:01 PM Staff 3 (LPN Resident Care Manager) reported she spoke to CNAs and reviewed Resident 8's care task logs and confirmed Resident 8's care plan did not accurately reflect her/his level of ADL care needs. On 4/8/24 at 10:33 AM Staff 2 (DNS) stated she expected Resident 8's care plan to accurately reflect her/his current level of ADL functioning.

Resident 8 had their care plan updated to their current ADL functional abilities. Potential for effect to all residents. All residents will have their care plan reviewed and updated to their current ADL functional abilities. The assigned RCM will be given performance improvement education on the facility policy for care plan revision. All Nurses and RCMs will be in-serviced on the facility policy for updating resident care plans to the residents current ADL function. An audit will be performed on 5 resident care plans for accurate ADL functionality weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 1 sampled resident (#53) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 53 was admitted to the facility in 10/2023 with diagnoses including normal pressure hydrocephalus (abnormal buildup of fluid in the brain). The resident was discharged from the facility on 1/14/24 as a resident initiated discharge. A review of Resident 53's health record indicated there was no discharge summary documentation. On 4/8/24 at 10:55 AM Staff 2 (DNS) was not able to provide documentation of a discharge summary for Resident 53.

Resident 53 had a DC summary recap of stay completed and added to the EHR. Potential for effect to all residents. All residents discharged in the last 30days will have their charts for reviewed for DC summary recap of stay and completed if needed. The SSD will be given education the facility policy for Discharge summary and recap of stay process. All Nurses and RCMs will be in-serviced on the facility policy Discharge summary and recap of stay process. An audit will be performed on all residents discharging from facility for completion of the DC summary recap of stay weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 8 and 19) reviewed for edema and hospice services. This placed residents at risk for unmet care needs. Findings include: 1. The undated Hospice and Nursing Facility Services Agreement specified the facility shall provide in a timely manner, those drugs related to the management of the terminal illness. Resident 19 was admitted to the facility in 4/2018 with diagnoses including Huntington's disease (a degenerative disease which affects movement and cognitive functions). Resident 19's 2/8/24 Significant Change MDS indicated the resident received Hospice services. On 4/2/24 at 10:58 AM Witness 1 (Hospice RN) stated an order for glycopyrrolate 1 mg, prescribed to control Resident 19's oral secretions, was faxed to the facility on 3/29/24. Review of Resident 19's health record revealed the glycopyrrolate was not implemented and administered to Resident 19 until 4/3/24, five days after the medication was prescribed. On 4/4/24 at 4:14 PM Staff 3 (LPN Resident Care Manager) reviewed Resident 19's health record and acknowledged the glycopyrrolate was ordered on 3/29/24 and was not implemented and administered to Resident 19 until 4/3/24. Staff 3 explained Hospice provided medication orders by fax and she expected staff to implement the medication orders upon receipt. On 4/8/24 at 10:17 AM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation and acknowledged the medication was not implemented as ordered. , 2. Resident 8 was admitted to the facility in 12/2023 with diagnoses including schizoaffective disorder (a mental health condition), bipolar disorder (a mental health condition) and stroke. A 1/18/24 Physician Order instructed nursing staff to monitor Resident 8's bilateral, lower leg edema (swelling caused by too much fluid trapped in tissues) every 12 hours. There was no evidence in Resident 8's health record to indicate nursing staff monitored Resident 8's bilateral, lower leg edema. On 4/2/24 at 1:21 PM, both of Resident 8's lower legs and ankles were observed to be swollen. On 4/5/24 at 1:35 PM Staff 34 (LPN) stated she was unaware Resident 8 had edema in her/his lower legs and she had not been monitoring the resident's edema until a new order "popped up today." On 4/5/24 at 1:42 PM and 2:24 PM Staff 3 (LPN Resident Care Manager) reported she expected nursing staff to monitor Resident 8's bilateral, lower leg edema. Staff 3 confirmed there was no evidence in Resident 8's health record to indicate the resident's bilateral, lower leg edema was monitored by nursing staff. On 4/8/24 at 10:33 AM Staff 2 (DNS) stated she expected nursing staff to follow physician orders for monitoring Resident 8's lower leg edema.

Resident 8 had their treatment order for monitoring edema updated to include appropriate LN documentation task. Resident 19 had no ill effect from the delay in medication order processing. The Hospice Provider of Resident 19 will now communicate all orders to the assigned RCM via electronic message and fax. Potential for effect to all residents. All residents with orders for edema monitoring will have the order updated to include appropriate LN documentation. The assigned RCM will be given performance improvement education on the facility policy for care plan revision. All Nurses and RCMs will be in-serviced on the facility policy for managing CHF, physical assessment, and process for assessment of edema. An audit will be performed on 5 resident treatment orders to ensure LNs are completing appropriate edema monitoring weekly x4 weeks and monthly x2 months. An audit will be performed on 5 Hospice residents orders for timely order processing weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to ensure nursing staff competencies for 5 of 5 sampled staff (#s 14, 22, 23, 24 and 25) reviewed for competencies. This placed residents at risk for poor quality of care. Findings include: On 4/4/24 at 3:08 PM and 4/5/24 at 8:40 AM Staff 2 (DNS) and Staff 27 (Staffing Coordinator) were asked to provide evidence of staff competencies for Staff 14 (RN), Staff 22 (LPN), Staff 23 (LPN), Staff 24 (RN) and Staff 25 (RN). On 4/4/24 at 4:40 PM and 4/5/24 at 2:38 PM Staff 2 provided an incomplete competency review for Staff 14. Staff 1 (Administrator) and Staff 27 stated they did not have the requested competencies for Staff 22, Staff 23, Staff 24 and Staff 25. Refer to F880

No resident affected. The DNS and Staffing coordinator will be in serviced on the facility policy for performing competency checks of nursing staff and to not put new staff on the floor until a competency is completed or received. All LN/RN staff employee files will be audited to be determine if competency check list is current; any out of date will be brought current. An audit will be performed on all new hire LN/RN staff for completed competency check list weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNA staff (#s 8, 17, 18 and 19) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of personnel records on 4/5/24 with Staff 27 (Staffing Coordinator) indicated the following employees had not received their annual performance evaluations: -Staff 8 (CNA), adjusted seniority date 10/4/08: no annual performance review was completed. -Staff 17 (CNA), adjusted seniority date 11/22/22: no annual performance review was completed. -Staff 18 (CNA), adjusted seniority date 1/21/20: no annual performance review was completed. -Staff 19 (CNA), adjusted seniority date 10/9/21; no annual performance review was completed. On 4/5/24 at 11:52 AM Staff 27 confirmed annual performance reviews for Staff 8, Staff 17, Staff 18 and Staff 19 were not completed. On 4/8/24 at 10:33 AM Staff 2 (DNS) reported she was aware many CNA staff did not have their annual performance reviews completed including Staff 8, Staff 17, Staff 18 and Staff 19.

No resident affected. The staff members cited will have their annual reviews and in-service hour requirements brought current. The DNS will be in serviced on the facility policy for performing annual nurse aide performance reviews and nurse aide 12hrs of yearly in-services. All nurse aide staff employee files will be audited for current annual reviews and 12hrs of in-services completed within the last year; any out of date will be brought current. An audit will be performed on all new hire nurse aide staff for completed annual reviews and monthly completion of required in-service hours weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to ensure residents were not prescribed unnecessary medications for 1 of 5 sampled residents (#29) reviewed for medications. This placed residents at risk for experiencing adverse medication effects. Findings include: Resident 29 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease. A 1/11/24 Physician Order included acyclovir (anitviral medication used to treat herpes simplex viral infections), 800 mg, take one half tablet twice a day for prophylaxis (action taken to prevent disease). The order did not specify which disease the medication was prophylactically prescribed and no further information or rationale for the medication was included in the order. Resident 29's 1/2024, 2/2024, 3/2024 and 4/2024 MARs revealed the resident received acyclovir daily beginning 1/12/24. On 4/5/24 at 1:00 PM Staff 12 (LPN Resident Care Manager) was asked about the indication for use of acyclovir. Staff 12 stated "today" she asked Staff 35 (Physician) for clarification regarding the use of acyclovir and Staff 35 ordered the medication to be discontinued and to "watch for flares." When asked to define what the flares would be in relation to, Staff 12 stated she did not know. Staff 12 stated she reviewed Resident 29's records and was not able to determine an appropriate diagnosis or rationale for the use of daily acyclovir. Staff 12 stated she expected an antiviral medication order to include a proper indication for use and a stop date. On 4/8/24 at 10:38 AM Staff 2 (DNS) and Staff 12 were notified of the findings of this investigation. Staff 12 provided documentation which indicated the acyclovir medication was ordered to be given in addition to chemotherapy which ended in 8/2023. Staff 2 and Staff 12 acknowledged the acyclovir should not have been ordered in 1/2024 or administered beyond 8/2023 and Resident 29 received the acyclovir unnecessarily.

Resident 29 had the medication order discontinued after assessment by MD. Potential for effect to all residents. All resident orders will be assessed for accurate diagnosis and/or indication of use. The assigned RCM will be given performance improvement education on the facility policy for unnecessary drug use and resident order reviews. All Nurses and RCMs will be in-serviced on the facility policy for unnecessary medication and completing orders appropriately. An audit will be performed on 5 residents for complete orders to include diagnosis and/or indication weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on observation and interview it was determined the Dietary Manager failed to obtain the required certification to provide dietary management services for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: From 4/2/24 through 4/8/24 between the hours of 8:00 AM and 5:00 PM, Staff 33 (Dietary Manager) was observed providing Dietary Manager services in the facility kitchen. On 4/5/24 at 11:31 AM Staff 33 stated he had been the Dietary Manager since 4/2022 and had not completed the required certification required for his position as Dietary Manager. On 4/8/24 at 11:04 AM Staff 1 (Administrator) confirmed she was aware Staff 33 had not obtained the required certification.

No specific resident(s) was identified. The facility has hired a new Dietary Manager who has taken the Food Service Manager (FSM) exam and is awaiting results. Residents residing at the facility have the potential to be impacted by the alleged deficient practice. The Dietary Manager will continue to receive frequent scheduled consultations from a Qualified Dietitian who is available in person, by phone, by text or email. The Qualified Dietitian will continue the clinical nutrition oversight for the facility. The Dietary Manager has completed coursework and has taken the Food Service Manager exam and is awaiting test results. The Qualified Dietitian will evaluate the dietary department monthly and will report to the QAPI committee for two months and quarterly for two quarters. Results of the evaluation will be reviewed by the Administrator and DNS via the QAPI committee for further recommendations including the need to assess the Dietary Manager. If the Dietary Manager does not pass the Food Service Manager exam, the facility will continue with additional Qualified Dietitian oversight until the Dietary Manager passes the exam.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate infection control practices for 3 of 11 sampled staff (#s 8, 14 and 15) observed during medication administration and dining. This placed residents at risk for the spread of infection. Findings include: 1. The CDC website, section titled "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers (a device used to measure blood sugar levels) when shared. Using a glucometer for more than one person without cleaning and disinfecting it in between uses contributed to transmission of HBV (Hepatitis B virus). Glucometers should be cleaned and disinfected after every use. The facility's 7/2023 Glucometer Disinfection Policy & Procedure specified glucometers were disinfected after each use with an EPA-registered disinfectant that was effective against viruses. The disinfecting procedure directed staff to wash hands before and after the procedure and to remove and discard gloves and perform hand hygiene prior to exiting the resident room. The facility's 8/2015 Handwashing/Hand Hygiene Policy & Procedure specified hand hygiene was the primary means to prevent the spread of infections. Staff should perform hand hygiene before and after direct contact with residents, before and after handling medications, after contact with objects in the immediate vicinity of residents and after removing gloves. a. Resident 36 was admitted to the facility in 4/2022 with diagnoses including stroke. Resident 41 was admitted to the facility in 3/2022 with diagnoses including type 2 diabetes. On 4/4/24 from 11:55 AM to 12:26 PM Staff 14 (RN) was observed for capillary blood glucose monitoring and insulin administration for Resident 36 and Resident 41. Staff 14 stood at the treatment cart, did not perform hand hygiene, donned gloves, unlocked and opened the cart drawers, obtained Resident 41's insulin pen and obtained blood glucose monitoring supplies including a glucometer. Staff 14 entered Resident 41's room, placed the glucometer on the resident's walker seat and placed the insulin and other supplies directly on the resident's bedside table. Staff 14 used a lancet (a sharp device used to prick the finger to obtain blood) to prick the resident's finger, put a sample of blood on the test strip, plugged the test strip into the glucometer and placed the glucometer onto the resident's bedside table. Staff 14 then lifted Resident 41's shirt and administered the resident's insulin into her/his stomach. Staff 14 gathered all of the used supplies into her right gloved hand and escorted the resident to the dining room. Staff 14 returned to the treatment cart, discarded the used lancet and test strip and placed the used glucometer on the surface of the cart. Staff 14 used her gloved hands to retrieve keys from her shirt pocket, unlocked the cart, typed on the keyboard, opened the cart drawer and placed the glucometer into the cart drawer. Staff 14 did not disinfect the glucometer before or after use. Without changing her gloves or performing hand hygiene, Staff 14 then obtained Resident 36's insulin from the cart and drew up five units of insulin from the resident's insulin vial. At 12:17 PM Staff 14 entered Resident 36's room, picked up the resident's personal glucometer from the resident's table, scanned the resident's implanted glucose monitoring device, replaced the glucometer on the table, lifted the resident's shirt sleeve and administered the five units of insulin into the resident's arm. Staff 14 gathered all of the used supplies into her right gloved hand, returned to the cart, doffed her gloves, did not perform hand hygiene and entered the dining room where she stated she was needed to assist residents. On 4/4/24 at 12:31 PM and 1:33 PM Staff 14 was asked about the frequency of hand hygiene and stated she "usually" washed her hands after contact with a resident if she was not wearing gloves. Staff 14 stated if she wore gloves then she washed her hands after removing the gloves. Staff 14 was asked about her understanding related to glove use and stated if she got something on the gloves, then she put on a new pair. Staff 14 stated the same gloves should not be worn for other residents. When asked about her understanding related to glucometer use and disinfection, Staff 14 stated she "was supposed to wipe it down with alcohol between residents" and stated "I have not done that at all today." On 4/4/24 at 1:49 PM review of Resident 36's, Resident 41's, and all other diabetic residents' health records revealed no diagnoses including viral bloodborne pathogens. On 4/4/24 at 3:08 PM Staff 2 (DNS) was informed about Staff 14's lack of appropriate infection control practices during insulin administration and blood glucose monitoring. Staff 2 stated she expected staff to disinfect the glucometer between each use with an appropriate virucidal (destroys viruses) disinfecting wipe and to wait for the the adequate amount of time for the product to work. Staff 2 stated she expected staff to follow basic infection control practices, perform hand hygiene between resident contact, before and after glove use, and to change gloves if they were soiled and between residents. b. Resident 6 was admitted to the facility in 4/2017 with diagnoses including vascular disease. Resident 20 was admitted to the facility in 4/2022 with diagnoses including heart failure. On 4/8/24 from 9:09 AM to 9:37 AM Staff 15 (CMA) was observed for medication administration. Staff 15 dispensed Resident 20's medications, entered the resident's room, repositioned the resident by using the bed control, handled items in the resident's immediate environment and then administered the medications. Staff 15 returned to the medication cart, did not perform hand hygiene, and began to dispense Resident 6's medications which included opening a medication capsule with her bare hands. Staff 15 approached Resident 6, obtained the resident's blood pressure and then administered Resident 6's medications. On 4/8/24 at 9:38 AM Staff 15 was asked about the frequency of hand hygiene and stated she "should" wash her hands after touching a resident or their items and upon entrance and exit of resident rooms. On 4/8/24 at 10:18 AM Staff 2 (DNS) was notified regarding Staff 15's lack of appropriate hand hygiene during medication administration. Staff 2 acknowledged the lack of appropriate infection control practices. , 2. On 4/2/24 between the hours of 11:55 AM and 12:30 PM, during the lunch meal in the East dining room, the following observations were made: -12:02 PM an unidentified CNA put on clean gloves and then removed them, positioned a resident upright for eating and placed a bedside table in front of the resident. The staff member then removed a clean pair of gloves from a box of gloves and put them on without completing hand hygiene. Staff 8 (CNA) also removed a pair of clean gloves from a box of gloves and put them on to pass a tray and set-up the resident to eat. Staff 8 removed her gloves, discarded the gloves and then immediately removed another pair of clean gloves from the box of gloves. Both staff put clean gloves on without completing hand hygiene. -12:11 PM Staff 8 repositioned a resident's leg onto leg rests then removed a clean pair of gloves from a box of gloves and put them on without completing hand hygiene. -12:14 PM Staff 8 wore the same pair of gloves while providing eating assistance to two residents at the same time. Staff 8 alternated between one resident and then the other without changing her gloves or completing hand hygiene between residents. -12:18 PM Staff 8 removed her gloves then obtained a clean pair of gloves from a box. Staff 8 put the clean gloves on, retrieved a stool and sat down to assist a resident with eating. Staff 8 did not complete hand hygiene. -12:30 PM Staff 8 assisted two residents with eating, alternating between the two residents while using the same pair of gloves. Resident 8 touched each resident to adjust clothing or sooth the residents. Staff 8 did not change her gloves or complete hand hygiene. On 4/2/24 at 12: 30 PM Staff 8 stated she was supposed to put on gloves, pass a tray, set-up the resident, remove the gloves, complete hand hygiene and put on a new pair of gloves. Staff 8 reported staff were not supposed to use the same gloves between residents. Staff 8 reported she did not consistently change her gloves between residents and did not complete hand hygiene after removing her gloves. She stated, "I sometimes get with the motion and just go." On 4/8/24 at 10:33 AM Staff 2 (DNS) stated it was not "ok" for staff to wear the same gloves between residents and it was her expectation staff complete hand hygiene after removing dirty gloves and prior to putting on clean gloves.

No Residents were cited. Staff member 8 received performance improvement education for infection prevention policy, hand hygiene, glucometer cleaning/disinfection. Staff member 15 received education regarding hand hygiene and opening capsules with out gloves. All Nursing staff will be serviced on hand hygiene and PPE use. All LN/RN staff will be in serviced on infection prevention/control policy and glucometer cleaning/disinfection. Hand Sanitizer will be placed on appropriate dining room tables during meals. An audit will be performed on 5 CBG checks performed by LN/RN staff for appropriate cleaning/disinfection and PPE use weekly x4 weeks and monthly x2 months. An audit will be performed on 10 nursing staff of various shifts for appropriate hand hygiene and PPE use weekly x4 weeks and monthly x2 months. Audits will be completed by DNS or Designee. All audit results will be brought to facility QAPI meeting to be reviewed and determined if further action is needed.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 16, 17, 18, and 19) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 4/5/24 at 1:00 PM Staff 2 (DNS) provided a list of training hours for the sampled staff and confirmed the following: -Staff 16 (CNA): 8.6 annual training hours; -Staff 17 (CNA): 0 annual training hours; -Staff 18 (CNA): 9.10 annual training hours and -Staff 19 (CNA): 4 annual training hours. On 4/5/24 at 1:00 PM and 4/8/24 at 10:33 AM Staff 2 confirmed Staff 16, Staff 17, Staff 18 and Staff 19 did not complete the required 12 hours of annual in-service trainings. Staff 2 stated she was aware CNA trainings were not being completed.

No specific resident(s) was identified. Staff #s 16, 17, 18 and 19 were assigned in-service training and education. Residents residing at the facility have the potential to be impacted by the alleged deficient practice. An audit of staff will be conducted to determine specific staff members who may require additional in-service training and education. Staff identified as needing additional education will be assigned trainings as indicated. Staff will be provided education on the yearly educational requirements. A monthly tracking system has been initiated to ensure that staff is on track with required education. The Administrator/Designee will conduct monthly audits for 3 months to ensure that the required in-service education is completed. Compliance will be reported to the monthly QAPI committee for two months and quarterly QAPI for further recommendations including the need and frequency of continued audits.

Based on interview and record review it was determined the facility failed to obtain reference checks for 1 of 5 newly hired facility staff members (#20) reviewed for background checks. This placed residents at risk for abuse. Findings include: A review of the facility's undated Employee Licensure and Reference Checks policy revealed employment candidates' references checks were completed prior to an employee being hired. On 4/5/24 at 9:54 AM Staff 27 (Staffing Coordinator) stated she completed reference checks for employment candidates. A review of the facility's new hires in the previous four months revealed the following: -Staff 20 (CNA) was hired on 3/14/24. There was no evidence reference checks were completed for Staff 20. On 4/8/24 at 8:04 AM Staff 27 confirmed she was unable to locate any reference checks for Staff 20.

No specific resident(s) was identified. Reference check for staff member 20 was conducted. Residents residing at the facility have the potential to be impacted by the alleged deficient practice. An audit of staff will be conducted to determine if staff members have had reference checks completed. If there are staff members missing reference checks, those will be completed. Education will be provided for hiring managers regarding reference check process. The facilitys hiring process provides guidance for timeline of reference checks which is prior to hire. Reference checks can be completed electronically through the automated hiring process or by handwritten means using the reference check form. The hiring managers at the facility will be provided education on this process. Administrator/Designee will review reference check process monthly for two months and quarterly for to quarters. Results of the reference check review will be reported to QAPI committee who will make recommendations including the need and frequency of continued audits.

Based on interview and record review it was determined the facility failed to ensure background checks were completed for newly hired staff for 1 of 5 sampled staff (#21) reviewed for background checks. This placed residents at risk for abuse. Findings include: On 4/5/24 at 9:22 AM, during a review of five randomly selected staff backgrounds checks, Staff 27 (Staffing Coordinator) stated the following: -Staff 21 (CNA), hire date of 2/5/24, had no background check completed. On 4/5/24 at 12:46 PM Staff 1 (Administrator) provided Staff 21's background check determination report which indicated a background check was started on 2/1/24 and closed on 2/16/24 due to Staff 21 not submitting required information. Staff 1 reported she was not aware Staff 21's background check was not completed, until today. On 4/8/24 at 9:04 AM Staff 30 (Staffing Coordinator) confirmed Staff 21 worked, without a background check being in process, on the following days in 2/2024, 3/2024 and 4/2024: 2/17, 2/19, 2/20, 2/21, 2/24, 2/27, 2/28, 2/29, 3/1, 3/2, 3/5, 3/6, 3/7, 3/8, 3/9, 3/11, 3/12, 3/13, 3/14, 3/19, 3/20, 3/22, 3/23, 3/26, 3/27, 4/1, 4/2 and 4/3.

No specific resident(s) was identified. Background check for staff member 21 was conducted. Residents residing at the facility have the potential to be impacted by the alleged deficient practice. An audit of staff will be conducted to determine if staff members have had their background checks completed. If there are staff members missing reference checks, those will be completed. Education will be provided for hiring managers regarding background check process. The facilitys hiring process provides guidance for timeline of reference checks which is at the time the job offer is accepted. The hiring managers at the facility will be provided education on this process. The Facility has reviewed and updated its Abuse Prevention, Investigation and Reporting Policy to include the process to ensure active supervision of all staff whose background checks are pending in preliminary status. Staffing Coordinator has been trained in the updated policy and process. Staff have been provided with education to their part in the active supervision process. The Staffing Coordinator will keep a running list of staff on preliminary status and ensure timeclock are posting and Nurse station posting are up to date. Administrator/Designee will review background check process monthly for two months and quarterly for two quarters. Results of the background check review will be reported to QAPI committee who will make recommendations including the need and frequency of continued audits.

******************** OAR 411-085-0310 Residents Rights: Generally Refer to F550 and F552 ******************** OAR 411-086-0360 Residents furnishings, equipment Refer to F558 ******************** OAR 411-087-0100 Physical Environment: Generally Refer to F584 ******************** OAR 411-085-0360 Abuse Refer to F600 and F609 ******************** OAR 411-085-0310 Residents Rights: Generally (physical restraints) Refer to F604 ******************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F657 ******************** OAR 411-086-0160 Nursing Services: Discharge Summary Refer to F661 ******************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ******************** OAR 411-086-0100 Nursing Services: Staffing Refer to F726 ******************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F730 ******************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F757 ******************** OAR 411-086-0250 Dietary Services Refer to F801 ******************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ******************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F947 ********************

******************** 411-085-0360 Abuse Refer to F-600 ********************

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 10/16/2023 and 10/22/2023, 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 10/09/2023 and 10/15/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to immediately notify the physician of a significant change in condition and head injury for 2 of 3 sampled residents (#s 1 and 3) reviewed for change in condition. This resulted in delayed treatment for Resident 3's significant change in condition and placed residents at risk for unmet needs and delayed treatment. Findings include: 1. Resident 3 was admitted to the facility in 2021 with diagnoses including dementia and partial paralysis. Resident 3's Progress Notes revealed the following: - On 5/23/23: Witness 4 (Physician) assessed Resident 3 related to the resident's family report of pain during a bowel movement. An immediate x-ray was ordered. - On 5/24/23: Results from the x-ray found no definitive evidence of lack of bowel motility or obstruction. - On 6/1/23 at 10:20 AM: Resident 3 was found in their bed with brown and yellow emesis (vomit). The resident's temperature was 101.7 (normal is 98.6), blood sugar 404 (normal is 70 to 100), blood pressure 195/85 (normal is 120/80). The resident's "current status" was reported to Staff 3 (RNCM) who indicated she would contact the resident's family and physician for possible "send out" [to the hospital]. (No evidence was found to indicate the resident's physician was immediately notified.) On 9/19/23 at 1:18 PM Staff 3 verified there was no evidence the resident's physician was immediately notified of her/his change in condition. On 9/20/23 at 11:01 AM Witness 4 stated he did not recall, or have notes to indicate, the facility notified him of the resident's change in condition on 6/1/23 at or around 10:20 AM. Refer to F684 example 1. 2. Resident 1 was admitted to the facility in 2018 with diagnoses including Alzheimer's disease. On 12/5/22 a Nursing Facility Reported Incident was received which indicated Resident 1 was found with a raised, red lump on the back of her/his head. The (unnamed) RNCM, DNS and Administrator were notified. A review of Resident 1's health record revealed no notification to the physician of the injury. On 9/21/23 at 10:04 AM Staff 1 (Administrator) and Staff 2 (DNS) verified there was no assessment of the bump, assessment of neurological status, the injury was not monitored or the physician notified. Refer to F684 example 3.

F580 SS=G Notify of Changes (Injury/Decline/Room, etc.) Problem: Based on interview and record review it was determined the facility failed to immediately notify the physician of a significant change in condition and head injury for 2 of 3 sampled residents (#s 1 and 3) reviewed for change in condition. This resulted in delayed treatment for Resident 3's significant change in condition and placed residents at risk for unmet needs and delayed treatment. #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #1 -Resident was assessed by DNS, it was determined the bump may reasonably be the result of recurrent botox injections, no evidence of a care deficiency, fall, abuse or neglect. -Residents representative will be notified of investigation results. -Care Plan will be reviewed and updated to reflect all treatments. -Charge Nurse, RCMs, DNS will be in-serviced on incident reporting and investigation policies and procedures including: -Assessment of injury -Assessment of neurological status -Monitoring injuries -Notifying physician of significant changes Resident #3 Resident no longer resides at community. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have potential to be affected by the deficient practice. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: -All new nursing leadership in facility. -Facility leadership will review and update incident procedure as needed. -Facility leadership will review onboarding materials to ensure inclusion of monitoring for change of condition, alert charting, incident procedures and use of SBAR form for physician communication. -Facility leadership will ensure a summary of alert charting and notification protocols are readily available to nursing staff for reference. -Facility leadership will ensure SBAR form is available for staff use. -All nursing and housekeeping staff will receive training on monitoring residents for change of condition. Staff will complete a post training quiz to demonstrate comprehension. A passing score is 80%. Staff will be required to retake the training and quiz until they are able to pass the quiz. -All LNs will receive training on alert charting. -All LNs will receive training on notification protocols. All LNs will receive training using the SBAR form for physician notification. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. -Nursing leadership will review the 24-Hr Report 5x/week. -Monitor for appropriate management of incidents, changes of condition. -Facility leadership will perform a weekly audit of residents to monitor adherence to appropriate monitoring for change of condition, notification protocols and use of SBAR form for physician communication. -Audit results will be reported to and progress monitored through facility QAPI committee. #5 Title of Person Responsible to ensure correction and sustain compliance. DNS, Cynthia Fulton-Tinawi

Based on interview and record reviewed it was determined the facility failed to ensure residents were free from physical restraints for 1 of 3 sampled residents (#6) reviewed for use of physical restraints. This failure resulted in Resident 6 displaying signs of emotional distress and verbalizing feelings of having been raped. Findings include: The facility's Physical Restraint policy and procedure last updated 6/22/23, indicated the following: -Physical restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Emergency use of physical restraints could be used when it was determined the resident or others were in a life threatening or safety threatening situation (fear for the safety of the resident or others due to violent behavior such as attacking others). The emergency use of a restraint is only for the period of imminent danger. -The RCM (Resident Care Manager), DNS and Administrator must be notified of any emergency situation that required the use of a physical restraint. -Restraints shall not be used for staff convenience or discipline. Resident 6 was admitted to the facility in 2021 with diagnoses including dementia with behavioral disturbance and delusional disorder. A 5/9/23 Progress Note written at 1:36 PM by Staff 4 (Former RNCM) indicated Resident 6 required a brief change, was agitated and refused care. Staff 4 indicated all attempts to calm, console, redirect and distract the resident were ineffective so Staff 4 held Resident 6's arms above the wrists to prevent her/him from hitting and scratching CNAs so they could complete the resident's brief change, complete peri-care and change the resident's clothing. Staff 4 documented there was no injury to the staff but the resident was emotionally upset. A 6/9/23 Facility Investigation indicated Resident 6 required extensive assistance with incontinence care and the resident often refused to have her/his briefs changed when soiled. Resident 6 was combative at times during hands on care, and the resident had a history of rape which triggered her/him to become fearful when personal hands-on care was provided. On 5/9/23, Resident 6 was brought to her/his room and resisted having her/his brief changed so Staff 4 physically held Resident 6 down by her/his arms to allow the CNA staff to complete the resident's brief change. The investigation substantiated abuse. The 7/6/23 Annual MDS indicated Resident 6 had severe cognitive impairments, had verbal and physical behaviors directed towards others which did not put the resident at risk for physical injury or illness but significantly interfered with the resident's care. Resident 6 rejected care on a daily basis. The behavioral CAA indicated as a result of prior traumatic events, Resident 6 often refused personal care assistance and could become anxious and agitated at times when staff approached her/him too frequently. Resident 6 was known to strike out if staff were persistent in providing her/him care. On 9/18/23 at 11:15 AM Staff 8 (Social Service Director) stated she assisted with the investigation regarding the 5/9/23 incident which involved Resident 6 and confirmed the resident was physically restrained by Staff 4 during ADL care. Staff 8 stated the resident had a fear of people touching her/him based on her/his past history of being raped and being restrained triggered "something with the resident" associated with being raped. Staff 8 stated the incident occurred on 5/9/23 but was not identified as a problem until a staff member brought the incident up while Staff 8 was completing staff interviews related to a different incident. Staff 8 stated no resident "should ever be treated like that" and the practice of physically restraining Resident 6 was immediately stopped. On 9/18/23 at 5:52 PM Staff 9 (Nurse Consultant) reported she reviewed Resident 6's health care record and interviewed staff members regarding the 5/9/23 incident. Staff 9 stated she concluded that no interventions were attempted with Resident 6 prior to Staff 4 physically restraining Resident 6. Staff 9 stated her interviews with staff revealed the practice of physically restraining Resident 6 had been going on "for a long time." Staff 9 reported many staff stated they were uncomfortable with the practice of restraining Resident 6 but were told by Staff 5 (Former DNS) they had to do "whatever necessary" to change the resident's brief. On 9/19/23 at 9:22 AM Staff 4 stated on 5/9/23, Resident 6 was in the common area, her/his brief was soiled and she/he needed to have her/his brief changed. Staff 4 reported the resident was agitated and refused ADL care so she asked two CNAs to walk the resident arm-in-arm to her/his room so ADL care could be provided. Staff 4 stated she went to Resident 6's room to assist with ADL care and the resident was attempting to hit and kick the CNAs so she "blocked" her/him. Staff 4 stated Resident 6's behaviors continued to escalate so she physically restrained the resident because "there was no other way to deal with the situation except to restrain [her/him]." Staff 4 stated there were no other staff in the area so she was unable to attempt other interventions. When asked if staff left Resident 6's room to allow her/him time to calm down, Staff 4 stated "no." On 9/18/23 and 9/20/21 between 8:46 AM and 12:42 PM, Staff 6 (CNA), Staff 7 (CNA), Staff 10 (CNA), Staff 11 (RN) and Staff 12 (CNA) reported, prior to the 6/9/23 investigation, it was a regular practice to physically restrain Resident 6 by holding her/him down to change her/his briefs. Staff 12 stated she told Staff 4 and Staff 5 she was uncomfortable restraining Resident 6. Staff 12 stated this practice was approved by Staff 4 and Staff 5 when Resident 6 refused to allow her/his briefs to be changed and Staff 4 and Staff 5 assisted in restraining Resident 6, at times. On 9/20/23 at 1:21 PM and 9/21/23 at 9:09 AM Staff 1 (Administrator) confirmed Resident 6 was physically restrained to allow staff to change her/his brief which constituted abuse. Staff 1 stated there were other interventions in place that should have been utilized. Staff 1 stated Resident 6 had a past history of rape and Resident 6 experienced psychosocial harm as a result of being physically restrained to provide ADL care .

F604 SS=G Right to be Free from Physical Restraints Problem: Based on interview and record reviewed it was determined the facility failed to ensure residents were free from physical restraints for 1 of 3 sampled residents (#6) reviewed for use of physical restraints. This failure resulted in Resident 6 displaying signs of emotional distress and verbalizing feelings of having been raped. #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #6 - Resident was placed on monitoring for psycho-social harm related to the incident. She has returned to baseline behaviors. - Residents care plan will be updated to reflect trauma-informed care needs. - Staff involved were in-serviced on facility physical restraint policy. - All staff will be in-serviced on physical restraint policy. - Former DNS and former RCM were counseled on following resident care plan and physical restraint policy and no longer work at facility. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents reviewed to identify residents with restraints, known or potential resistance to care based on history or past trauma who may be affected by the deficient practice. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: - All new nursing leadership in the facility. - Restraint review will be part of clinical meetings with new DNS as appropriate and needed. - Restraint committee formed to review use of restraints in the facility. Committee to review ¿483.12 Freedom from Abuse, Neglect, and Exploitation and ¿483.21(b) Comprehensive Care Plans in relation to trauma-informed care. Committee to review and update as necessary physical and chemical restraint policies. - Social Services Director will review and evaluate residents for trauma-based care. - Care plans for residents identified at risk due to history of restraints or trauma will be reviewed and updated to provide staff with clear instructions on providing care in a trauma-informed and appropriate manner. - Onboarding training materials will be reviewed and modified as needed to include information regarding trauma-informed care. - Staff will complete training on trauma-informed care. - Staff will receive training on facility policies regarding physical and chemical restraints. - Staff will be notified and receive training on care plan updates. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. - Facility leadership or designee will facilitate shift huddle discussions regarding effectiveness of planned interventions for trauma informed care and to seek direct care staff input. - Facility leadership or designee will observe care for at-risk residents at least 1x/week to ensure care plans are followed and appropriate for each residents needs providing just in time training as needed. Observations will be recorded in a log/audit. Log/audit will be shared with restraint committee - Restraint committee will perform a monthly review of residents with any type of restraint or at risk of restraints and effectiveness of care planned interventions. Committee reports findings in QAPI meetings. #5 Title of Person Responsible to ensure correction and sustain compliance. DNS Cynthia Fulton-Tinawi

1.

Based on interview and record review it was determined the facility failed to promptly transfer a resident to the hospital related to a significant change in condition for 1 of 3 sampled residents (#3) reviewed for change in condition. This resulted in a subsequent decline in condition and delayed treatment for Resident 3. Findings include: Resident 3 was admitted to the facility in 2021 with diagnoses including dementia and partial paralysis. On 9/18/23 at 9:26 AM Witness 3 (Complainant) stated the facility failed to get Resident 3 timely medical attention prior to the resident being transferred to the hospital on 6/1/23. Resident 3's Progress Notes revealed the following: - On 5/23/23: Witness 4 (Physician) assessed Resident 3 related to the resident's family report of pain during a bowel movement. An immediate x-ray was ordered. - On 5/24/23: Results from the x-ray found no definitive evidence of lack of bowel motility or obstruction. - On 6/1/23 at 10:20 AM: Resident 3 was found in their bed with brown and yellow emesis (vomit). The resident's temperature was 101.7 (normal is 98.6), blood sugar 404 (normal is 70 to 100), blood pressure 195/85 (normal is 120/80). The resident's "current status" was reported to Staff 3 (RNCM) who indicated she would contact the resident's family and physician for possible "send out" [to the hospital]. (No clinical rationale was provided for why the resident was not immediately transferred to the hospital.) - On 6/1/23 at 2:18 PM: Resident 3's blood pressure was 85/55, blood sugar 297 and the resident was unresponsive. Staff 3 gave instructions to send the resident to the hospital. - On 6/2/23: Resident 3 was admitted to the hospital for a large kidney stone. On 9/19/23 at 1:18 PM Staff 3 verified no clinical rational was provided for the decision not to immediately send Resident 3 to the hospital 6/1/23 at or around 10:20 AM. On 9/20/23 at 11:01 AM The 6/1/23 10:20 AM Progress Note was reviewed with Witness 4 and he was asked what orders he would have given to the facility had he been notified. Witness 4 stated he would have instructed the facility to send the resident to the hospital. 2. Based on interview and record review it was determined the facility failed to ensure residents were free from avoidable skin impairment for 1 of 3 sampled residents (#2) reviewed for skin. This placed residents at risk for skin injuries and infection. Findings include: Resident 2 was admitted to the facility in 2023 with diagnoses including failure to thrive. On 5/6/23 a Nursing Facility Reported Incident was received which indicated on 5/5/23 a pack of wipes was left underneath the resident's back which caused a skin injury to the resident's left upper back. The wound was described as an open blister with indentation marks. On 9/19/23 at 2:00 PM Staff 1 (Administrator) verified a pack of wipes was left under Resident 2 which caused a skin injury. 3. Based on interview and record review it was determined the facility failed to assess and monitor a head injury for 1 of 3 sampled residents (#1) reviewed for skin. This placed residents at risk for complications related to head injuries snd unmet needs. Findings include: Resident 1 was admitted to the facility in 2018 with diagnoses including Alzheimer's disease. On 12/5/22 a Nursing Facility Reported Incident was received which indicated Resident 1 was found with a raised, red lump on the back of her/his head. The (unnamed) RNCM, DNS and Administrator were notified. A review of Resident 1's clinical record revealed no assessment to rule out a potential head injury, alert charting for a new head injury, assessment of the resident's neurological status, or notification to the physician of the injury. No ongoing monitoring of the injury or the resident's neurological status was found. On 9/21/23 at 10:04 AM Staff 1 (Administrator) and Staff 2 (DNS) verified there was no assessment of the bump, assessment of neurological status, the injury was not monitored or the physician notified.

F684 SS=G Quality of Care Problem: Based on interview and record review it was determined the facility failed to promptly transfer a resident to the hospital related to a significant change in condition for 1 of 3 sampled residents (#3) reviewed for change in condition. This resulted in a subsequent decline in condition and delayed treatment for Resident 3. #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #3 Resident no longer resides at the facility. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by the deficient practice. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: -All new nursing leadership in the facility. -Facility leadership will review onboarding materials to ensure inclusion of monitoring for change of condition, alert charting, notification protocols and use of SBAR form for physician communication. -Facility leadership will ensure a summary of alert charting and notification protocols are readily available to nursing staff for reference. -Facility leadership will ensure SBAR form is available for staff use. -All staff will receive training on monitoring residents for change of condition. Staff will complete a post training quiz to demonstrate comprehension. A passing score is 80%. Staff will be required to retake the training and quiz until they achieve a passing score. -Nursing staff will receive documentation training. Staff will complete a post training quiz to demonstrate comprehension. A passing score is 80%. Staff will be required to retake the training and quiz until they achieve a passing score. -Nursing staff will receive training on alert charting protocols. -Nursing staff will receive training on use of notification protocols and use of SBAR form. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. -Nursing leadership will review the 24-Hr Report 5x/week. Monitor for appropriate management of changes of condition. -Facility leadership or designee will facilitate shift huddle discussions to ensure shift to shift transfer of information regarding resident status and to seek direct care staff input. -Facility leadership will perform a weekly audit of residents to monitor adherence to appropriate monitoring for change of condition, alert charting, notifications and use of SBAR form. Audit results will be reported to and monitored by facility QAPI committee. #5 Title of Person Responsible to ensure correction and sustain compliance. DNS, Cynthia Fulton-Tinawi

Based on interview and record review it was determined the facility failed to assess a pressure ulcer for 1 of 3 sampled residents (#3) reviewed for skin impairment. This placed residents at risk for worsening pressure ulcers and delayed healing. Findings include: CMS Appendix PP dated 2/3/23 defined the following: Stage 1 Pressure Injury (PI): Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Resident 3 was admitted to the facility in 2021 with diagnoses including partial paralysis. A Progress Note dated 7/12/22 indicated a "Red patch of skin smaller than a dime was found on resident's upper buttocks, close to the left cheek." An order was entered for a sacrum (tail bone) dressing to be changed daily and monitor for increased redness. (The note failed to indicate if the redness was blanchable.) Resident 3's TARs from 10/2021 through 6/1/23 revealed from 7/12/22 through 6/1/23 treatment was in place for a bandage to the resident's sacrum. A review of Resident 3's health record from 7/12/22 through 6/1/23 revealed no assessments of the resident's sacrum/buttock wound. On 9/21/23 at 2:00 PM Staff 2 (DNS) confirmed there were no assessments of Resident 3's sacrum/buttock in the health record.

F686 SS=D Treatment / Svcs to Prevent / Heal Pressure Ulcer Problem: Based on interview and record review it was determined the facility failed to assess a pressure ulcer for 1 of 3 sampled residents (#3) reviewed for skin impairment. This placed residents at risk for worsening pressure ulcers and delayed healing. #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #3 Resident no longer resides at facility. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents will be reviewed to determine risk for or presence of pressure ulcers. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: -All new nursing leadership in the facility. -Involved CNA no longer working at the facility due to the incident. -Care Staff will receive training on appropriate resident care including monitoring location of supplies used and ensuring they are put away properly after use. -Weekly skin rounds/monitoring system to be implemented. All skin concerns will be assessed at least weekly or more often as indicated/ordered. Physicians will be notified of results of skin assessments as appropriate. Treatment orders will be promptly implemented. -All Nursing Staff will receive training on skin monitoring. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. -DNS or designee will record results of weekly skin rounds. -DNS or designee will perform and record a weekly assessment of known skin conditions. -Facility Leadership will perform weekly audits of ordered skin treatments to ensure treatments were completed as ordered and physicians notified as appropriate. Audit results will be reported to and monitored by the QAPI committee. #5 Title of Person Responsible to ensure correction and sustain compliance. DNS, Cynthia Fulton-Tinawi

Based on interview and record review it was determined the facility to ensure safe transfers were performed for 1 of 3 sampled residents (#4) reviewed for transfer safety. This placed residents at risk for accidents and falls. Findings include: Resident 4 was admitted to the facility in 2017 with diagnoses including Alzheimer's. The facility's Using a Mechanical Lifting Machine policy from 4/2017 stated, "at least two nursing assistants are needed to safely move a resident with a mechanical lift." Resident 4's 2/2023 Care Plan stated all transfers were to be performed with a sit to stand mechanical lift. A 5/17/23 Incident Review reported Resident 4 experienced 2 lacerations on her/his head which were determined to be as a result of injury from an unsafe transfer using a sit to stand mechanical lift with the assistance of only one CNA. On 9/19/23 at 9:26 AM Staff 15 stated Resident 4 required the use of a sit to stand mechanical lift which always required two trained nurses to safely use. Staff 15 stated she observed Staff 16 assisting Resident 4 with ADLs on the morning of 5/17/23 and stated she would return to assist with the use of the sit to stand mechanical lift when Staff 16 was ready. Staff 15 reported she returned to Resident 4's room and saw Resident 4 in a wheelchair with two new cuts on her/his forehead. Staff 15 stated she "could tell Resident 4 had fallen and Staff 16 was trying to cover up the accident." Staff 15 stated "Staff 16 attempted to cover up the incident by stating I was in the room during the fall, assisting her with Resident 4's transfer." On 9/19/23 at 9:38 AM Staff 4 (Former RNCM) confirmed Resident 4 received the assistance of only one CNA who used a sit to stand mechanical lift alone, which resulted in a fall and two small cuts.

F689 SS=D Free of Accident Hazards/Supervision/Devices Problem: Based on interview and record review it was determined the facility to ensure safe transfers were performed for 1 of 3 sampled residents (#4) reviewed for transfer safety. This placed residents at risk for accidents and falls. #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #4. -Residents care plan will be reviewed and updated as needed. -Staff will be educated on reading and following the residents care plan. -Agency CNA involved in improper transfer technique is no longer permitted to work at this facility. -Residents representative will be notified of the investigation outcome. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents will be reviewed to identify residents requiring 2 person staff assistance for transfers. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: -All new nursing leadership in the facility. -Involved CNA no longer working at the facility due to the incident. -Onboarding materials will be reviewed to ensure safe transferring practices are included in orientation. -All Nursing Staff will receive training on appropriate and safe transfer practices. -Care plans of all residents who require 2 person transfers will be reviewed and updated as needed. -Nursing leadership or designee will facilitate shift huddles to discuss transfers and allow staff an opportunity to provide feedback regarding care plans. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. DNS or designee will observe resident transfers randomly to monitor for safe transfer practices and provide just in time training as needed. DNS or designee will keep a log/audit of: Transfers observed Adherence to care plan/safe transfer practices Just in time training provided Log/audit results will be presented to QAPI committee. #5 Title of Person Responsible to ensure correction and sustain compliance. DNS, Cynthia Fulton-Tinawi

Based on interview and record review it was determined the facility failed to ensure residents maintained acceptable parameters for nutrition for 2 of 3 sampled residents (#s 1 and 3) reviewed for weight loss. This resulted in Resident 1 and Resident 3 having severe weight loss and placed residents at risk for weight loss. Findings include: 1. Resident 3 was admitted to the facility in 2021 with diagnoses including dementia and partial paralysis. Resident 3's weight record revealed the following: - On 10/25/21 the resident weighed 177 pounds. - On 11/23/21 the resident weighed 167.2 pounds (a 5.5% weight loss in 29 days). - On 5/4/22 the resident weighed 146.8 pounds (a 17% weight loss over six months). Resident 3's Nutrition At Risk notes revealed the following: - 11/28/21: The resident's 30-day meal intake indicated the resident consumed less than 50% 20 times, 51-75% 24 times, 76-100% 25 times and refused 17 meals. Interventions included a liquid supplement (administration frequency was not specified). The resident required extensive assistance with dining. The "Plan" was for monthly weights, assistance and encouragement with eating. There was no evidence to indicate the resident's weight loss was addressed or any specific interventions were added to increase the resident's nutritional intake. - 12/13/21: The resident's 30-day meal intake indicated the resident consumed less than 50% 11 times, 51-75% 21 times, 76-100% 53 times and refused 12 meals. Interventions included a liquid supplement (administration frequency was not specified). "Resident meal intakes improved with staff assistance" The "Plan" was unchanged from 11/28/21. - 1/25/22: The resident had lost 11.4 pounds or 6.6% from 12/1/21. The resident's 30-day meal intake indicated the resident consumed less than 50% 21 times, 51-75% 27 times, 76-100% 35 times and refused four meals. Interventions included a liquid supplement 240 ml (administration frequency was not specified). The "Plan" was unchanged from 11/28/21. - 2/15/22: The resident was identified with a seven pound or 4% weight loss since 1/4/22. The resident's 30-day meal intake indicated the resident consumed less than 50% 8 times, 51-75% 33 times, 76-100% 40 times and refused six meals. Interventions included a liquid supplement although administration frequency was not specified). "Staff report [the resident] doesn't want to eat but will accept liquid supplement." The "Plan" included a new intervention for a liquid supplement with meals. No assessment was included related to the indication the resident "doesn't want to eat" and the resident only refused six meal. - 3/18/22: The resident's 30-day meal intake indicated the resident consumed less than 50% 9 times, 51-75% 29 times, 76-100% 42 times and refused seven meals. Interventions included a liquid supplement (administration frequency was not specified). The resident was identified as having a 18.8 pound or 10.9% weight loss from 10/26/21 to 3/3/22. The "Plan" included staff assistance and encouragement with intake. No new interventions were included. - 4/21/22: The resident's 30-day meal intake indicated the resident consumed less than 50% 17 times, 51-75% 26 times, 76-100% 31 times and refused 13 meals. Interventions included a liquid supplement which was refused seven times in 14 days . The resident was identified as having a 16.4 pound or 9.7% weight loss from 10/26/21 to 4/2/22. The "Plan" was unchanged from 3/18/22. - 5/17/22: The resident's 30-day meal intake indicated the resident consumed less than 50% 31 times, 51-75% 17 times, 76-100% 27 times and refused 12 meals. Interventions included a liquid supplement (administration frequency was not specified). The resident was identified as having a 21.7 pound or 12.8% weight loss since 11/3/21. The "Plan" was updated to include weekly weights for 30 days. No new interventions were included. On 9/20/23 at 11:10 AM Staff 17 (RD) stated the resident admitted to the facility on palliative care and the (unnamed) former Director of Nursing told her it was expected the resident would decline. Staff 17 stated supplements were available, the resident would refuse to eat and they couldn't "force" her/him to eat. Staff 17 did not provide a clinical rationale for how the resident's condition or being on palliative care was pertinent to the resident's weight loss and lack of additional nutritional interventions. On 9/21/23 at 9:46 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed there were no new interventions despite Resident 3's ongoing weight loss, or a rationale for why no new interventions were appropriate. 2. Resident 1 was admitted to the facility in 2018 with diagnoses including Alzheimer's disease. Resident 1's weight record revealed the following: - On 3/2/23 the resident weighed 235 pounds. - On 9/1/23 the resident weighed 208 pounds. This was a 27 pound or 11.5% weight loss over six months. A review of Resident 1's Nutrition At Risk notes revealed the following: - 4/19/23: The resident was identified with an 8 pound weight loss since 3/2/23. The resident was dependent on staff for dining assistance. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. - 5/4/23: The resident was identified with a 5.8 pound weight loss since 4/4/23 and 12.4 pounds since 2/6/23. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. - 5/9/23: The resident was identified with a 4.6 pound weight gain. No new interventions were implemented. - 7/4/23: The resident was identified with a 12.2 pound weight loss since 6/1/23 and 22.8 pounds since 1/5/23. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. - 8/3/23: The resident was identified with a 11.2 pound weight loss since 5/2/23. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. - 9/6/23: The resident was identified with a 2 pound weight loss since 8/1/23 and 27 pounds since 3/2/23. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. On 9/20/23 at 11:10 AM Staff 17 (RD) did not provide a clinical rationale for the lack of additional nutritional interventions. On 9/21/23 at 10:04 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed there was no assessment to indicate a rationale for why no new interventions were implemented.

F692 SS=G Nutrition/Hydration Status Maintenance Problem: Based on interview and record review it was determined the facility failed to ensure residents maintained acceptable parameters for nutrition for 2 of 3 sampled residents (#s 1 and 3) reviewed for weight loss. This resulted in Resident 1 and Resident 3 having severe weight loss and placed residents at risk of weight loss. #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #1 Revised and updated the weekly NAR Audit completed by RD. Added a column to specify if weight loss of 5% in 1 month & 10% in 6 months, and if loss was avoidable or unavoidable. DM in training will interview resident/family for food preferences. Assessed the need for Nutrition Enhanced Meals (NEMS) and/or house supplements. Notifications will be made for recommendations and/or need for diagnostics labs, Speech/ PT/OT consults and medication review. Ongoing review with interdisciplinary team for appropriate interventions. Updated Care Plan documentation demonstrates the different interventions recommended and needed. Resident status will be reviewed in the NAR meeting. Resident #3 Resident no longer resides at facility. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: -Comprehensive Dietitian Nutrition Assessment completed on admission, quarterly and annually or when indicated. -Residents identified to be at risk will be monitored in the weekly NAR meetings. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: -Educate Dietician and staff on documentation requirements. -Facility will implement weekly Nutrition at Risk IDT meetings to review identified residents. Residents at risk will be reviewed during the meeting. An IDT progress note will be entered during the meeting. -The Dietician will perform and document Nutrition at Risk (NAR) assessments as appropriate. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. Administrator or designee will perform weekly audit of resident records to ensure: Admission and quarterly nutrition assessments are completed Residents at risk are being assessed weekly, receiving appropriate interventions and that interventions and associated assessments are documented in the resident record. Audit results will be monitored through QAPI committee. #5 Title of Person Responsible to ensure correction and sustain compliance. Administrator, Kelli Cannon

Based on interview and record review it was determined the facility failed to provide timely lab services for 1 of 3 sampled residents (#1) reviewed for change in condition. This placed residents at risk for delayed treatment. Findings include: Resident 1 was admitted to the facility in 2018 with diagnoses including Alzheimer's disease. Resident 1's Progress Notes revealed the following: - On 6/6/23 at 2:49 PM: The resident's spouse notified the facility the resident's hands and feet were twitching which the spouse thought might be related to a UTI. The resident's provider was notified and a urine sample would be collected. - On 6/6/23 at 8:35 PM: A urine sample was obtained from a urinal. - On 6/7/23 at 2:15 PM: The urine sample was collected. - On 6/9/23 at 9:06 PM: The lab was called to make sure a urine sample could be collected on the weekend before a sample was obtained. No notes were found to indicate why a second urine sample was needed. - On 6/11/23 at 6:41 AM: A urine sample was obtained by straight catheter. - On 6/16/23 at 7:09 AM: A lab report dated 6/14/23 revealed no indication of infection. On 9/21/23 at 10:04 AM Staff 2 (DNS) confirmed the urine sample collected on 6/6/23 was obtained by a urinal which was not the proper procedure and resulted in a delay obtaining a valid urine sample.

F777 SS=D Radiology / Diag Srvcs Ordered / Notify Results Problem: Based on interview and record review it was determined the facility failed to provide timely lab services for 1 of 3 sampled residents (#1) reviewed for change in condition. This placed residents at risk for delayed treatment. #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #1 No negative outcome for the resident. The Charge Nurse on duty did not follow standing orders or use correct criteria to determine the need for screening, leading to an unnecessary specimen collection. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents are at risk of being affected by the deficient practice. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: All new nursing leadership in building. All nursing staff will receive education and training on: Appropriate diagnostic criteria to determine need/requests for lab services. Facility Standing Orders Correct procedures for specimen collection, including appropriate infection control measures Communication with challenging residents/family members Standing Orders will be accessible to staff for reference. Instructions for specimen collection will be accessible to staff for reference. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. DNS or designee will randomly observe specimen collection and provide just in time training as appropriate. A log/audit will be kept of observations. Nursing leadership will review the 24-Hr Report 5x/week. Follow up during clinical meeting to verify lab orders are completed timely and appropriately. ICP Nurse will monitor and keep a log of lab results. Monthly ICP report for QAPI will include relevant data. #5 Title of Person Responsible to ensure correction and sustain compliance. DNS, Cynthia Fulton-Tinawi

***************************** 411-085-0310 Residents' Rights: Generally Refer to F580 and F604 ***************************** 411-086-0110 Nursing Services: Resident Care Refer to F684 ***************************** 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686, F689 and F692 ***************************** 411-086-0200 Physician Services Refer to F777 *****************************

Based on observation, interview and record review it was determined the facility failed to ensure dignity for 1 of 3 sampled residents (#59) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: The facility's Quality of Life - Dignity policy revised 3/11/22 revealed: -Residents shall be treated with dignity and respect at all times and -Demeaning practices and standards of care that compromise dignity are prohibited. Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Resident 59's 11/18/22 Admission MDS indicated the resident was cognitively intact. Multiple random observations from 1/8/23 through 1/17/23 between the hours of 8:00 AM and 11:50 PM revealed food and cups of liquid were frequently observed on the bedside table near Resident 59's urinal. On 1/13/23 at 11:47 AM Staff 3 (RNCM) and surveyor were with Resident 59 when Staff 31 (CNA) brought Resident 59's lunch into her/his room. Staff 31 removed the plastic wrap from Resident 59's plate then set the plate followed by cups of liquid on the bedside table approximately one inch from Resident 59's partially filled urinal and in approximately two to three minutes, Staff 3 left the room and returned with Staff 31. Staff 3 asked Staff 31 to remove the urinal from the bedside table, remove and discard the food and liquids from the bedside table, disinfect the bedside table and provide the resident with a new plate of food and liquids. On 1/17/23 at 2:13 PM Resident 59 stated staff frequently placed her/his food and liquids on the bedside table next to or near the urinal and she/he did not like staff putting her/his food and liquids next to the urinal, she/he asked staff to move the urinal but it was always a "major" issue to get anything done. Resident 59 stated sometimes she/he was laying in bed and staff put the nearly full urinal right by her/his plate of food then placed the bedside table over her/him so she/he could eat. Resident 59 stated her/his urinal sometimes "sloshed over" and spilled on her/his bedside table or bed linens and smelled. The resident stated the urinal often left a ring on the bedside table and staff put her/his silverware in the dirty area. Resident 59 stated she/he would not have "pee" sitting on her/his dining room table at home and did not want that done at the facility, either. On 1/18/23 at 11:19 AM Staff 1 (Administrator) and Staff 2 (DNS) were provided with the findings of this investigation and acknowledged this practice showed a lack of respect for resident dignity.

F550 Resident Rights/Exercise of Rights 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #59’s urinal was removed from his overbed table, table was sanitized, and new food and drink were brought in for him. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents who use a urinal have the potential to be affected by this deficient practice. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? Facility Quality of Life - Dignity policy and Infection Control Standards have been reviewed and updated. All staff who provide direct patient care have been in-serviced to the facility dignity policy and infection control standards to include cleaning the table that a used urinal has been placed on, prior to placing any food or beverage on same table. Facility is reviewing options with resident for urinal placement. Care plans for all residents who use a urinal have been reviewed and updated to include not leaving the urinal on the bedside table when food or beverage is placed on same table until urinal has been moved and table disinfected. A nurse management audit tool has been created for nurse managers or designee to randomly check each week during meal and snack times to ensure staff compliance. Facility has contracted the services of a nurse educator to focus on consistent education of staff. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Weekly audits will be brought to the Monday, Wednesday, Friday clinical meeting and to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RNs; RCM’s, RN educator, and ICP with oversight of DNS

Based on interview and record review it was determined the facility failed to notify a resident's representative in a timely manner regarding a resident-to-resident incident for 1 of 3 sampled residents (# 32) reviewed for accidents. This placed residents and responsible parties at risk for lack of timely notification. Findings include: Resident 32 was admitted to the facility in 4/2018 with diagnoses including Huntington's disease (a progressive brain disorder) and a mental health disorder. Resident 32's Admission Record indicated: Witness 1 (Complainant) was Guardian, Care Conference Person, Emergency Contact #1, and Next of Kin. A FRI revealed on 10/14/22 Resident 32 was involved in an incident with Resident 31. It was reported Resident 31 stood behind Resident 32 and grasped and shook Resident 32's head. The facility Alleged Abuse Checklist form dated 10/14/22 revealed Witness 1 (Complainant) was notified of the incident on 10/17/22, three days after the incident occurred. On 1/8/22 at 6:25 PM Witness 1 stated the facility did not notify her until 72 hours after the incident. On 1/13/22 at 2:58 PM Staff 2 (DNS) stated it was the facility's policy to notify the family and/or representative "immediately" after an accident/incident.

F580 Notify of Change (Injury/Decline/Room, etc) 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #32 was involved in a resident-to-resident altercation on a Friday evening. When the RCM started her investigation on Monday, she saw that no notifications were documented as being done. At that time the RCM called the family to notify them. The charge nurses have been educated on the importance of notifying families at the time of the incident. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents have the potential to be affected by this deficient practice. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? The Facility Accidents and Incidents-Investigation and reporting policy has been reviewed and updated to include timely notification at the time of the incident. Charge nurses have been in-serviced on the updated policy to include timely notification. A charge nurse accident and incident check list has been created to be used with steps that must be taken for each incident including timely notification at the time of the incident. Charge nurses have been in-serviced to complete this checklist at the time of the incident. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: A charge nurse completed checklist will be submitted to the RCM in-box on the wall in the East nurses station. RCM’s will check every day that they are on duty. If only 1 RCM is on duty that RCM will check all the risk managements for both sides. Risk management (Accidents and incidents) along with the charge nurse checklist will continue to be reviewed at each clinical meeting on Monday’s, Wednesday’s, and Friday’s by the nurse management team for completion. Any missing information will be added to the clinical follow up tool for correction. Compliance of completed checklists will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with oversight of DNS

Based on observation, interview and record review the facility failed to ensure a personalized, homelike environment for 1 of 1 sampled resident (#41) reviewed for personal property. This placed residents at risk for living in an unhomelike environment. Findings include: Resident 41 was admitted to the facility in 6/2018 with diagnoses including frontotemporal dementia (a type of dementia characterized by changes in emotions, behavior, personality and language). A review of Resident 41's clinical record revealed the resident moved into a new room on 11/2/22. Observations of Resident 41's room from 1/8/23 to 1/12/23 between the hours of 8:10 AM to 3:20 PM revealed the resident's room to have blank walls except for one picture that did not belong to the resident. On 1/8/23 at 2:04 PM Witness 8 (Family Member) stated Resident 41 moved into her/his current room a few months ago. She stated the resident's previous room had numerous family photos and personalized pictures hanging on the walls. Witness 8 stated she requested the photos and pictures be moved to the resident's current room approximately three weeks ago but the facility had yet to transfer the resident's personal belongings. On 1/8/22 at 2:05 PM Resident 41 confirmed she/he wanted her/his photos and pictures hanging on the walls of her/his current room. On 1/12/23 at 8:16 AM Staff 12 (Activity Director) stated residents and families were encouraged to personalize rooms upon admission to the facility and throughout their stay. She stated activity staff were responsible for hanging photos and pictures on the walls in resident rooms and the goal was to have photos and pictures hung within the first few days post admission and on the same day in the case of a resident room change. Staff 12 confirmed Resident 41 changed rooms a few months prior and she did not transfer her/his personalized belongings in a timely manner. On 1/19/23 at 11:04 AM Staff 1 (Administrator) was informed of these findings and no additional information was provided.

F584 Safe/Clean/Comfortable/Homelike Environment #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #41. Resident’s family photos and personalized pictures were moved from the prior room to current room immediately by Activity staff when it was brought to their attention by the Surveyor. All other personal belongings had been moved at the initial room change time from the prior room to the current room. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All new admissions and residents with a room change have the potential to be affected by not having personal belongings (including photos and personalized pictures hung) in the room in a timely manner. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Facility Homelike Environment policy has been reviewed and updated. An audit of all new admissions and residents with room changes since October 1, 2022, has been conducted to ensure that resident personal belongings including photos and personalized pictures are in room if resident/guardian choose. Any situations found in the audit have been corrected. An audit of all resident rooms has been conducted to ensure that resident personal belongings including photos and personalized pictures are in the room if resident/guardian choose. Any situations found in the audit have been corrected. A checklist has been created to ensure new admissions and residents who experience a room change have personal belongings (including photos and personalized pictures hung) timely. Staff with a portion of the responsibility to ensure resident belongings (including photos and personalized pictures hung) are in resident room timely, have been in-serviced. (Social Services or designee, Activities, Housekeeping, Nursing (CNA, LN, RCM). #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. The checklist for new admissions and residents who experience a room change have personal belongings (including photos and personalized pictures hung) will be completed at each room change (by Activities for wall hangings and Housekeeping/Nursing for other personal items) or new admissions (by Social Services or designee) and audited for completion at each clinical meeting on Monday, Wednesday and Friday. New admissions and room changes will continue to be on agenda of bi-weekly Administrative Staff Team meetings to prompt staff with a portion of the responsibility to follow up on their task and to discuss any obstacles to completing task so timely correction can be made. Compliance of completed checklists and Team meeting discussion will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. #5 Title of Person Responsible to ensure correction and sustain compliance. Social Services or designee, Activities, Housekeeping, Nursing (CNA, LN, RCM), with Clinical Meeting, QAPI Committee and Quarterly QA Committee oversight.

Based on observation, interview and record review it was determined the facility failed to obtain consent, assess, monitor and reevaluate for use of a restraint for 3 of 4 sampled residents (#s 22, 41 and 50) reviewed for restraints. This placed residents at risk for inappropriate use of a restraint. Findings include: 1. Resident 22 was admitted to the facility in 9/2021 with diagnoses including schizophrenia. Resident 22's 12/15/21 Quarterly MDS indicated the resident had two or more falls and used a chair alarm daily. Resident 22's 3/16/22 Quarterly MDS, 6/15/22 Quarterly MDS, 9/14/22 Annual MDS and 12/14/22 Quarterly MDS assessments indicated the resident had no falls and used a chair alarm daily. Resident 22's 9/14/22 Fall CAA revealed the following: - "[Resident] actually takes the device with [her/him] to bed to remind [her/himself] to wait for help to get up. If [she/he] turns in bed and activates device accidentally, [she/he] deactivates device by replacing magnet to reset the device." The CAA lacked comprehensive assessment components such as justification for the ongoing use of the TAB alarm (a device with a pull-string clipped to the resident's clothing which emits a loud, piercing sound activated when the resident attempts to rise from a chair or bed), where, when and how the alarm was used, identification and implementation of alternative interventions to prevent falls and attempts to reduce or discontinue the use of the alarm. Resident 22's Care Plan included the following: - 9/9/21 Focus: At risk for falls related to cognitive impairment. - 9/9/21 Goal: No avoidable falls. - 9/9/21 Interventions: TAB alarm when up in wheelchair. Review of Resident 22's health record revealed no initial assessment which identified a medical symptom or clinical rationale for the TAB alarm, no evidence the risks and benefits of the TAB alarm were reviewed with the resident or her/his representative, no indication consent for the TAB alarm was obtained, no re-evaluations to support the continued need for the TAB alarm and no physician order for the TAB alarm. Observations of Resident 22 conducted from 1/8/23 through 1/18/23 between the hours of 7:15 AM and 7:45 PM revealed the resident was either in bed or in her/his room in a wheelchair. Resident 22 had a TAB alarm attached to her/his wheelchair and clothing. On 1/9/23 at 3:33 PM and 1/10/23 at 10:49 AM Resident 22 was interviewed and she/he was unable to answer questions related to the TAB alarm. On 1/12/23 at 9:59 AM Staff 10 (CNA) stated Resident 22 used a TAB alarm while up in her/his wheelchair and in bed because she/he self transferred. 1/12/23 at 1:52 PM Staff 4 (RNCM) and Staff 2 (DNS) were presented with the findings of this investigation. Staff 4 confirmed Resident 22 used a TAB alarm, stated Resident 22 liked the TAB alarm, and the resident removed the alarm independently from her/his chair and bed. Staff 2 reviewed Resident 22's health record and stated Resident 22 had no falls since 11/6/21. During the interview, Staff 2 and Staff 4 were unable to provide the following: - an initial assessment and clinical rationale for the TAB alarm; - documentation of ongoing monitoring and evaluation for the continued use of the alarm; - evidence the risks and benefits were reviewed with the resident or her/his representative; - a physician order; - consent for the TAB alarm. On 1/18/23 at 9:47 AM no further information regarding the TAB alarm was received. On 1/18/23 at 10:59 AM Staff 2 stated TAB alarms were considered a restraint and required an initial assessment, ongoing monitoring and evaluation, less restrictive intervention attempts, consent from the resident and/or the representative and a physician order. 2. Resident 50 was admitted to the facility in 4/2021 with diagnoses including Parkinson's disease. Resident 50's 7/14/21 Physical Restraint Assessment and Initial Evaluation indicated the resident used a bed and chair alarm. Resident 50's 12/14/22 Annual MDS indicated the resident used a bed and chair alarm. A review of Resident 50's health record revealed no physician order for the use of the bed and chair alarm. Observations of Resident 50 from 1/8/23 through 1/18/23 between the hours of 7:15 AM and 7:45 PM revealed the resident used an alarm in her/his bed and chair. On 1/12/23 at 9:59 AM Staff 10 (CNA) stated Resident 50 used a bed and chair alarm. On 1/12/23 at 2:02 PM Staff 4 (RNCM) confirmed Resident 50 used a bed and chair alarm. On 1/18/23 at 11:03 AM Staff 2 (DNS) was notified of the findings of this investigation. Staff 2 stated the TAB alarm was considered a restraint and a physician order was required for use of the specific restraint. , 3. Resident 41 was admitted to the facility in 6/2018 with diagnoses including frontotemporal dementia (a type of dementia characterized by changes in emotions, behavior, personality and language). Observations of Resident 41 conducted from 1/8/23 through 1/18/23 between the hours of 8:00 AM and 3:00 PM revealed the resident either in bed or in her/his chair. Resident 41 had a TAB alarm (a device with a pull-string clipped to the resident's clothing which emits a loud, piercing sound activated when the resident attempts to rise from a chair or bed) attached to her/his bed or geri chair (a large, padded chair with a wheeled base designed to assist people with limited mobility) and clothing. On 1/8/23 at 2:09 PM Resident 41's TAB alarm sounded. The resident was unable to turn off the alarm independently. Review of Resident 41's health record revealed no initial assessment which identified a medical symptom or clinical rationale for the TAB alarm and no physician order. A Restraint-Physical Quarterly/Annual Evaluation was completed on 6/15/22 with no evidence additional re-evaluations needed to support the continued use of the TAB alarm were completed. Resident 41's 12/20/22 Significant Change of Condition Assessment indicated the resident had experienced a fall with a major injury and used a bed and chair alarm daily. The Physical Restraints CAA indicated the resident used a TAB alarm when up in her/his wheelchair and when in bed in order to alert staff of attempts to self transfer. The CAA lacked comprehensive assessment components such as justification for the ongoing use of the TAB alarm, including the identification and implementation of alternative interventions to prevent falls and provision of attempts to reduce or discontinue the use of the TAB alarm. A review of Resident 41's 12/21/22 care plan revealed the resident was at risk for falls due to cognitive impairment and lack of impulse control. The care plan included the following interventions related to safety and falls: -A TAB alarm was to be in place when the resident was in bed; and -A TAB alarm was to be in place when the resident was in her/his geri chair. On 1/13/23 at 10:12 AM Staff 4 (RNCM) and Staff 2 (DNS) were presented with the findings of this investigation. Staff 4 confirmed Resident 41 used a TAB alarm both in bed and when up in the geri chair. Staff 2 reviewed Resident 41's health record and confirmed no additional evaluations of the use of the TAB alarm for Resident 41 were completed since 6/15/22. During the interview, Staff 2 and Staff 4 were unable to provide any additional documentation. On 1/19/23 at 10:41 AM Staff 2 (DNS) stated TAB alarms were considered a restraint and required an initial assessment, ongoing monitoring and evaluation, less restrictive intervention attempts, consent from the resident and/or the representative and a physician order.

F604 Right to be Free from Physical Restraints 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? RCM called the families or guardians for residents #22, #41, and #50 to ensure that they are still in agreement with use of tab alarms from prior verbal consent. Assessments, documented consent, MD orders, and care plans are updated. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents who are currently using devices that may be considered restraints are considered affected and will have assessments conducted to determine continued use. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? Facility Physical Restraint policy has been reviewed and updated. RCM’s have been in-serviced to this policy. A whole house audit has been completed to identify those residents with physical restraints and to ensure that they have all required elements place; assessments, documented consent, MD orders, and care plans. Re-assessment will be performed quarterly with the quarterly MDS to determine continued need and discussed at the Quarterly care conference for continued consent and documentation. DNS or designee will complete a periodic whole house audit to ensure that all residents with physical restraints have been thoroughly addressed. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: All new and existing physical restraints will be brought to clinical meeting by the RCM to ensure that all elements are in place. DNS audit will also be cross-referenced at that time. Compliance will be reported to bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with oversight of DNS

Based on observation, interview and record review it was determined the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 2 sampled residents (#59) reviewed for aspiration precautions (practices to help prevent food or fluids from entering the lungs). This placed residents at risk for choking or developing lung infections. Findings include: Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Resident 59's 11/18/22 Admission MDS indicated the resident was cognitively intact. Resident 59's current Care Plan located in the resident's clinical record indicated Resident 59 was on a modified diet consisting of minced and moist diet textures (diet textures requiring little chewing and are finely chopped, grated, ground or mashed) and mildly thick liquids (liquids thickened to nectar consistency). The following aspiration precautions were in place: -Small bites, chew food completely; -Small sips of fluids between bites; -Check for pocketing of foods; -Position at 90 degree angle when eating or drinking; -Remain upright for 30 minutes after meals and snacks; -If choking or coughing, stop oral intake and remove food and liquids; -Do not place meal plate or drink on table until caregiver is present and seated for one to one assist; -No thin water pitcher at bedside. Resident 59's current CNA Care Plan Reference Sheet located in a binder at the nursing station indicated the resident was on a minced and moist diet and mildly thick liquids. None of Resident 59's aspiration precautions were listed on the Care Plan Reference Sheet. The 1/10/23 Diet Roster, provided each meal by the dietary department to notify staff of residents' diets and required assistance levels, indicated Resident 59 was on a minced and moist diet and mildly thick liquids. The Diet Roster did not indicate Resident 59's aspiration precautions including one to one assist and staff were not to place food or liquids at the resident's bedside until a caregiver was present and seated. Multiple random observations from 1/8/23 through 1/12/23 between the hours of 8:00 AM and 11:50 PM revealed Resident 59 had food at her/his bedside during mealtime and mildly thick liquids at the bedside all of the time within Resident 59's reach and the resident did not have one to one assist. Thin liquids were also observed, at times, sitting on Resident 59's bedside table within the resident's reach. On 1/12/23 at 8:46 AM Staff 34 (CNA) stated she worked with Resident 59 frequently and was unaware Resident 59 had aspiration precautions. Staff 34 stated residents' diet type and aspiration precautions were on the CNA Care Plan Reference Sheet located in the red binder at the nursing station and the kitchen also sent out a Diet Roster at each meal which provided each resident's diet and assist level. After reviewing the Diet Roster, Staff 34 stated it was confusing but she thought Resident 59 was able to eat and drink independently. On 1/12/23 at 9:04 AM Staff 35 (CNA) stated Resident 59 did not have any aspiration precautions. On 1/12/23 at 11:16 AM Staff 16 (Agency LPN) stated she provided thin liquids to Resident 59 and was unaware she/he required thickened liquids. On 1/12/23 at 12:04 PM Staff 3 (RNCM) observed Resident 59 in her/his bed with cups of mildly thick and thin liquids at the bedside. Staff 3 confirmed Resident 59 had mildly thick and thin liquids at her/his bedside within her/his reach and no staff provided one to one assist. Staff 3 stated staff were not following Resident 59's aspiration precautions and the resident was not to have thin liquids. On 1/12/23 at 12:31 PM Resident 59 stated she/he did not like or need her/his diet modified. Resident 59 stated staff were never with her/him during meals or when she/he ate or drank. Resident 59 stated she/he had problems swallowing in the hospital but did not think she/he had problems swallowing any longer. Resident 59 stated she/he did not have her/his swallowing assessed since being in the hospital and did not have any choking episodes at the facility. On 1/17/23 at 1:15 PM Staff 2 (DNS) stated she expected staff to follow Resident 59's diet and aspiration precautions Care Plan. She reviewed Resident 59's Care Plan, the CNA Care Plan Reference Sheet and the Diet Roster and stated staff would not be able to determine Resident 59's aspiration precautions when referencing the CNA Care Plan Reference Sheet or Diet Roster which posed a concern for staff having accurate information regarding Resident 59's aspiration precautions.

F656 Development/Implement Comprehensive Care Plan 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #59 had orders on admit for supervision at all times when eating. The resident requires mildly thick liquids and he was given thin water with the med pass. The diet roster has been clarified to state whether or not the resident needs 1:1 supervision at all times during meals and snacks. The resident will either eat in his room with supervision or he will eat in the dining room where staff is present. The one-page care plan has been updated to include the supervision level needed for the resident prone to aspiration. The agency LPN was educated in the moment of where to look for diet texture and consistency. A Speech Evaluation has been requested to determine if thickened liquids are still recommended. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents with aspiration precautions have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? A checklist will be created for all new admissions to ensure that all orders are entered correctly. A whole house audit will be done to ensure that all diet orders and textures match what is in the care plan. The diet texture, liquid consistency, and instructions on how meds are to be given will be listed in the special instructions on the resident’s profile. Aspiration precautions and resident’s who cannot have food or beverages left at bedside without supervision has also been added to the resident’s profile and to the one-page care plan. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: All new admissions will be brought to clinical meeting to ensure that everything is completed appropriately. RCM’s review care plans quarterly to ensure that nothing has changed, and orders are correct. RCM’s or DNS will cross check each RCMs care plans on admit to ensure everything matches. Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCM’s with DNS oversight.

Based on interview and record review it was determined the facility failed to ensure resident care plans were revised to accurately reflect the resident needs for 2 of 9 sampled residents (#s 26 and 41) reviewed for ADLs and accidents. This placed residents at risk for unmet needs. Findings include: 1. Resident 26 was admitted to the facility in 3/2020 with diagnoses including stroke. Resident 26's 11/9/22 Quarterly MDS indicated the resident was not on Hospice. Resident 26's undated CNA Care Plan Reference Sheet indicated the resident was on Hospice. On 1/12/23 at 1:39 PM Staff 4 (RNCM) stated the CNA Care Plan Reference Sheet was designed to be used by staff, such as new CNAs and agency CNAs, who were unfamiliar with the resident. Staff 4 stated the reference sheet served as a quick reference with information about the resident and the type of care needed. Staff 4 reviewed Resident 26's CNA Care Plan Reference Sheet, stated Resident 26 was discharged from Hospice in 8/2022 and acknowledged the Care Plan was inaccurate. On 1/18/23 at 10:57 AM Staff 2 (DNS) stated she expected the CNA Care Plan Reference Sheet to accurately reflect Resident 26's health status so the resident received care that aligned with her/his actual needs. , 2. Resident 41 was admitted to the facility in 6/2018 with diagnoses including frontotemporal dementia (a type of dementia characterized by changes in emotions, behavior, personality and language). Resident 41's 12/20/22 Significant Change of Condition Assessment ADL CAA indicated the resident recently admitted to Hospice and a geri chair (a large, padded chair with a wheeled base designed to assist people with limited mobility) was ordered to provide comfort. The Physical Restraints CAA indicated the restorative program was discontinued. Resident 41's 12/2022 Care Plan revealed the resident was on a restorative plan in order to maintain or improve strength and endurance in daily activities. Resident 41's current CNA Care Plan Reference Sheet revealed the resident utilized a wheelchair with a seat belt. The Care Plan made no reference to Hospice services being provided. On 1/13/22 at 10:12 AM Staff 4 (RNCM) stated the CNA Care Plan Reference Sheet was designed to be used by staff, such as new CNAs and agency CNAs, who were unfamiliar with the resident and was based on resident care plans. Staff 4 stated Resident 41 was on Hospice and utilized a geri chair for comfort. Staff 4 reviewed Resident 41's CNA Care Plan Reference Sheet and stated Resident 41 no longer utilized a regular wheelchair with a seatbelt. Staff 4 acknowledged the CNA Care Plan Reference Sheet was not revised and missed any reference to Hospice services. Staff 4 also reviewed Resident 41's Care Plan and confirmed the resident was no longer on a restorative plan and acknowledged the Care Plan was not revised to reflect the changes. On 1/13/23 at 10:12 AM Staff 2 (DNS) stated she expected both the CNA Care Plan Reference Sheet and Care Plan to be revised when necessary to accurately reflect Resident 41's health status so the resident received care that aligned with her/his actual needs.

F657 Care Plan Timing and Revision 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? `Resident #26, one-page care plan and comprehensive care plan has been updated to show current non-hospice status. Resident #41 one-page care plan and comprehensive care plan has been updated to reflect hospice admission and assistive device’s. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents with changes have the potential to be affected. Therefore, accuracy of the current care plan and care needs have been reviewed. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? The following policies have been reviewed and updated: Assistive devices and equipment, Care planning, and hospice program. RCM’s have been in-serviced to these policies. A checklist has been created for the RCM or designee to complete to show all the steps needed for when a resident is admitted to or graduated from hospice and a check list to show all the steps to follow when assistive devices have been added, removed, or changed. Charge nurses and RCM’s have been in-serviced to the checklists. RCM’s will check the one-page care plans for accuracy whenever a change is made to the comprehensive care plan. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The completed check list will be brought to the clinical meeting to ensure that resident care plans have been updated. The completed checklists will then be signed by RCM’s and DNS. Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with DNS oversight.

Based on observation, interview and record review it was determined the facility failed to provide necessary care and services related to bathing/showering and nail care for 1 of 6 sampled residents (#59) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Resident 59's 11/18/22 Admission MDS indicated the resident had intact cognition and required extensive assistance of one person for bathing/showering and personal hygiene. Resident 59's 12/13/22 through 1/13/23 bathing/showering task logs indicated the resident received showers on Tuesday and Friday evening shift. Resident 59's bathing/showering task logs revealed the following: -12/13 not applicable; -12/16 not applicable; -12/20 not applicable; -12/23 not applicable; -12/27 not applicable; -12/30 shower completed; -1/3 shower completed; -1/6 not applicable; -1/10 not applicable and -1/13 not applicable. No records were found in Resident 59's clinical record regarding nail care. On 1/8/23 at 12:47 PM Resident 59 stated she/he was supposed to receive showers twice a week but was not showered in a while with her/his most recent shower being around five days ago. Resident 59 stated her/his toenails were too long and she/he asked to have them trimmed but nobody did anything about it. Resident 59 was observed to have long, yellowish toenails and was in a hospital gown. On 1/11/23 at 11:16 PM Staff 24 (CNA) stated Resident 59 was supposed to receive a shower on day shift and was not being showered regularly. Staff 24 stated Resident 59 did not refuse showers and asked why she/he was not getting showered like she/he was supposed to. Staff 24 stated Resident 59 was showered one time in the past 30 days. On 1/12/23 at 8:46 AM Staff 34 (CNA) stated Resident 59 did not refuse showers. She stated there was confusion regarding Resident 59's shower times because the resident's showers were recently moved from day to evening shift. Staff 34 stated Resident 59 received two showers in the past 30 days. Staff 34 stated resident's nails were trimmed on shower days and since Resident 59 was not being showered, she/he did not get her/his nails trimmed. On 1/13/23 at 11:24 AM Staff 3 (RNCM) observed Resident 59's toenails and confirmed her/his toenails were long and needed trimming. Resident 59 stated she/he had not been regularly showered and Staff 3 told Resident 59 she/he should receive showers twice a week and there was no reason her/his toenails could not be trimmed. On 1/13/23 at 1:15 PM Staff 2 (DNS) stated she was unable to find documentation to indicate when the resident's nails were last trimmed. Staff 2 stated Resident 59's showers were changed from day to evening shift a while ago but the care plan was not updated and the new shower time was not reflected on the shower assignment sheets which was the reason Resident 59 did not receive her/his showers.

F677 ADL Care Provided for Dependent Residents 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #59 had a room change which changed shower schedule. Shower schedule and skin check were updated with the residents new room so that staff would know shower/skin check days. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents who change rooms have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? The Activities of Daily Living policy has been reviewed and updated. A whole house audit has been completed to ensure that all residents are captured on shower/skin check roster per their current room. Education has been provided to all staff who provide direct care on the importance of providing showers and nail care and reporting refusals to the charge nurse. Skin check sheet has been updated with check boxes asking if nail care is needed and another check box asking if nail care has been provided if needed. RCM’s will report to the Monday, Wednesday, Friday clinical meeting when there is a change in the resident’s room to ensure that the shower/skin check day has been updated. Shower completion has been added to the alert listing report that the charge nurses print and review daily. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Monday, Wednesday, Friday clinical meeting will review any room changes, shower schedule changes, or refusals via the Alert listing report. Any items not completed or frequent refusals will be added to the clinical follow up tool. Shower schedule, room moves, and nail care compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with DNS oversight.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 3 of 4 sampled residents (#s 22, 28 and 50) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: 1. Resident 22 was admitted to the facility in 9/2021 with diagnoses including schizophrenia. Resident 22's 9/14/22 Annual MDS indicated the resident's cognition was moderately impaired, her/his vision and hearing were adequate and she/he preferred to read books, newspapers and magazines and liked to listen to music. The Activities CAA indicated Resident 22 liked magazines with news articles and the news was important to her/him. Resident 22's Care Plan included the following activity goals and interventions: - 10/13/22 Goal: provide activities that match resident's preference, ability, skill set and participation level. - Interventions: activities very important to [resident]: read magazines with news in them, rock & roll music, news was important to [her/him]. - 10/13/22 Goal: will participate in sensory (visual, hearing, touch, smell, taste); and mentally stimulating activities as offered per the monthly activities calendar. - Interventions: hand hygiene sanitization of both staff and resident's hands before and after. Review of the 1/2023 Activities Calendar revealed the following scheduled activities from 1/8/23 through 1/18/23: - 1/8/23: coffee cart, room visits, fancy fingers (manicure) and movie/snack. - 1/9/23: coffee and treat, religious services, exercise/garden walk, Bingo. - 1/10/23: coffee cart, room visits, exercise/garden walk, brain games. - 1/11/23: coffee cart, feed the wildlife, exercise/garden walk, arts & crafts. - 1/12/23: coffee cart, religious services, exercise/garden walk, movie of choice. - 1/13/23: coffee & cookie, room visits, root beer floats. - 1/14/23: Resident choice movies. - 1/15/23: Resident choice movies. - 1/16/23: coffee & treat, religious services, exercise/garden walk. - 1/17/23: coffee cart, room visits, exercise/garden walk. - 1/18/23: feed the wildlife, movie of choice. Resident 22's 1/2023 Activity Participation Sheet, completed by Staff 12 (Activity Director) indicated the resident participated in the following: - "Coffee" on 1/8/23, 1/9/23, 1/10/23, 1/11/23 and 1/12/23. - "Goodie visit" on 1/12/23. - "Movie/TV/Music" 1/8/23, 1/9/23, 1/10/23, 1/11/23, 1/12/23, 1/13/23, 1/14/23, 1/16/23, 1/17/23 and 1/18/23. - "Drop in Visit" 1/8/23, 1/9/23, 1/10/23, 1/11/23, 1/12/23, 1/13/23, 1/16/23, 1/17/23 and 1/18/23. None of the activities outlined on the calendar and the participation sheet were person-centered to Resident 22's activity preferences. Observations of Resident 22 conducted from 1/8/23 through 1/18/23 between the hours of 7:15 AM and 7:45 PM revealed the resident was either in bed or in her/his room in a wheelchair and her/his TV was on at various times. There were no reading materials, such as magazines or newspapers in Resident 22's environment and there was no rock & roll music played. On 1/9/23 at 3:33 PM and 1/10/23 at 10:49 AM Resident 22 declined to discuss her/his activity preferences. On 1/12/23 at 9:59 AM Staff 10 (CNA) stated Resident 22 liked to watch television. Staff 10 stated group activities were not provided and Staff 38 (Kitchen Staff/Food & Nutrition) visited the residents in their rooms. On 1/17/23 at 11:06 AM and 1/19/23 at 8:56 AM Staff 12 stated general activities for the facility consisted mostly of passing coffee and resident room visits which lasted between five and 35 minutes. Staff 12 stated group activities, live events and sensory stimulating activities had not occurred frequently or regularly since 2020. Staff 12 stated Resident 22's activities mostly consisted of the resident watching television in her/his room and in the dining room. Staff 12 stated Resident 22 enjoyed magazines and was unsure when the resident was last offered or provided with magazines which met her/his interests. When asked how Resident 22's interest in the news was satiated, Staff 12 stated the facility received only a few newspapers a week and a select few residents received them. On 1/19/23 at 11:04 AM Staff 1 (Administrator) was informed of the findings of this investigation and acknowledged the facility did not provide adequate person-centered activities. 2. Resident 50 was admitted to the facility in 4/2021 with diagnoses including Parkinson's disease. Resident 50's 12/14/22 Annual MDS indicated the resident was severely impaired, her/his vision and hearing were adequate and she/he preferred reading books, listening to music, being around animals, doing things with groups of people, participating in favorite activities and spending time outdoors. The Activities CAA indicated activities were very important to Resident 50. Resident 50's Care Plan included the following activity goals and interventions: - 1/5/23 Goal: Provide activities that match resident's preference, ability, skill set and participation level; - Interventions: activities very important to [resident]: listen to music especially blues, pets, play cards and chess, go outside when the weather is good. - 1/5/23 Goal: Will participate in sensory (visual, hearing, touch, smell, taste) and mentally stimulating activities as offered per the monthly activities calendar. - Interventions: hand hygiene sanitization of both staff and resident's hands before and after activity and adapt personal activities for [her/him] accordingly. Review of the 1/2023 Activities Calendar revealed the following scheduled activities from 1/8/23 through 1/18/23: - 1/8/23: coffee cart, room visits, fancy fingers (manicure) and movie/snack. - 1/9/23: coffee and treat, religious services, exercise/garden walk, Bingo. - 1/10/23: coffee cart, room visits, exercise/garden walk, brain games. - 1/11/23: coffee cart, feed the wildlife, exercise/garden walk, arts & crafts. - 1/12/23: coffee cart, religious services, exercise/garden walk, movie of choice. - 1/13/23: coffee & cookie, room visits, root beer floats. - 1/14/23: Resident choice movies. - 1/15/23: Resident choice movies. - 1/16/23: coffee & treat, religious services, exercise/garden walk. - 1/17/23: coffee cart, room visits, exercise/garden walk. - 1/18/23: feed the wildlife, movie of choice. Resident 50's 1/2023 Activity Participation Sheet, completed by Staff 12 (Activities Director) and Staff 38 (Kitchen Staff/Food & Nutrition) indicated the resident participated in the following: - "Coffee" on 1/9/23, 1/11/23, 1/12/23, /13/23, 1/16/23 and 1/17/23. - "Goodie visit" on 1/12/23, 1/13/23, 1/16/23 and 1/17/23. - "Movie/TV/Music" on 1/8/23, 1/9/23, 1/10/23, 1/11/23, 1/12/23, 1/13/23, 1/14/23, 1/16/23, 1/17/23 and 1/18/23. - "Drop in visit" on 1/8/23, 1/9/23, 1/10/23, 1/11/23, 1/12/23, 1/13/23, 1/14/23, 1/16/23, 1/17/23 and 1/18/23. None of the activities outlined on the calendar and the participation sheet were person-centered to Resident 50's activity preferences and care plan. Observations of Resident 22 conducted from 1/8/23 through 1/18/23 between the hours of 7:15 AM and 7:45 PM revealed the resident in her/his room with the television turned off, or in the main dining room with the television on various shows. On 1/9/23 at 3:26 PM and 1/10/23 at 9:22 AM Resident 50 was interviewed and she/he was unable to provide information related to her/his activity preferences On 1/12/23 at 9:59 AM Staff 10 (CNA) stated she was familiar with Resident 50 and the resident liked to watch television, listen to music and "hang out" in the dining room. Staff 10 stated group activities were not often provided and Staff 38 (Kitchen Staff/Food & Nutrition) visited the residents in their rooms. On 1/17/23 at 11:06 AM and 1/19/23 at 8:56 AM Staff 12 stated general activities for the facility consisted mostly of passing coffee and resident room visits which lasted between five and 35 minutes for each resident. Staff 12 stated group activities, live events and sensory stimulating activities had not occurred frequently or regularly since 2020. Staff 12 stated Resident 50's activities mostly consisted of the resident watching television in the dining room and interacting with staff. When asked if any of the activities on the calendar or participation sheet aligned with Resident 50's preferences, Staff 12 stated Resident 50 was independent and chose her/his own activities. On 1/19/23 at 11:04 AM Staff 1 (Administrator) was informed of the findings of this investigation and acknowledged the facility did not provide adequate person-centered activities. , 3. Resident 28 was admitted to the facility in 5/2017 with diagnoses including Alzheimer's disease (a type of dementia that affects memory, thinking and behavior). Resident 28's 11/2/22 Quarterly MDS indicated the resident's cognition was severely impaired and her/his vision and hearing were adequate. Resident 28's 11/15/22 Activities Quarterly/Annual Participation Review revealed the resident enjoyed watching television both in her/his room and in the dining room, listening to guest entertainers, going outside when the weather was nice, doing things with groups of people, listening to old country music, and participating in her/his favorite activities. The review also indicated the resident received one to one visits, participated in regular phone calls with her/his family and activities were very important to the resident. Resident 28's 11/15/22 Activity Care Plan included the following goals and interventions: -Provide activities that match the resident's preference, ability, skill set and participation level. -Participate in sensory (visual, hearing, touch, smell, taste) and mentally stimulating activities as offered per the monthly activities calendar. -Daily drop in visits, 1 to 1 visits, rides in the garden, goodie visits and assistance with her/his television, phone calls and face time. -Enjoys watching traveling, fishing and car show videos as well as listen to music, especially old country music. -Likes dogs, doing things with groups of people, going outside when the weather is good, gardening and fishing. -Inform, invite and assist to activities of choice. Observations of Resident 28 conducted from 1/8/23 through 1/13/23 between the hours of 7:30 AM and 4:45 PM revealed the resident in bed or in her/his wheelchair and in her/his room or in the dining room. The television was on at various times in both locations. The resident was observed to be either sleeping or not engaged with her/his surroundings. On 1/8/23 at 12:57 PM and 1/9/23 at 8:45 AM Resident 28 was unable to provide information related to her/his activity preferences. Review of the 1/2023 Activities Calendar revealed the following scheduled activities from 1/8/23 through 1/18/23: - 1/8/23: coffee cart, room visits, fancy fingers (manicure) and movie/snack. - 1/9/23: coffee and treat, religious services, exercise/garden walk, Bingo. - 1/10/23: coffee cart, room visits, exercise/garden walk, brain games. - 1/11/23: coffee cart, feed the wildlife, exercise/garden walk, arts & crafts. - 1/12/23: coffee cart, religious services, exercise/garden walk, movie of choice. - 1/13/23: coffee & cookie, room visits, root beer floats. - 1/14/23: Resident choice movies. - 1/15/23: Resident choice movies. - 1/16/23: coffee & treat, religious services, exercise/garden walk. - 1/17/23: coffee cart, room visits, exercise/garden walk. - 1/18/23: feed the wildlife, movie of choice. Resident 28's 1/2023 Activity Participation Sheet, completed by Staff 12 (Activity Director), indicated the resident participated in the following: -"Coffee" on 1/13/23. -"Goodie visit" on 1/6/23 and 1/13/23. -"Movie/TV/Music" on 1/2/23, 1/3/23, 1/4/23, 1/5/23, 1/6/23, 1/7/23, 1/8/23, 1/9/23, 1/10/23, 1/11/23, 1/12/23, 1/13/23, 1/14/23, 1/16/23 and 1/17/23. -"Drop in Visit" on 1/2/23, 1/3/23, 1/4/23, 1/5/23, 1/6/23, 1/7/23, 1/8/23, 1/9/23, 1/10/23, 1/11/23, 1/12/23, 1/13/23, 1/14/23, 1/16/23 and 1/17/23. -"Other" on 1/4/23 (listened to music in the dining room), 1/6/23 (haircut), 1/9/23 (watched a fishing video on the tablet with activity staff) and 1/11/23 (watched an aquarium video on the tablet with activity staff). None of the activities outlined on the calendar included sensory or mentally stimulating activities consistent with the Resident 41's preferences and abilities outside of garden walks in which the resident did not participate. On 1/13/23 at 8:47 AM Staff 15 (CNA) stated Resident 28 enjoyed music but she was otherwise not sure of the resident's interests. On 1/17/23 at 12:46 PM Staff 12 (Activity Director) stated general activities for the facility consisted mostly of passing coffee and resident room visits which lasted between five and 35 minutes. Staff 12 stated group activities, live events and sensory stimulating activities had not occurred frequently or regularly since 2020. Staff 12 stated Resident 28's activities mostly consisted of watching television and listening to music in her/his room or the dining room. Staff 12 stated Resident 28's family no longer called or visited and Resident 28 enjoyed going outside when the weather was nice but the activity had not occurred in a while. On 1/19/23 at 11:04 AM Staff 1 (Administrator) was informed of the findings of this investigation and acknowledged the facility did not provide adequate person-centered activities.

F679 Activities meet interest/needs each resident #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #22, 28, 50 Resident’s /Guardian have been re-interviewed for updated Activity Preferences and Care Plans have been reviewed and updated. Individual and Group Activity programming has been tailored to include updated Activity Preferences and sensory stimulation per resident care plan to ensure person centered activities are offered. Facility Activity calendar has been updated to include resident preference activities and sensory stimulation per resident care plans. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Facility Activity Program policies related to person-centered Activities have been reviewed and updated. All residents/Guardians have been re-interviewed for updated Activity Preferences and Care Plans have been reviewed and updated. Care plans will be reviewed and updated quarterly and as needed. Individual and Group Activity programming has been tailored to include updated Activity Preferences and sensory stimulation per resident care plan to ensure person centered activities are offered. Facility Activity calendar has been updated to include resident preference activities and sensory stimulation per resident care plans. Facility has contracted the services of an Activity Consultant to assist Activity Department through the activity preference updates, care plan review and update and activity programming update to ensure activities include sensory stimulation and activity preferences for person centered programming. The Activity Staff have been re-structured, placing the prior in-house Activity Consultant in Activity Director position and prior Activity Director as Activity Director in Training/Assistant to Activity Director. Job Description review and competencies have been completed for the Activity Director and the Activity Director in Training/Assistant to the Activity Director. All partial remote work allowed during the height of the pandemic has been eliminated. All Activity tasks and labor hours are back to fully on-site. A menu board of daily activities has been placed at each Nurse station with a reminder for staff to encourage resident participation in scheduled activities. Nursing staff have been in-serviced to expectations of encouraging residents to be up and involved in scheduled activities. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. Activity consultant will be on-site two days per week auditing the plan of correction until compliance is reached and on-going thereafter as needed to ensure compliance is maintained. Activity consultant will submit weekly status report to Administrator for review and follow if needed. Resident participation will be audited weekly by the Activity Director or designee. Compliance of resident participation and Activity Consultant reviews will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. #5 Title of Person Responsible to ensure correction and sustain compliance. Activity Director as overseen by Activity Consultant and Administrator.

1.

Based on observation, interview and record review it was determined the facility failed to comprehensively assess/measure resident wounds, monitor wounds for signs/symptoms of infection and document the effectiveness of wound treatment for 1 of 1 sampled resident (#27) reviewed for skin conditions. This failure resulted in Resident 27's worsening wound as evidenced by two emergency room trips and three antibiotic courses. Findings include: Resident 27 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease and stroke with hemiparesis (weakness to one side of the body) affecting left non-dominant side. The 10/26/22 Care Plan indicated Resident 27 was at risk for actual skin impairment/pressure ulcer. Interventions included: Encourage small, frequent position changes, pressure reduction mattress on bed and chair, turn and reposition every two hours while in bed, use pillows to separate pressure areas, weekly skin audit by the nurse and as needed. The 10/26/22 Annual MDS indicated Resident 27 was moderately cognitively impaired and at risk for pressure ulcers/injuries. The 10/26/22 CAA for Pressure Ulcer/Injury revealed Resident 27 was at risk for skin impairment, required the assistance of two people for all turning and repositioning, had a pressure reducing mattress, and was on a turn and repositioning schedule when in bed to offload any pressure points. A review of Resident 27's progress notes indicated the following; -On 11/11/22 a slight skin breakdown was found upon assessment of lump on Resident 27's upper back. -On 11/15/22 a provider visit indicated Resident 27 was seen due to staff concerns of an area of skin breakdown on her/his back. A lump was noticed on the resident's back and "may be an infected cyst." Treatment orders included Keflex (an antibiotic) for seven days, obtain a skin culture, consider a surgical referral if needed and continue to monitor closely. -On 11/15/22 when staff removed the padded bandage from the area, the lump on Resident 27's back was macerated (soft, wet or soggy to the touch) underneath and the bandage was soiled. Resident 27 was started on antibiotics and put on alert monitoring. -On 11/16/22 the physician order was updated to include: Notify RCM (Resident Care Manager) if any signs of redness, swelling, drainage, odor, warmth, or any other signs of worsening or infection every two day(s) for skin breakdown on lump. -On 11/17/22 no worsening condition noted to back. -On 11/18/22 Resident 27 was sent to the emergency department (ED) at the request of Witness 9 (POA/family member) and the Witness's concern the wound looked infected. The resident returned on the same day. The ED after-visit summary indicated a diagnoses of cellulitis and an abscess on Resident 27's back. The discharge orders included a prescription for Bactrim (an antibiotic) and the Keflex was discontinued. -On 11/19/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 11/20/22 there was no swelling observed, scant bloody drainage on old dressing, darkened (red/purple) skin surrounded the open area, 5cm in diameter. Between 11/21/22- 11/28/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 11/29/22 the facility provider note indicated Resident 27's back infection had improved, continue to apply dressing until it was fully healed and monitor for any recurring infection. Antibiotic treatment was completed. Between 11/30/22 to 12/9/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 12/10/22 Resident 27 was noted to have bloody drainage from the wound on her/his back. A request was made for a change in the order to prevent damage from moisture. The new order was scheduled to start the next day. Between 12/11/22 and 12/24/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 12/25/22 wound assessment documentation indicated the wound on Resident 27's back had signs of infection. The bandage was stuck to the resident's back, worn down with no date written on it and saturated with fluid. When the bandage was removed there was draining fluid, a strong odor, redness, swelling and pain at the site. The resident was laying on her/his side and was given PRN pain medicine for the pain. The family and provider were notified. -On 12/26/22 a nurse changed the dressing on Resident 27's back wound. The bandage was saturated. The on-call provider was notified and gave orders to send the resident out to the hospital. -On 12/26/22 Resident 27 was sent to the ED and returned the same day. The ED visit note indicated Resident 27 had an upper back wound related to an abscess. A new order for antibiotics was given for a soft tissue infection. -On 12/27/22 no signs/symptoms of infection, wound was draining. -On 12/27/22 the facility provider looked at the wound on Resident 27's back after she/he returned from the ED for suspected infection. The facility provider noted the wound looked good and was healing well. The facility provider updated the order and the wound was to be kept clean, dry, and covered. Between 12/28/22-12/31/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 1/1/23 the dressing was changed on Resident 27's back. The wound had tunneling and drainage was serosanguineous (yellowish with small amounts of blood). Resident 27 was turned side to side. Between 1/2/23-1/5/23, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation on the effectiveness of the wound treatment in Resident 27's record. -On 1/6/23 the dressing was saturated with puss and the wound dressing was changed. The packing was saturated in puss, there was a strong odor, redness, increased pain for resident and the wound had tunneled 1/4cm deeper. On 1/8/23 at 5:54 PM Witness 9 stated the facility notified her on 11/15/22 of a "lump" on Resident 27's back and it was being watched. Witness 9 stated she/he visited Resident 27 on 11/18/22, was shocked by how the "lump" looked and requested Resident 27 be sent to the hospital. Between 1/7/23-1/13/23, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. On 1/12/23 at 9:21 AM with the resident's permission, wound care was observed by an RN surveyor and a non-RN surveyor. Staff 23 (RN) provided wound care. The RN surveyor observation revealed: wound was jagged, with a linear open area, approximately 1 cm long and .5 cm wide located in the center of Resident 27's mid back, with a small amount of pink-tinged drainage observed. Staff 23 removed the dressing, cleansed the wound with wound cleanser spray and gauze, used a long Q-tip and pressed approximately five inches of gauze packing into the wound and covered the wound with a clean dressing. Staff 23 did not measure the length, width or depth of the wound. Staff 23 did not document characteristics of the wound including the location, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor and whether or not the resident experienced pain. Staff 23 stated she believed the wound was measured by the RNCM and the RNCM should document in the progress notes. On 1/12/23 at 11:03 AM Staff 16 (LPN) stated she was concerned wound care was not done daily because of the lack of documentation. On 1/13/23 at 2:17 PM Staff 3 (RNCM) stated Resident 27's wound was not measured daily and nursing staff should measure the wound weekly and document their findings in the progress notes. Staff 3 confirmed there was no documentation of weekly assessments/measurements, treatment, and effectiveness of treatment to indicate if the wound was healing or not. Staff 3 stated the wound was monitored daily and if there was no progress note, then the wound "presumably" was healing. Resident 27's progress notes revealed the following: -On 1/14/23 the wound dressing was changed on Resident 27's upper back. The dressing was saturated. The wound was cleaned and packed with calcium alginate per order. The wound was covered with 4x4 adhesive foam dressing. Resident 27 was on her side. Will continue to monitor. On 1/15/23 there was no documentation of the wound treatment in Resident 27's record. -On 1/16/23 wound is healing, tunneling stalled, new tissue was present, drainage has decreased and pain has decreased. -On 1/17/23 there was no documentation of the wound treatment in Resident 27's record. -On 1/18/23 the wound dressing to Resident 27's mid back was changed. The old dressing/packing was removed with yellow brownish drainage. The wound site looked a bit discolored with greyish edges near the wound opening. There was no redness to the wound site. The tunneling wound was packed with packing gauze and covered with a dressing. Resident 27 tolerated the dressing change and was turned, repositioned every 2 hours and as needed. -On 1/19/23, there was no documentation of the wound treatment in Resident 27's record. On 1/19/23 at 11:28 AM Staff 2 (DNS) stated wound assessments and documentation needed to improve. She further stated wound assessment/measurements, monitoring and documentation needed to be completed at least weekly. On 1/19/23 at 11:58 AM Staff 5 (RN/IP) stated wound care documentation was not completed as expected. The expectation was the wound should be assessed/measured, monitored, and documented at least weekly. , 2. Based on observation, interview and record review it was determined the facility failed to provide appropriate equipment to address the positioning needs of residents for 1 of 4 sampled residents (#35) reviewed for positioning. This placed residents at risk for discomfort. Findings include: Resident 35 was admitted to the facility in 7/2017 with diagnoses including Alzheimer's disease. The 8/12/20 Assistive Device Evaluation indicated Resident 35 used a tilt-in-space wheelchair (a reclining wheelchair which allowed the resident to tilt backwards). Observations of Resident 35 from 1/8/23 through 1/17/23 between the hours of 9:14 AM and 7:45 PM revealed the resident in a tilt-in-space wheelchair without a head rest. Resident 35 was positioned in a backwards reclined position with her/his head, neck and upper shoulders unsupported. The resident's neck was extended with the top of her/his head tilted backwards and her/his chin directed towards the ceiling. On 1/11/23 at 10:55 AM and 11:04 AM Staff 10 (CNA) and Staff 15 (CNA) observed Resident 35 in her/his tilt-in-space chair and confirmed the resident's head and neck was not supported. On 1/11/23 at 11:19 AM Staff 4 (RNCM) stated she thought Resident 35's tilt-in-space wheelchair headrest was removed a long time ago and she was unsure why it was not replaced. On 1/11/23 at 11:34 AM Staff 2 (DNS) stated she was unaware Resident 35's tilt-in-space wheelchair did not have a headrest and she expected the resident's head, neck and shoulders to be supported while in the chair. On 1/19/23 at 10:58 AM Staff 1 (Administrator) was notified of the findings of this investigation and provided no additional comments or information.

F684 Quality of Care 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #27’s wound was brought to the MD’s attention and a lab swab was ordered. Lab results have been received and reported to MD. Antibiotics and surgical consult were ordered. Awaiting confirmation of surgical appointment. Weekly documentation of healing and progress will occur weekly. Resident #35 had a pillow placed behind his head and maintenance was alerted to the broken headrest. The chair was fixed the next morning. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents with wounds have the potential to be affected-see plan of correction below, all residents with wounds have been assessed during weekly skin rounds. All residents with tilt in space or reclining wheelchairs have the potential to be affected-we have reviewed these residents for further positioning needs. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? Facility Wound Care policy has been reviewed and updated. Nursing has been in-serviced to the facility policy including assessing and measuring wounds, monitoring for infection, and effectiveness of treatment. Charge nurses will do daily wound care per the Treatment Administration Record. RCM’s and DNS will do weekly skin rounds on all residents with wounds, these round tools will include measurements and descriptions of the wound. All nursing staff have been in-serviced to log any equipment issues (broken headrest) on the maintenance work order log. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: All weekly wound monitoring forms will be brought to morning clinical meetings each week to ensure that the wounds are healing and that there is documentation. RCM’s and DNS will review the maintenance log daily and any resident related issues will be added to our Monday, Wednesday, Friday clinical meeting for follow up. Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with DNS oversight.

Based on observation, interview and record review it was determined the facility failed to ensure adequate supervision and a safe environment for 2 of 3 sampled residents (#s 41 and 58) reviewed for accidents. This failure placed residents at increased risk for injuries and resulted in Resident 41 sustaining a hip fracture from a fall. Findings include: 1. Resident 41 was admitted to the facility in 6/2018 with diagnoses including frontotemporal dementia (a type of dementia characterized by changes in emotions, behavior, personality and language). Resident 41's 8/31/22 Quarterly MDS indicated the resident's cognition was severely impaired, she/he required extensive assistance from at least two staff for transfers and was totally dependent on staff for locomotion on and off of the unit. Resident 41's 9/12/22 Morse Fall Scale revealed the resident was at high risk for falling. A review of Resident 41's 9/14/22 Care Plan revealed the resident was at risk for falls due to cognitive impairment and lack of impulse control and included the following interventions related to safety and falls: -The resident's room was to be kept free from clutter and floors free from spills; -A fall mat was to be in place; -A tab alarm was to be in place when the resident was in bed; -A seatbelt and tab alarm were to be in place when the resident was in her/his wheelchair; -The bed was to be in the lowest position when occupied; and -The resident was not to be left unattended with her/his bed in the highest position. A review of Resident 41's progress notes revealed she/he fell on 9/21/22 and 10/1/22 as a result of failed self transfers. A 12/1/22 FRI Form revealed Resident 41 was sent to the hospital on 11/29/22 and returned to the facility on 11/30/22 with a diagnosis of a left hip fracture, cause unknown. A review of the facility's 12/5/22 Incident Note completed by Staff 4 (RNCM) revealed the following: -11/28/22 Staff 36 (CNA) left the resident unattended in bed with her/his bed in the high position before leaving for a break. While Staff 36 was on her break, the resident was found on the floor in the middle of her/his room. Staff 44 (Agency LPN) determined the resident did not experience discomfort with transferring from the floor into her/his wheelchair and did not have problems standing or pivoting. Staff 44 did not inform Staff 36 the resident had fallen when she returned from her break. -11/29/22 Resident 41 was transferred to the hospital as she/he was observed to be unresponsive. -11/30/22 Resident 41 returned to the facility from the hospital with a diagnosis of left hip fracture. -12/5/22 the left hip fracture was a result of the resident attempting to self transfer and being left unattended in her/his room with her/his bed in a high position. Resident 41's care plan was not followed. A review of Resident 41's health record revealed the following related to Resident 41's fall on 11/28/22: -No evidence the resident was assessed for injury or pain; -No evidence neurological checks were completed; -No evidence the resident was put on alert charting to assess for signs of latent injury; -No evidence an investigation into the root cause of the fall was initiated; and -No evidence the DNS, RNCM, the resident's responsible party or staff working the next scheduled shift were notified the resident experienced a fall. An attempt was made to contact Staff 44 via phone and no return phone call was received. On 1/8/23 at 1:40 PM Witness 8 (Family Member) stated she received a phone call on 11/29/22 at 5:00 PM from Resident 41's attending physician at the hospital who informed her the resident had sustained a left hip fracture which appeared to be from the result of a recent fall. On 1/8/23 at 2:05 PM Staff 36 stated Resident 41 was considered at risk for falls prior to the resident's 11/28/22 fall. She stated Resident 41's care plan at the time of the 11/28/22 fall was for the resident to be supervised when in bed if the bed was in a high position. Staff 36 confirmed she was Resident 41's assigned CNA on 11/28/22. She stated she left Resident 41 in bed unattended with her/his bed in a high position as the resident was not finished drinking her/his liquids before leaving for her break. She stated she was not informed of Resident 41's fall when she returned from her break but was made aware a few days later when she was called by Staff 4 (RNCM) who was completing the fall investigation. On 1/11/23 at 11:32 AM Staff 37 (CNA) stated she worked on 11/28/22 and checked on Resident 41 after she heard a noise coming from the resident's room. She stated she entered the room and discovered the resident on the ground and the resident's bed was raised to a high position. She stated she assisted the resident off of the ground with the help of the nurse and another CNA. On 1/13/23 at 10:12 AM Staff 4 (RNCM) stated Resident 41's bed should have been at knee level for care and during meal times and the resident should have been supervised during these instances. She confirmed Staff 36 should have lowered the resident's bed prior to leaving the room on 11/28/22. Staff 4 further stated Staff 44 should have informed the DNS, RNCM, family and staff working the next shift of the resident's fall, documented her assessment of the resident, started an incident report and initiated alert monitoring. On 1/19/23 at 10:41 AM Staff 2 (DNS) was informed of the findings and no additional information was provided. 2. Resident 58 was admitted to the facility in 10/2022 with diagnoses including alcohol abuse and Wernicke's encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1). Resident 58's 10/19/22 Wandering Risk Scale revealed the resident to be at risk to wander. Resident 58's 10/26/22 Admission MDS revealed the resident was moderately impaired in terms of cognitive functioning, was independent for locomotion on and off the unit and wandered. Resident 58's 10/26/22 Admission MDS Behavior CAA revealed the resident eloped from the facility shortly after her/his admission due to a malfunction of the keylock pad equipment on the facility's east gate. The resident exited out the east gate and she/he was found shortly thereafter in the facility's parking lot. The resident had wandering/exit-seeking behaviors and regularly talked about returning home and drinking whiskey. Resident 58's 11/28/22 Wandering/Wants To Go Home/Elopement Risk Care Plan listed the following interventions: -Assess and provide appropriate seating in dining room; -Complete wandering assessment on admission, 72 hours post admission, one month post admission, quarterly and as needed; -Encourage socialization with other appropriate residents and provide activities; -Reinforce reasons for placement; -15 minute checks and -Assign one to one if staff were available. A 12/27/22 FRI Form revealed Resident 58 eloped from the facility from the outer east gate which was discovered to be unlocked. A review of the 15 Minute Safety Checks CNA Task completed on 12/27/22 revealed no evidence Resident 58 was checked on from 7:00 PM to 7:43 PM. A review of the 12/30/22 Incident Review/Summary completed by Staff 4 (RNCM) indicated Resident 58 walked outside every day since his admission "trying to get the gates open." This Review/Summary revealed the following about the resident's 12/27/22 elopement: -15 minute checks of Resident 58 were completed by Staff 40 (CNA) until she went on break at 7:00 PM and did not resume until she returned from break at approximately 7:30 PM. Staff 40 stated the last time she saw the resident was around 7:00 PM prior to leaving for her break. -Staff 30 (CNA) along with the other CNA assisted another resident in the shower during Staff 40's break. -Staff 40 asked Staff 30 about Resident 58's whereabouts upon return from her break around 7:30 PM. Staff 30 assisted a resident in the shower at this time. -Staff 30 notified Resident 58 was missing around 7:30 PM to 7:35 PM. -It was determined the resident had eloped after the east gate was discovered to be unlocked at approximately 7:45 PM. The facility's video camera footage confirmed Resident 58 eloped through the east gate which was unlocked. Observations of Resident 58 conducted between 1/9/23 and 1/18/23 from 8:00 AM to 4:40 PM revealed the resident to be in bed either watching television, reading the newspaper or walking outside of the facility within the gated grounds. The resident was observed to frequently walk from the west to the east side of the building and push on the east gate. On 1/8/23 2:31 PM Resident 58 reported she/he independently took a trip to the city of Cornelius on TriMet (public transportation company) approximately a week prior. The resident reported falling a few times when on this outing and stated she/he was helped by strangers. On 1/11/23 at 12:05 PM Staff 37 (CNA) stated Resident 58 had a CNA regularly scheduled to provide one to one supervision but this was discontinued. Staff 37 stated when Resident 58's exit-seeking behavior was observed to be more frequent/heightened during a shift, staff reported this behavior, and if there was availability, the resident was assigned a staff person to provide one to one supervision. Staff 37 observed Resident 58's exit-seeking behavior increased in the evenings and nights and the resident usually attempted to exit out of the east gate. On 1/13/23 at 8:54 AM Staff 16 (LPN) stated staff were supposed to redirect Resident 58 when she/he was observed wandering or exit-seeking. She stated CNAs were responsible for completing 15-minute checks of the resident and they implemented one to one supervision of Resident 58 when increased exit-seeking was observed and/or if the resident was talking about wanting to leave the facility. On 1/13/23 at 10:12 AM Staff 4 (RNCM) stated Resident 58 talked about eloping since her/his admission to the facility and the resident checked the integrity of the gates daily since her/his admission. Staff 4 stated the resident eloped in 10/2022 after punching random numbers on the east gate's keypad which opened the gate. After this 10/2022 elopement, Staff 4 stated Resident 58 received daily one to one staff supervision until 12/7/22 when the gates were repaired. Staff 4 stated the 12/27/22 elopement was a result of a power outage and the magnet on the east gate malfunctioning. She stated on 12/27/22 the facility experienced three power glitches when the electricity in the building flickered but did not fully go out. She further stated staff had checked on the integrity of the gates until approximately 5:00 PM and they were locked. Staff 4 stated the gates had a 45-90 minute back up should the power completely go out. In the event of a power outage, a staff person was to chain the gates to prevent any potential resident elopements. Staff 4 stated Staff 39 (Staffing Coordinator) was assigned to train staff what to do in the event of a power outage. On 1/13/23 at 11:00 AM Staff 39 (Staffing Coordinator) stated she did not provide staff with any orientation specific to resident elopements or power outages, including what to do about the facility gates in the case of a power outage. On 1/13/23 at 2:33 PM Staff 40 (CNA) stated she was Resident 58's assigned CNA on the evening of 12/27/22. She stated she observed the resident to have increased wandering that evening as the resident was observed walking outside and around the building approximately every 30 minutes since the start of her shift at 2:00 PM. She further stated Resident 58 was not assigned one to one supervision despite her/his increased behaviors. She stated she took her break from 7:00 PM to 7:30 PM and informed the other two CNAs working in the east wing of the building. She then stated the CNAs were assisting another resident with a shower at the time she left for her break. At approximately 7:35 PM after returning from her break she went to check on Resident 58 and discovered the resident was missing. On 1/13/23 at 3:13 PM Staff 41 (Agency LPN) stated she was the nurse scheduled on the west wing on the evening of 12/27/22. She stated she observed Resident 58 to have increased wandering and exit-seeking behaviors on this evening of 12/27/22, but no one to one supervision was provided. She further stated she was not made aware of the resident's 10/2022 elopement until after her/his elopement on 12/27/22. Staff 41 was not aware of any elopement precautions, including the CNAs completing 15-minute checks on Resident 58. On 1/18/23 at 8:30 AM Staff 15 (CNA) stated Resident 58 gave various reasons where she/he was going when exit-seeking, including going to the bar. Staff 15 stated the resident told her she/he pushed on the gate every day to see if it was locked. On 1/18/23 at 9:34 AM Staff 8 (Maintenance Director) stated he checked the east and west gates on a daily basis to make sure they were locked since Resident 58's 10/2022 elopement. On 12/27/22, Staff 8 stated he and his assistant checked on the east and west gates approximately three times to make sure they remained locked due to the storms and power flickering that occurred on that day. He further stated he checked on the gates around 5:00 PM before leaving for the day and thought all staff were aware of the gate being a potential problem. Before leaving for the day, he spoke to Staff 42 (LPN) because he was worried about the possibility of the gates malfunctioning. He stated he informed Staff 42 of Resident 58's previous elopement and of the gates' previous malfunction. He confirmed there was no system in place for monitoring the gates to make sure they remained locked after he left the facility. On 1/18/23 at 12:44 PM Staff 42 stated Staff 8 did not provide with any warning about the possibility of the gates malfunctioning. She stated she was not made aware of Resident 58's prior elopement in 10/2022 until after her/his 12/27/22 elopement. On 1/19/23 at 10:41 AM Staff 2 (DNS) was informed of the findings of this investigation and provided no additional information.

F689 Free of Accident Hazards/Supervision/Devices 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #41. Staff member was educated/counseled on the importance of following resident care plan which stated to not leave the resident alone when bed was in a high position. The LN was educated on following Accident and Incident Policy of initiating a Risk Management on every fall at the time of the incident and reporting to family, RCM, and DNS at the time of the incident. Resident #58 had eloped and was found around midnight. Owner/CEO picked him up and brought him back to the facility. The gates which were found to be malfunctioning were chained shut and padlocked after the incident. All staff have a key to the padlock. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents are at risk for care plans not being followed. All residents who wander/exit seek have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? Accident and Investigation and the Abuse policies were reviewed and updated. CNA standards of care and the gate malfunctioning checklist were also reviewed and updated. LN’s have been in-serviced on the Accident and Investigation Policy, CNA’s have been in-serviced to the Abuse policy and the CNA standards of care. Nursing staff has been in-serviced on the Gate malfunctioning checklist. CNA’s have also been educated that when they are on a 1:1 with a resident they need to alert their charge nurse when they go on breaks so that supervision can occur. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Nurse managers or designee will each do rounds at least once a day with a charge nurse to ensure that there are no safety issues that need to be addressed. The charge nurses are expected to make rounds every shift as a part of their normal job description. These results will be presented to the Monday, Wednesday, Friday clinical meeting for review. Random weekly, for 4 weeks then monthly interviews thereafter, by DNS or designee and Maintenance director with staff to validate their understanding of what to do after hours if the gates malfunction. Results of the interviews will be presented to the bi-monthly QAPI committee and Quarterly QA Committee meetings for further review and recommendations. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with DNS oversight for following the Care Plan and Accident and Investigation Policies.

Based on observation, interview and record review it was determined the facility failed to ensure residents received care and services related to the use of an indwelling catheter for 1 of 1 sampled resident (#15) reviewed for catheter care. This placed residents at risk for unmet catheter needs. Findings include: Resident 15 was admitted to the facility in 2022 with diagnoses including stroke, urinary tract infection (infection in the bladder, kidneys or urethra) and urinary incontinence. The facility policy, Urinary Incontinence-Clinical Protocol, dated 3/11/22 indicated the following: -The staff and physician will monitor the individual for complications of an indwelling catheter such as symptomatic urinary infection, urosepsis, or urethral erosion or pain and for complications of medications used to treat urinary incontinence. -Upon admission or re-admission, residents will be assessed for a catheter in place and will ensure MD (Medical Doctor) order, care plan and TAR are in place. Resident 15's Progress Notes indicated on 12/15/22, Resident 15 was sent to the emergency room due to severe back pain, was diagnosed with urinary retention, an indwelling (Foley) catheter was placed and Resident 15 returned to the facility with the Foley catheter later that day. A review of Resident 15's clinical record indicated there were no physician orders for care and services of Resident 15's catheter until 12/25/22, no care plan was in place for the new catheter and the 12/2022 TAR was blank. There was no evidence found in the clinical record to indicate Resident 15's catheter, drainage bag and drainage tubing were being routinely monitored, maintained and cleaned or changed when necessary prior to 1/1/23. Observations of Resident 15 from 1/8/23 through 1/18/23 between the hours of 8:00 AM and 11:50 PM revealed the resident had an indwelling catheter in place. On 1/12/23 at 9:24 AM Staff 34 (CNA) stated CNA catheter care typically consisted of emptying catheter bags, cleaning the catheter tubing and completing peri-care. Staff 34 stated Resident 15's peri-care was not completed consistently. On 1/12/23 at 11:19 AM Staff 16 (Agency LPN) stated most of Resident 15's catheter care was being done by CNAs. She stated sometimes the licensed nurses did the catheter care but she had not provided Resident 15 with any catheter care for a while. On 1/12/23 at 11:30 AM Staff 23 (Agency RN) stated she was not sure when or how often Resident 15's catheter needed to be changed. She stated licensed nurses did not do much with catheters because the CNAs did most of the care like emptying catheter bags. On 1/13/23 at 10:46 AM Staff 3 (RNCM) stated on 12/15/22 Resident 15 went to the emergency room and returned that day with a catheter. Staff 3 confirmed there were no physician orders for catheter care until 12/25/22 and those orders were not specific enough. She confirmed Resident 15's Care Plan was not updated and Resident 15's catheter TAR was blank. Staff 3 reported there were no CNA task logs set up to document catheter care so she was unable to know if the CNAs were completing catheter care. On 1/17/23 at 10:35 AM Staff 2 (DNS) stated she expected Resident 15 to have physician orders and an updated care plan for catheter care and services and nursing staff should complete the resident's TAR when catheter care and services were provided.

F690 Bowel/Bladder Incontinence, Catheter, UTI 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #15. All orders were updated to reflect more detail on catheter care. Instructions were added to the CNA task list to ensure that they were providing appropriate catheter care. Resident #15’s catheter was removed on 1/17/2023 with orders to monitor for urinary retention. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents with a history of urinary retention or new/re admits who come from the hospital with a catheter are at risk of being affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? Facility Urinary incontinence clinical protocol has been reviewed and updated. All nursing staff have been in-serviced to this policy. A check list has been created and will be added to the admit/readmit instructions to check for a catheter when they do the comprehensive admit/readmit skin check. If a catheter is found and there are no orders then protocol will be followed with the charge nurse contacting the MD to get orders and a thorough progress note will be written. Charge nurses have been in-serviced to not add anything to the TAR without an order. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: All new admits or readmits with catheters will be reviewed at our clinical meeting to ensure that all orders and care plans are in place. Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with DNS oversight

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours per day 7 days per week for 9 out of 100 days reviewed for staffing. This placed residents at risk for lack of timely assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 7/1/22 through 8/31/22 and 12/1/22 through 1/8/23 revealed on 7/3, 7/10, 7/11, 8/12, 8/13, 8/14, 12/15, 12/26 and 1/2 there was no RN coverage for eight consecutive hours. On 1/17/23 at 8:41 AM Staff 2 (DNS) acknowledged the facility lacked RN coverage on the identified days.

F727 RN 8Hrs/7 days/WK, Full Time DON 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? No individual residents have been named. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? RN coverage. We have a contract agency RN scheduled 5 days per week. The remaining 2 days per week are covered by our RN ICP or RN RCM’s. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: DNS with bi-monthly QAPI committee, Quarterly QA Committee, and Administrator oversight.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 2 of 5 sampled residents (#s12 and 32) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 32 was admitted to the facility in 4/2018 with diagnoses including Huntington's disease. Resident 32's 12/2022 physician orders included Senna Plus tablet (a laxative and stool softener) 8.6-50 MG, two tablets by mouth twice a day related to constipation, HOLD for loose stools. Resident 32's 1/2023 MAR revealed Senna Plus was administered twice a day from 1/1/2023 through 1/18/23. Resident 32's 1/2023 Bowel Elimination Flowsheet revealed the resident had loose/diarrhea stools on the following days: - 1/1/23 - 1/3/23 - 1/5/23, two episodes of loose/diarrhea stools - 1/7/23 - 1/11/23 - 1/13/23, two episodes of loose/diarrhea stools - 1/14/23, two episodes of loose/diarrhea stools On 1/17/23 at 1:09 PM and 1:32 PM Staff 13 (CNA) and Staff 14 (CNA) stated they were responsible for documenting residents' bowel movements on the Bowel Elimination Flowsheet. Staff 13 and Staff 14 stated runny, watery or "liquidy" stool was documented as loose/diarrhea and when a resident had loose stools, it was reported to the nurse. Staff 13 stated Resident 32's bowel movements were "always watery and loose" and it was reported to the nurse. On 1/17/23 at 2:16 PM Staff 3 (RNCM) reviewed Resident 32's 1/2023 MAR, the physician orders and the Bowel Elimination Flowsheet. Staff 3 verified the Senna Plus order included directions to hold for loose stools, confirmed the resident had loose stools on the identified dates and she/he received the bowel medication unnecessarily. Staff 3 stated she expected the CNAs to report loose stools to the nurse so the nurse could follow the physician order to hold the bowel medication appropriately. On 1/18/23 at 10:50 AM Staff 2 (DNS) was informed of the findings of this investigation. Staff 2 agreed Resident 32 should not have received the bowel medication when she/he experienced loose stools on the identified dates. , 2. Resident 12 was admitted to the facility in 2017 with diagnoses including bipolar disorder, Alzheimer's disease and vascular dementia. Resident 12's 10/26/22 Quarterly MDS indicated Resident 12 had severe cognitive deficits. A review of Resident 12's 1/1/23 through 1/12/23 MAR indicated an order for Senna Plus (a laxative and stool softener) which was administered twice daily for constipation. The order indicated to hold the medication for 24 hours if Resident 12 had loose stools and to notify the Resident Care Manager. The MAR indicated Resident 12 was administered Senna Plus twice daily and there were no instances when the medication was held. A review of Resident 12's Bowel Elimination Flowsheets from 1/1/23 through 1/12/23 indicated Resident 12 had loose stools on 1/5, 1/6, 1/7, 1/9, 1/10, 1/11 and 1/12. On 1/17/23 at 1:09 PM and 1:32 PM Staff 13 (CNA) and Staff 14 (CNA) stated they were responsible for documenting residents' bowel movements on the Bowel Elimination Flowsheet. Staff 13 and Staff 14 stated runny, watery or "liquidy" stool was documented as loose/diarrhea and when a resident had loose stools, it was reported to the nurse. On 1/17/23 at 12:10 PM and 1/18/23 at 8:41 AM Staff 33 (LPN) and Staff 2 (DNS) reviewed Resident 12's MAR and Bowel Elimination Flowsheets and confirmed Resident 12's Senna Plus should have been held on the identified dates due to the resident having loose stools.

F757 Drug Regimen is Free from Unnecessary Drugs 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #12, #16, and #32’s orders were audited to ensure that they state Hold for loose stools. Education was provided to the CNAs to report to the charge nurse when a resident has loose stools. CMAs were educated to hold bowel medications when a resident reports having loose stools. RCM audited the elimination record of these three residents to determine if each resident is having frequent loose stools and their bowel medications need to be adjusted. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents on routine bowel medications have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? Facility has reviewed and updated Policies related to medication administration and medication holds. All nursing staff that administer medications have been in-serviced to the policies. Education was provided to the CNAs to report to the charge nurse when a resident has loose stools which the LN’s will then report to the CMA’s to hold the medications. CMAs were educated to notify the LN and hold bowel medications when a resident reports having loose stools. A whole house audit will be done to determine which residents are having frequent loose stools as well as who is on bowel medications. PCC was updated to show loose stools on the alert listing report that the nurses print every morning. RCM’s will also review quarterly at care conferences the continued need for bowel medications. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: RCM’s and DNS will review the alert listing report daily, Monday-Friday, and will print a copy on Mondays, Wednesdays, and Fridays and bring it to clinical meetings for review. Any residents found to have had loose stools will have their administration record audited to ensure that bowel meds were held. Education will be provided to direct care staff on the importance of documenting loose stools and ensuring that the LN’s and CMAs are aware of any loose stools so that bowel meds can be held. Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with DNS oversight

Based on observation, interview and record review it was determined the facility failed to ensure a medication pass error rate of less than 5%. There were six errors in 33 opportunities resulting in an 18.18% error rate. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 16 was admitted to the facility in 4/2018 with diagnoses including stroke. Resident 16's 12/2022 physician orders included the following medications: - Senna 8.6 mg (laxative) 1 tab, hold for loose stool; - DSS (stool softener) 250 mg, hold for loose stool; - Protonix (medication for stomach problems) 20 mg, give before breakfast. On 1/12/23 at 7:36 AM Staff 16 (LPN) was observed for Resident 16's medication administration. Staff 16 prepared the Senna, DSS and Protonix and other medications ordered for Resident 16's high blood pressure and entered the resident's room. Resident 16 was eating her/his breakfast and asked Staff 16 to wait a minute so she/he could eat the last two bites of her/his egg. After Resident 16 finished eating, the resident told Staff 16 she/he had diarrhea the night before and asked what medications she/he was taking. Staff 16 told the resident the medications were for her/his blood pressure and administered the medications. On 1/12/23 at 7:54 AM Staff 16 reviewed Resident 16's physician orders for Senna, DSS and Protonix. Staff 16 stated she should not have administered the Senna and DSS after the resident reported diarrhea and confirmed the order directed staff to hold for loose stool. Staff 16 confirmed the Protonix order included directions to administer before breakfast and acknowledged the resident took the medication after her/his breakfast was consumed. On 1/19/23 at 10:23 Staff 2 (DNS) was informed of the identified medication errors. Staff 2 stated she expected the nurse to remove bowel medications if the resident reported loose stools and confirmed the Protonix was ordered to be given before breakfast. 2. Resident 35 was admitted to the facility in 7/2017 with diagnoses including Alzheimer's disease. Resident 35's Standards of Care: Eating and Nutrition Care Plan, last revised on 7/31/20, indicated the resident was at risk for aspiration (inhalation of food and liquids into the lungs) and directed staff to do the following: - Feed slowly with teaspoon, allow to swallow before offering next teaspoon; - encourage chin tuck position; - encourage extra swallow between bites and sips: - check for pocketing (holding food in the cheeks or under the tongue); - must be upright 90 degrees for all oral intake. Resident 35's 12/2022 physician orders included the following: - Acetaminophen 325 mg, 2 tablets - Senna Plus 8.6-50 mg, 1 tablet - Multivitamin, 1 tablet The physician orders included "may crush all crushable medications for easier swallowing." On 1/12/23 at 8:06 AM Staff 17 (LPN) was observed for Resident 35's medication administration. Staff 17 dispensed the acetaminophen, Senna Plus and multivitamin, crushed the tablets together and combined the mixture with pudding. Staff 17 entered Resident 35's room, approached the resident who was lying in her/his bed with the head of the bed raised to 60 degrees. Staff 17 quickly administered two full teaspoons of the medication/pudding combination into Resident 35's mouth and exited the room. Staff 17 failed to ensure the resident was positioned appropriately, failed to allow the resident adequate time to swallow before offering the second teaspoonful and failed to ensure the resident swallowed the medication. On 1/12/23 at 8:16 AM Staff 17 stated she was unsure if Resident 35 had medication residue in her/his mouth and stated she did not verify the resident swallowed the medication/pudding mixture. On 1/19/23 at 10:23 AM Staff 2 (DNS) was informed of Resident 35's medication administration observation. Staff 2 stated she expected the nurse to slow down and ensure residents swallowed medications, did not pocket the medication and there was no residue left in the resident's mouth.

F759 Free of Medication Error Rts 5 Prcnt or More 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #16’s medication list was audited to ensure that orders were input correctly and that the instructions were clear, including the times to be given. Resident #35: Education was given to staff on giving crushed meds to a resident on aspiration precautions as well as following the care plan. Crushed medications have been added to the Medication Administration Record. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents who are on aspiration precautions, and those on meds for GERD have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? Facility has reviewed and updated its policies related to Medication Administration, Crushed Medication, Adverse Consequences and Medication Error policies. All nursing staff that administer medications have been in-service to the policies and following the residents care plan. Education has been given to all nurses and CMA’s on how to properly give medications to residents and following the 6 rights of medication administration. PCC has been changed to show loose stools on the alert report so that nurses can alert the CMA to the loose stools and to hold bowel medication. The administration times on Gerd medications has been moved to an earlier time period so that it is given before breakfast. All residents with thickened liquids or crushed medication has been added to the Medication Administration Record. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: RCM’s, DNS or Pharmacy nurse have observed all staff passing medications prior to compliance date. Staff members with continued medication pass concerns will continue being observed until concerns resolve or the staff member is taken off the task. All staff members passing medications will be reviewed annually for competencies as part of the annual evaluation process. Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with DNS oversight.

Based on observation and interview it was determined the Dietary Manager (DM) did not obtain the required certification to provide dietary management services for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: Observations from 1/9/23 through 1/19/23 from 8:30 AM to 4:30 PM revealed Staff 6 (Dietary Manager) functioned in the capacity of the facility's Dietary Manager. On 1/13/23 at 10:18 AM Staff 6 stated he had been the Dietary Manager since 4/2022 and did not complete the required certification for the position as Dietary Manager. Staff 6 stated it would be approximately nine months until he finished the course. On 1/19/23 at 11:28 AM Staff 2 (DNS) confirmed Staff 6 did not have the required certification for the Dietary Manager position.

F801 Qualified Dietary Staff #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: No specific residents were identified. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Food and Nutrition in Training (Dietary Manager in Training) has and will continue to receive frequent scheduled consultations from a Qualified Dietician who is available in person, by phone, by text, or by email. The Qualified Dietitian has and will continue Nutritional at Risk (NAR) monthly assessment of each resident. The Qualified Dietitian has and will continue daily/weekly meal observations, resident interviews, review of weights (weekly/monthly), review skin assessments and review lab reports. The Qualified Dietitian has resumed the dual role of Dietitian/Director of Food and Nutrition Services until which time the Dietary Manager in Training completes the Florida University CDM/CFPP course of study and received certification for Certified Dietary Manager (CDM). The Qualified Dietitian has and continues supervising the training of the Dietary Manager in Training and assists with completion of CDM/CFPP correspondence courses. The policies for Director of Food and Nutrition and Qualified Dietitian have been reviewed and revised. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. The Qualified Dietitian will evaluate the Dietary Manager Competency Assessment every 90 days and compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. #5 Include dates when corrective action will be completed. The Dietitian/Director of Food and Nutrition Services with oversight from the QAPI Committee, QA Committee and Administrator will ensure on-going compliance.

Based on observation, interview and record review it was determined the facility failed to ensure residents received timely specialized rehabilitative services (PT and OT services) for 2 of 3 sampled residents (#s15 and 59) reviewed for therapy. This failure resulted in Resident 59 displaying signs of distress, depressed mood, a decline from former social patterns and repeatedly verbalizing feelings of frustration. Findings include: The Stroke Foundation, "What to Expect From a Stroke", dated 2023, explained that stroke rehabilitation (PT, OT and SLP) is the therapy and activities that drive recovery by helping to re-learn ways of doing things affected by a stroke. It aims to stimulate the brain to change and adapt. By creating new pathways a person can learn to use other parts of the brain to recover function of those parts affected by the stroke. Improvement after a stroke can continue for years but for many people it's quickest in the first six months. 1. Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Multiple random observations from 1/8/23 through 1/17/23 between the hours of 8:00 AM and 11:50 PM revealed Resident 59 had left-sided hemiparesis with no functional movement of her/his left arm or hand and limited movement of her/his left leg. At times the resident was observed laying on her/his left arm/hand. Resident 59 was typically in bed with a hospital gown on. No PT or OT therapy was observed. The 11/11/22 Hospital Discharge Orders indicated the reason Resident 59 discharged to nursing home care was to receive PT and OT services. Written orders for PT and OT to assess and treat were provided. Resident 59's 11/18/22 Admission MDS indicated the resident had intact cognition and upper and lower extremity impairment on one side. Resident 59 required limited assistance with one person physical assist for bed mobility, total dependence with two plus persons physical assist for transferring, extensive assistance with one person physical assist for dressing, toilet use and personal hygiene and walking did not occur. The functional rehabilitation section revealed Resident 59 and direct care staff believed the resident was capable of increased independence. The special treatements section indicated there were no therapy minutes documented. There was no evidence in Resident 59's clinical record to show she/he received PT and OT assessments or treatment. On 1/8/23 at 1:02 PM, 1/11/23 at 7:56 AM and 1/12/23 at 8:35 AM and 12:31 PM and 1/18/23 at 8:27 AM Resident 59 stated when she/he was in the hospital, she/he had PT and OT services. Resident 59 stated she/he was told she/he would have rehab services at the facility but had no rehab therapy services. Resident 59 stated she/he was "pissed because these people don't even care about us. Why did they even take me when they knew they couldn't give me the rehab I needed. I haven't had shit. I am just sitting in this bed rotting." Resident 59 stated she/he spoke to Staff 3 (RNCM) many times regarding rehab services and "went up the chain of command" but nothing happened. Resident 59 stated she/he used to be very active; rode her/his bike and walked all of the time. Resident 59 stated up until her/his stroke she/he worked full-time. Resident 59 stated she/he was the "goofy" grandparent but did not want her/his grandkids to come to visit because Resident 59 did not want them to see her/him this way. Resident 59 stated she/he just wanted to get better so she/he could see her/his grandkids and go home. Resident 59 frequently spoke in an elevated voice, was teary at times and repeatedly verbalized frustration with not having therapy services. On 1/11/23 at 11:16 PM Staff 24 (CNA) stated Resident 59 was uncomfortable with her/his condition and "has not learned to live with it." Staff 24 stated Resident 59 needed PT and then she/he would feel more comfortable sitting in her/his wheelchair in the common areas, around others. Staff 24 stated Resident 59 just wanted to work with PT so she/he could get better and then Resident 59 would be so much happier. Staff 24 stated they told Staff 2 (DNS) and Staff 3 (RNCM) many times that Resident 59 needed PT but nothing was done. On 1/13/23 at 11:24 Staff 3 confirmed Resident 59's PT and OT services were not scheduled. Staff 3 stated she was not aware Resident 59 had PT and OT orders when she/he first admitted to the facility and there was a breakdown in communication. Staff 3 stated she learned Resident 59 had PT and OT orders sometime later and notified Staff 7 (SSD) because Staff 7 was responsible for scheduling therapy services. Staff 3 stated she spoke with Resident 59 a couple of times about her/his PT and OT and communicated with Staff 7 but the resident still did not have services. Staff 3 stated it sometimes took a week or two for therapy to be scheduled but services should have been ordered by now. Staff 3 acknowledged Resident 59 was upset and frustrated because of the lack of PT and OT services. On 1/13/23 at 11:47 AM Resident 59 was observed speaking to Staff 3 about her/his frustrations with PT and OT services not being scheduled. Resident 59 verbalized to Staff 3 that she/he did not want to be "shitting" or "pissing" in her/his bed. The resident stated she/he should not even be at the facility and her/his goal was to be as independent as possible. Resident 59 stated "the whole ball got dropped because nobody cares about me." Resident 59 spoke in an elevated voice and verbalized feelings of frustration. Staff 3 told Resident 59 once therapy started she/he would be able to do better and be more independent. On 1/13/23 at 1:15 PM Staff 2 (DNS) stated Staff 7 scheduled all therapies. Staff 2 stated therapy should be scheduled pretty quickly but sometimes it took up to two weeks but should not take over two months to get therapy services scheduled. She stated the facility did not typically have residents who were at the facility for therapy because therapy was not the focus of the facility so that was probably why Resident 59's therapy orders were missed. Multiple attempts were made by the facility administration and surveyor to contact Staff 7 via email, text and phone and Staff 7 indicated she was not available to be interviewed until her anticipated return on 1/23/23 or 1/26/23. On 1/18/23 at 11:19 AM Staff 1 (Administrator) and Staff 2 were informed of the findings of this investigation. Staff 1 and Staff 2 acknowledged Resident 59 was upset and frustrated over the lack of PT and OT services. No additional information was provided. 2. Resident 15 was admitted to the facility in 2/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Multiple random observations from 1/8/23 through 1/17/23 between the hours of 8:00 AM and 11:50 PM revealed Resident 15 had left-sided hemiparesis with some movement of her/his left side. Resident 15 was always in bed with a hospital gown on. No PT or OT therapy was observed. Resident 15's 12/3/22 Progress Notes indicated the resident was sent to the hospital on an emergency basis and was admitted for care and treatment. Resident 15 was re-admitted to the facility on 12/7/22. Resident 15's 12/7/22 Hospital Discharge Orders indicated the resident had signed physician orders for PT and OT services. There was no evidence in Resident 59's clinical record to show she/he received PT or OT assessments or treatment. On 1/8/23 at 2:06 PM Resident 15 stated she/he needed PT to help her/him sit up in a chair. On 1/13/23 at 10:46 AM Staff 3 (RNCM) stated she did not realize Resident 15 had orders for PT and OT but Staff 7 (SSD) should have received a copy of the therapy orders because she was responsible for scheduling therapy services. Staff 3 confirmed Resident 15 was readmitted on 12/7/22 with orders for PT and OT services and no therapy services were scheduled or completed. On 1/17/23 at 10:23 AM Staff 2 (DNS) stated she was not aware Resident 15 had PT and OT orders. She stated Staff 7 scheduled therapy services but she did not know if Staff 7 scheduled Resident 15's PT and OT therapy. Multiple attempts were made by the facility administration and surveyor to contact Staff 7 via email, text and phone and Staff 7 indicated she was not available to be interviewed until her anticipated return on 1/23/23 or 1/26/23. On 1/18/23 at 11:19 AM Staff 1 (Administrator) and Staff 2 were informed of the findings of this investigation. No additional information was provided.

F825 Provide/Obtain Specialized Rehab Services 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #15. Kaiser Permanente was called, and Kaiser stated that the residents insurance plan has dropped the referral due to the resident being in an Intermediate Care Facility. Multiple therapy agencies have been contacted in an attempt to get PT/OT to come see the resident in the facility. If unable to find therapy services to come into the facility attempts will be made to find outside therapy services that can accommodate a stretcher as he is unable to sit up in a wheelchair for prolonged periods. If unable to find therapy services onsite, offsite, or if resident refuses such appointments restorative services will be offered. Resident #59. Facility continues attempts to find a therapy company that will come into the facility. If unable to find therapy services to come into the facility, efforts will be made to find an outside therapy services. If this is unsuccessful a restorative program will be offered. Both residents have been offered discharge planning to a skilled facility that offers therapy services in-house. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents that are admitted to the facility with PT/OT orders have the potential to be affected. Facility standard process will continue of informing transferring facility that if resident has discharge orders PT/OT therapy, that we do not have a contract with a therapy company and may not be able to secure such services-in such cases, restorative services will be offered. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? Facility will continue to clarify that we are an Intermediate Care Facility (ICF facilities do not have routine PT/OT/ST services seeing clients in our setting). We do have an in-house restorative program that we can offer to residents while we continue efforts to find outside services offsite or onsite to see the residents but will offer restorative services in the meantime. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The status of any resident who we are unable to find either onsite or offsite therapies and offered discharge planning to a skilled facility, will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustained compliance: RCMs with DNS oversight.

Based on interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to systematically identify and correct deficiencies in the areas of dignity, quality of care, accidents, nursing services, staffing and infection control. This placed residents at risk for adverse consequences, injury and contracting infectious diseases and resulted in a hip fracture for Resident 41 and a worsening wound for Resident 27. Findings include: The facility's 8/15/22 Quality Assurance and Performance Improvement (QAPI) Plan identified the following goal for improvement: -To improve and maintain survey compliance for the rest of 2022 and on-going. The facility's 1/19/2023 survey identified the following: 1. The facility failed to ensure residents were treated in a dignified manner. This deficient practice was also identified on the 1/2022 survey. Refer to F550. 2. The facility failed to assess, monitor and document non-pressure related wounds, provide appropriate equipment to address the positioning needs of residents and follow physician orders. These deficient practices were also identified on the 1/2022 survey. Refer to F684. 3. The facility failed to ensure adequate supervision and a safe environment for residents. This deficient practice was also identified on the 5/2022 and 8/2022 complaint surveys. Refer to F689. 4. The facility failed to provide care and services related to catheter care. This deficient practice was also identified on the 1/2022 survey. Refer to F690. 5. The facility failed to ensure RN coverage for eight consecutive hours per day, seven days per week. This deficient practice was also identified on the 1/2022 survey. Refer to F727. 6. The facility failed to ensure provision of education related to risks and benefits, informed consent and the opportunity to receive administration of pneumococcal immunizations. This deficient practice was also identified on the 1/2022 survey. Refer to F883. There was no indication the facility's QAA Committee developed and implemented action plans to correct previously identified quality deficiencies. On 1/19/23 at 2:21 PM Staff 1 (Administrator) acknowledged the repeated deficient practices. Staff 1 stated the facility's QAA team met quarterly with a smaller sub group of the team meeting at least every other week. Staff 1 stated the focus on the QAA committee was on high level survey issues, specifically abuse prevention and COVID. Staff 1 further stated the facility experienced staffing changes in the positions of the Infection Preventionist (IP) and Resident Care Manager (RNCM) which contributed to failure to correct previously identified deficiencies.

F867 QAPI/QAA Improvement Activities #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #58-See F550 Resident # 27-See F684 Resident # 41-See F689 Resident #15-See F690 Resident #52-See F880 and #3 below. Resident #55-See F883 #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: F550. All residents who use a urinal have the potential to be affected. F684. All residents with wounds have the potential to be affected. F689. All residents have the potential to be affected. F690. All residents with a catheter have the potential to be affected. F727. All residents have the potential to be affected. F880. All residents with a diagnosis of a bloodborne pathogen and a bleeding wound have the potential to be affected. F883. All residents have the potential to be affected. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Abatement Plan for F880: 1. Facility failed to have a system in place to ensure that Resident 52's hands and personal property were clean and free of blood at all times. A. Resident 52 has been moved to a private room, room 19, across from the nurse’s station and has been assigned 1:1 caregiver 24 hours a day 7 days a week starting 1/9/2023 at 1900. This room will be stocked with all new uncontaminated items and her former room, 26-3 will be completely disinfected by housekeeping as soon as she is moved out of her current room (1/9/2023 at 1900). She will have a commode in room 19 so that she can remain in her room as much as possible. B. The assigned 1:1 caregiver will have gloves, appropriate alcohol-based hand sanitizer, and clean rags and/or paper towels to clean resident’s hands. When they become visibly soiled the 1:1 caregiver will take her to the sink to wash with soap and water. Clothing will also be changed when contaminated. If resident refuses to change clothes or wash her hands she will be re-approached by 1:1 or nurse every 15 minutes until the task (washing her hands or changing clothes) is completed. C. 1:1 caregiver will have separate red biohazard bags and garbage bins available in room 19 one for any waste and another for laundry, washable linen, clothes. 1:1 caregiver will have purple top wipes to clean surfaces in her room when they are contaminated with blood. Housekeeping will clean her room once each day shift and evening shift. All items will be set up in 3 drawer infection control bin for supplies to be used in the room and a portable tote, with spray disinfectant (Profect HP) instead of purple top wipes for the 1:1 caregiver will be set up for cleaning when she is up and moving. Both the purple top wipes and disinfectant spray (Profect HP) are effective against Hepatitis C. D. Either the ICP, RN Educator, or Staffing Coordinator will do education with each CNA prior to them being a 1:1. If education is needed after hours the charge nurse will provide this education. Education will be done verbally and with a handout for reference. A copy of this education will be kept in the 3-drawer bin located in room 19. This education will include disinfectant wipes, contact time, standard precautions, and what to do when resident is mobile. This will also include duties expected of the 1:1 caregiver. There will be a sign off sheet for when education is completed for each CNA. Housekeeping disinfects all community high touch areas 4 times a day and as needed. This is done after breakfast, after lunch, before dinner, and at bedtime. This high touch area cleaning was put into effect 8/2020 at the beginning of covid. 2. The facility failed to ensure the physician orders were followed to keep growth on top of her/his head clean, dry and covered with gauze at all times to prevent infection and to contain blood. A. Clarification has been added to the MD order on the TAR as follows: "If resident refuses the dressing changes per MD order re-approach in 15 minutes (1:1 caregiver will stay with the resident to clean anything she touches)". B. Order obtained from MD to discontinue Benadryl and start hydroxyzine TID to assist resident with her anxiety, itching, and picking wounds. 3. The facility failed to have a system in place to ensure residents followed appropriate infection control practices and standard precautions. A. Hand hygiene will be done for each resident before and after each meal in addition to morning and bedtime routine and as needed for using the bathroom/sneezing/touching nose and mouth or any other contamination. A portable tote, with disinfectant spray (Profect HP) instead of purple top wipes, for the 1:1 caregiver will be set up for when she is up and moving. Both the Profect HP and Purple top wipes are effective against Hepatitis C. The Purple top wipes cannot be used on wood furniture (handrails and dining room chairs. 4. The facility failed to ensure residents and staff have not contracted Viral Hepatitis C. A. A stat lab order was received and sent to the lab to confirm whether or not the resident has Viral Hepatitis C. If the resident’s lab results show that she is positive there is an order to treat if clinically appropriate. An order has been received and is in standby (until resident’s lab results are completed) to test and treat all residents and staff for Hepatitis C if the residents lab results come back positive and it is clinically appropriate. This diagnosis is from 2014, we will seek clarification from medical records on whether or not this was treated at that time. She has been placed on alert charting for the nurse to check in with the resident and her 1:1 every hour to ensure that she is free of blood on her clothing or body on 1/9/2023 at 1815. Facility policies related to Quality Assurance Committee and QAPI Committees have been reviewed and updated. Facility overall QAPI plan and Facility Assessment have been reviewed and updated with input from staff in various departments and positions. Facility entire QAPI Program has been reviewed and a review calendar has been initiated to ensure all facility operations are in compliance. Facility will use QAPI at a Glance as a guide and has incorporated templates to assist with Plan, Do, Study, Act (PDSA), 5 whys/root cause analysis, and PIPs to streamline the process and ensure all elements are present in the process. Root Cause Analysis has been conducted for F880 IJ/K and additional substandard Ftags to find out what happened, why it happened and determine what changes need to be made to prevent future like events. The Management Team has been in-serviced on this process and staff from various departments and positions will be invited to offer input, ideas, feedback for the QAPI process. Job Descriptions have been reviewed and competencies completed for DNS, RCMs, ICP, Activity Director, Activity Director in Training/Activity Director Assistant and Dietary Manager in Training. Competencies will be reviewed at 90-day intervals over the next 12 months and annually thereafter. A Nurse educator has been hired to strengthen the facility education program for staff. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. Compliance of Survey Citations will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of Survey audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. Facility QAPI review calendar compliance will be reported to Bi-Monthly QAPI Committee and Quarterly QA Committee for review and recommendation. #5 Title of Person Responsible to ensure correction and sustain compliance. RCM, ICP, DNS and Administrator with oversight from QAPI Committee, Quarterly QA Committee and Governing Board.

1.

Based on observation, interview, and record review it was determined the facility failed to implement infection control measures for a resident with exposed blood and bloodborne pathogens including Viral Hepatitis C for 1 of 1 sampled resident (#52) reviewed for infection control. This failure resulted in an immediate jeopardy situation. Resident 52 walked throughout the facility with an open bleeding head wound, touched various surfaces in common areas and held a bloodstained blanket with bloodstained hands. This placed all residents and staff at risk to contract Viral Hepatitis C, a life-threatening virus. Findings include: According to the CDC website, section titled, Hepatitis C Review, dated 7/28/20, Viral Hepatitis C is highly infectious and is spread through contact with blood from an infected person and inadequate infection control. Viral Hepatitis C can remain active on dry surfaces and equipment for up to six weeks, resulting in a longer period for transmission. Potential adverse outcomes of Viral Hepatitis C include cirrhosis, liver cancer and death. According to the CDC website, section titled, Recommendations for Prevention and Control for Viral Hepatitis C dated 8/7/20, included the following guidance: health-care workers should follow universal blood/body fluid precautions, wear gloves if they must touch another person's blood or open sores and avoid sharing and/or touching personal care items that might have blood on them, such as toothbrushes, razors, nail clippers, etc. Resident 52 was admitted to the facility in 6/2021 with diagnoses including moderate vascular dementia with behavioral disturbance, malignant melanoma (skin cancer), and Viral Hepatitis C. Resident 52's 9/9/22 Care Plan indicated the resident was at risk for actual skin impairment/pressure ulcer and had a sebaceous cyst (a type of liquid-filled bump that occurs on the skin) on top of her/his head. The care plan also indicated Resident 52 was resistant to treatment and ADL cares. The care plan lacked person-centered interventions related to the resident's bleeding cyst. The 10/5/22 Quarterly MDS indicated Resident 52 was severely cognitively impaired, required limited assistance with ADL care and was independent with ambulation. She/he was coded as having an open lesion other than ulcers, rashes, cuts (e.g., cancer lesion). On 1/8/23 between the hours of 11:27 AM and 4:23 PM observations were made of Resident 52. Resident 52's head had a golf-ball sized, protruding red nodule which was actively bleeding down both sides of her/his face and neck. Resident 52 was observed lying in her/his bed with bloodstained sheets and a blanket. Resident 52 walked independently throughout the facility and in communal areas, wore blood stained clothing, carried a bloodstained blanket, had an exposed bloody head wound, and touched/handled a communal chair in the dining room. Resident 52's hands were soiled with dried blood the entire time. Resident 52's hands were observed to have blood on each finger pad, on top of and under her/his nails. Interviews on 1/9/23 revealed the following: -12:35 PM Staff 19 (CNA) stated Resident 52 often picked at the exposed head wound and refused hand hygiene. Staff 19 stated Resident 52 often removed the gauze head bandage and discarded the soiled gauze bandage throughout the facility, including the communal bathroom. -12:36 PM Staff 35 (CNA) stated Resident 52 refused bandaging and treatment of her/his head wound. Staff 35 stated Resident 52 discarded the soiled gauze bandage in the dining room and communal bathroom. Staff 35 stated Resident 52 often picked at the exposed head wound and blood dripped down her/his face. Staff 35 stated Resident 52 easily became agitated and often refused hand hygiene. -12:36 PM Staff 5 (RN/IP) stated Resident 52 had a cancerous tumor on her/his head. Staff 5 stated Resident 52 refused treatment and bandaging of the head wound, walked around the facility with the exposed head wound bleeding, and stated "it's an ongoing problem." Staff 5 stated Resident 52, "can't keep from messing with it, there's nothing much else we can do." -12:36 PM Staff 3 (RNCM) stated Resident 52 could become belligerent and refused bandaging of the exposed head wound. Staff 3 stated Resident 52 often picked at the exposed head wound and had blood run down her/his face. Staff 3 stated "it's an infection control issue" because Resident 52 bled and walked around the facility. Staff 3 stated Resident 52 often refused hand hygiene and her/his hands were a "mess." -12:40 PM Staff 30 (CNA) stated Resident 52 picked at the exposed head wound, removed, and discarded the soiled gauze bandage throughout the facility daily. Staff 30 stated Resident 52 often refused hand hygiene. Resident 52's 1/9/23 physician order indicated: Keep growth on top of head clean, dry, and covered with gauze at all times. To prevent infection and to contain blood. If resident refuses, reapproach in 15 minutes. On 1/9/23 at 2:24 PM Staff 1 (Administrator) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to do the following: - Failure to have a system in place to ensure Resident 52's hands and personal property were clean and free from blood. - Failure to ensure the physician orders were followed to keep growth on top of her/his head clean, dry, and covered with gauze at all times to prevent infection and to contain blood. - Failure to have a system in place to ensure staff followed appropriate infection control practices and standard precautions. - Failure to ensure residents and staff did not contract Viral Hepatitis C. On 1/9/23 at 7:28 PM the facility submitted a removal plan which was reviewed and approved. The IJ removal plan indicated the facility would implement the following actions: - Resident 52 was moved to a private room and was assigned a one-on-one caregiver 24 hours a day seven days a week as of 1/9/23 at 7:00 PM. The resident's room was stocked with uncontaminated furniture and a commode to reduce the use of the communal bathroom. Resident 52's former room was completely disinfected by housekeeping as soon as the resident moved. - The assigned one-on-one caregiver would have gloves, appropriate alcohol-based hand sanitizer, and clean rags and/or paper towels to clean the resident's hands. When the resident's hands become visibly soiled the one-on-one caregiver would take the resident to the sink and wash her/his hands with soap and water. The resident's clothing would also be changed when contaminated. If the resident refused to change clothes or wash her/his hands, she/he would be re-approached by the one-on-one caregiver or nurse every 15 minutes until the task (washing hands or changing clothes) was completed. - The one-on-one caregiver would have separate red biohazard bags and garbage bins available in the resident's room, one for any waste, another for laundry, washable linen, and clothes. The one-on-one caregiver would have virucidal disinfectant to clean the surfaces in the resident's room when she/he was contaminated with blood. Housekeeping would clean the resident's room once each day shift and evening shift. PPE supplies would be set up in three drawer infection control bins accessible to staff. The supplies would be used in the room and on the portable tote, stocked with appropriate disinfectants and used by the one-on-one caregiver when the resident was up and ambulating. - The IP, RN Educator, or Staffing Coordinator would educate each CNA prior to becoming a one-on-one caregiver. If education was needed after hours, the charge nurse would provide the education. The education would be provided verbally and with a handout for reference. A copy of this education would be kept in the three-drawer bin located in the resident's room. This education would include disinfectant wipes, contact time, standard precautions, and what to do when the resident was mobile. The education would also include the duties expected of the one-on-one caregiver. There would be a sign off sheet when the education was completed for each CNA. Housekeeping would disinfect all community high touch areas four times a day and as needed. This would be done after breakfast and lunch, before dinner, and at bedtime. - A clarification was added to the physician order on the TAR as follows: "if resident refuses the dressing changes per MD order re-approach in 15 minutes (one-on-one caregiver will stay with the resident to clean anything she/he touches)". - An order was obtained from the physician to start hydroxyzine (anti-itch medication) TID to reduce the resident's anxiety, itching, and picking at wounds. - Hand hygiene will be done for each resident before and after each meal in addition to morning and bedtime routine and as needed for the bathroom/sneezing/touching nose and mouth or any other contamination. A portable tote with appropriate virucidal disinfectant for the one-on-one caregiver would be supplied when the resident was up and ambulating. - A stat lab order was received and sent to the lab to confirm whether the resident had Viral Hepatitis C. If the resident's lab results showed the resident was positive there would be an order to treat if clinically appropriate. An order was received to test and treat all residents and staff for Hepatitis C, if the resident's lab results came back positive. Resident 52's Viral Hepatitis C diagnosis was from 2014. The facility would seek clarification if the Viral Hepatitis C was treated at that time. The resident was placed on alert charting for the nurse to check in with the resident and her/his one-on-one caregiver every hour to ensure the resident was free of blood on her/his clothing or body. On 1/10/23 at 10:00 AM the survey team determined all components of the IJ removal plan were in place and the immediacy was removed. Following the removal of the immediacy, noncompliance remained at isolated with no actual harm with potential for more than minimal harm that is not IJ. , 2. Based on observation, interview and record review it was determined the facility failed to ensure proper infection control practices were followed during meal service for 2 of 3 hallways. This placed residents at risk for infections. Findings include: a. Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Resident 59's 11/18/22 Admission MDS indicated the resident was cognitively intact. On 1/13/23 at 11:47 AM Staff 3 (RNCM) and surveyor were with Resident 59 when Staff 31 (CNA) brought Resident 59's lunch into her/his room. Staff 31 removed the plastic wrap from Resident 59's plate then set the plate followed by cups of liquid on the bedside table approximately one inch from Resident 59's partially filled urinal. Staff 3 observed Staff 31 place the uncovered food and cups of liquid next to and near Resident 59's partially filled urinal and in approximately two to three minutes, Staff 3 left the room and returned with Staff 31. Staff 3 asked Staff 31 to remove the urinal from the bedside table, remove and discard the food and liquids from the bedside table, disinfect the bedside table and provide the resident with a new plate of food and liquids once the bedside table was disinfected. Staff 3 confirmed this practice was an infection control problem. On 1/17/23 at 2:13 PM Resident 59 stated staff frequently placed her/his food and liquids on the bedside table next to or near the urinal. Resident 59 stated she/he did not like staff putting her/his food and liquids next to the urinal, she/he asked staff to move the urinal but it was always a "major" issue to get anything done. Resident 59 stated sometimes she/he was laying in bed and staff put the nearly full urinal right by her/his plate of food then placed the bedside table over her/him so she/he could eat. Resident 59 stated her/his urinal sometimes "sloshed over" and spilled on her/his bedside table or bed linens and smelled. The resident stated the urinal often left a ring on the bedside table and staff put her/his silverware in the dirty area. Resident 59 stated she/he would not have "pee" sitting on her/his dining room table at home and did not want that done at the facility, either. On 1/18/23 at 11:19 AM Staff 1 (Administrator) and Staff 2 (DNS) were provided with the findings of this investigation and acknowledged this practice was an infection control concern. , b. A review of the facility's 2020 COVID-19 Infection Control Prevention policy revealed: "Staff will encourage and assist residents with hand hygiene prior to and after each meal..." Resident 55 was admitted to the facility in 2/2022 with diagnoses including calculus of the bile duct with acute cholecystitis without obstruction (a condition characterized by stones in the pathway connecting the liver with the small intestine). Resident 49 was admitted to the facility in 12/2022 with diagnoses including cerebral stroke. On 1/12/23 at 11:47 AM Staff 18 (CNA) was observed delivering lunch plates to Residents 55 and 49 in their shared room. Staff 18 entered the residents' room without performing hand hygiene, adjusted Resident 55's bedding and call light and then cleared and repositioned her/his tray table. Staff 18 then exited the room, collected Resident 55's plate from the cart in the hallway, returned to place it on her/his table and removed the plastic cling wrap covering the food. Without performing hand hygiene, Staff 18 approached Resident 49's bedside and cleared and adjusted her/his tray table. Staff 18 exited the room, collected Resident 49's plate from the cart in the hallway and returned to place it on her/his tray table. Without performing hand hygiene, he removed the cling wrap covering the plate. He then returned to the cart in the hallway, collected two sets of cutlery wrapped in napkins, returned to the room and placed them on the Residents' tray tables. Staff 18 did not perform hand hygiene during this process nor did he offer assistance to Residents 49 and 55 to perform hand hygiene. Staff 18 confirmed he sometimes performed hand hygiene during this process but did not do it today. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. c. On 1/8/23 at 12:04 PM Staff 30 wore gloves as she pushed a lunch cart on the east hallway. Staff 30 removed plastic wrap on the lunch plates and delivered the plates to four of four rooms with no hand hygiene or change of gloves. On 1/13/23 2:32 PM Staff 30 confirmed she did not perform hand hygiene or change gloves when she passed the lunch plates. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. 3. Based on observation and interview, it was determined the facility failed to process laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible for 2 of 2 laundry washing machines reviewed for infection control. This placed residents at risk of contaminated laundry. The findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D: -Do not leave damp textiles or fabrics in machines overnight. On 1/10/23 at 9:12 AM Staff 9 (HK/Laundry Supervisor) stated the laundry staff removed the final load of laundry from the washers and placed it in wire baskets at the end of every evening shift at approximately 10:00 PM. She reported housekeeping staff loaded wet laundry into the dryers at 6:30 AM the following morning. On 1/11/23 at 10:58 PM Staff 38 (LPN) provided access to the locked laundry facility using her key. No laundry staff were working and this part of the facility was locked for the night. Wet laundry was observed in two wire baskets covered with sheets and stationed adjacent to the two dryers. The sheets that covered the baskets were observed to be wet. Staff 38 confirmed the laundry was clean and wet and stated laundry should not be stored wet because mold and mildew could grow under these conditions. On 1/12/23 at 8:46 AM Staff 9 confirmed the wet laundry that was observed in the baskets on 1/11/23 at 10:58 PM was loaded into the dryers by laundry staff this morning without being rewashed. She stated this was how the laundry was handled every day. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. 4. Based on interview and record review, it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water borne pathogens. This placed all residents at risk for exposure to water borne pathogens. Findings include: On 1/17/23 at 2:25 PM Staff 8 (Maintenance Director) reported he did not complete a thorough analysis of the facility's water systems to identify and address the risk of water borne pathogens such as legionella. He reported his current plan to limit the risk of exposure to potentially harmful water borne bacteria involved flushing the eye wash stations regularly. He reported he did not complete regular testing of the facility's water supply nor did the facility contract with an agency to conduct a risk assessment or testing of the water supply on their behalf. Staff 8 confirmed the absence of a sustainable plan to mitigate the risks associated with the potential growth of water borne pathogens within the facility's water system. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information.

F880 Infection Prevention & Control 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1. An immediate action plan was implemented during the survey that included the following: Resident #52 has been moved to a private room, room 19, across from the nurse’s station and has been assigned 1:1 caregiver 24 hours a day 7 days a week starting 1/9/2023 at 1900. This room will be stocked with all new uncontaminated items and her former room, 26-3 will be completely disinfected by housekeeping as soon as she is moved out of her current room (1/9/2023 at 1900). She will have a commode in room 19 so that she can remain in her room as much as possible. B. The assigned 1:1 caregiver will have gloves, appropriate alcohol-based hand sanitizer, and clean rags and/or paper towels to clean resident’s hands. When they become visibly soiled the 1:1 caregiver will take her to the sink to wash with soap and water. Clothing will also be changed when contaminated. If resident refuses to change clothes or wash her hands she will be re-approached by 1:1 or nurse every 15 minutes until the task (washing her hands or changing clothes) is completed. C. 1:1 caregiver will have separate red biohazard bags and garbage bins available in room 19 one for any waste and another for laundry, washable linen, clothes. 1:1 caregiver will have purple top wipes to clean surfaces in her room when they are contaminated with blood. Housekeeping will clean her room once each day shift and evening shift. All items will be set up in 3 drawer infection control bins for supplies to be used in the room and a portable tote, with spray disinfectant (Profect HP) instead of purple top wipes for the 1:1 caregiver will be set up for cleaning when she is up and moving. Both the purple top wipes and disinfectant spray (Profect HP) are effective against Hepatitis C. D. Either the ICP, RN Educator, or Staffing Coordinator will do education with each CNA prior to them being a 1:1. If education is needed after hours the charge nurse will provide this education. Education will be done verbally and with a handout for reference. A copy of this education will be kept in the 3-drawer bin located in room 19. This education will include disinfectant wipes, contact time, standard precautions, and what to do when resident is mobile. This will also include duties expected of the 1:1 caregiver. There will be a sign off sheet for when education is completed for each CNA. Housekeeping disinfects all community high touch areas 4 times a day and as needed. This is done after breakfast, after lunch, before dinner, and at bedtime. This high touch area cleaning was put into effect 8/2020 at the beginning of covid. 2. The facility failed to ensure the physician orders were followed to keep growth on top of her/his head clean, dry and covered with gauze at all times to prevent infection and to contain blood. A. Clarification has been added to the MD order on the TAR as follows: "If resident refusesthe dressing changes per MD order re-approach in 15 minutes (1:1 caregiver will stay with the resident to clean anything she touches)". B. Order obtained from MD to discontinue Benadryl and start hydroxyzine TID to assist resident with her anxiety, itching, and picking wounds. 3. The facility failed to have a system in place to ensure residents followed appropriate infection control practices and standard precautions. A. Hand hygiene will be done for each resident before and after each meal in addition to morning and bedtime routine and as needed for using the bathroom/sneezing/touching nose and mouth or any other contamination. A portable tote, with disinfectant spray (Profect HP) instead of purple top wipes, for the 1:1 caregiver will be set up for when she is up and moving. Both the Profect HP and Purple top wipes are effective against Hepatitis C. The Purple top wipes cannot be used on wood furniture (handrails and dining room chairs. 4. The facility failed to ensure residents and staff have not contracted Viral Hepatitis C. A. A stat lab order was received and sent to the lab to confirm whether or not the resident has Viral Hepatitis C. If the resident’s lab results show that she is positive there is an order to treat if clinically appropriate. An order has been received and is in standby (until resident’s lab results are completed) to test and treat all residents and staff for Hepatitis C if the residents lab results come back positive and it is clinically appropriate. This diagnosis is from 2014, we will seek clarification from medical records on whether or not this was treated at that time. She has been placed on alert charting for the nurse to check in with the resident and her 1:1 every hour to ensure that she is free of blood on her clothing or body on 1/9/2023 at 1815. 2. Resident #59’s urinal was removed from his overbed table, table was sanitized, and new food and drink were brought in for him. 3.No specific residents identified. 4. No specific residents identified. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? 1. All residents with a diagnosis of a bloodborne pathogen and a bleeding wound have the potential to be affected. 2. All residents have the potential to be affected by the same deficient practice. 3. All residents have the potential to be affected. 4. All residents have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? 1. An immediate action plan was implemented during the survey. Reference F880 Question 1, above for resident #52. In addition, All staff have been in-serviced on bloodborne pathogens upon hire, annually and as needed. If a resident has a past diagnosis of a bloodborne pathogen they will have labs ordered to ensure that this is not a currently active diagnosis. They will be care planned appropriately with infection control measures for any incidents of bleeding. 2. Education will be provided to all direct care staff on the importance of hand hygiene and infection control. This will be done utilizing Relias as well as hands on education. The following videos have also been included in the education: Sparkling Surfaces, Clean Hands, Closely Monitor Residents, Keep COVID-19 Out!, and Lessons. 3. Environmental Service Laundry Standards and Laundry job description have been reviewed and updated to include that wet laundry is not to be left at end of shift for the next day to dry. Laundry Staff have been in-serviced to the updated Laundry Standards and Laundry job description. Environmental Services Manager or designee will conduct random weekly audits to ensure compliance. 4. Legionella Water Management Program policy and Legionella Surveillance and Detection policy have been reviewed and updated. A vendor has been secured and scheduled to conduct a risk analysis assessment for potential areas of growth and spread of water borne pathogens and to regularly test the water supply. Facility has incorporated the Legionella Water Management Program policy and Legionella Surveillance and Detection policy into the Facility Infection Control Program by: a. In-service the Water Management Program Team to follow facility Water Management Program Policy and b. In-service the ICP, DNS, Infection Control Committee to follow facility Legionella Surveillance and Detection Policy. The Water Management Program will be reviewed at least once a year or sooner as indicated in policy by the Legionella Water Management Team. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: 1. All new admits will be brought to the clinical meeting to ensure that all precautions are put into place as appropriate. They will also be brought to the infection control committee meeting to discuss any needs that the resident might have. All new staff will have a 1-hour Relias module on bloodborne pathogens that will be completed on orientation day. This will be a recuring module yearly. 2. Random weekly audits will be done and will be brought to clinical meeting as well as QAPI and infection committee meetings. 3. Results of random weekly audits will be reported to bi-monthly QAPI Committee and Quarterly QA Committee. 4. Results of vendor assessment and testing will be reported to bi-monthly QAPI Committee and Quarterly QA Committee for further review and recommendations. 5. Title of person responsible to ensure correction and sustain compliance: 1. ICP, RCM, and RN educator with DNS oversight. 2. ICP, RCM, RN educator with DNS oversight. 3. The Environmental Services Manager is responsible to ensure correction and sustain compliance. 4. The Water Management Program Team is responsible to ensure correction and sustain compliance.

Based on interview and record review it was determined the facility failed to designate a qualified and trained Infection Preventionist for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate care related to infection control. Findings include: On 1/8/23 at 12:40 PM Staff 5 (RN/IP) stated he began working as the facility's Infection Preventionist in 9/2022 and he did not complete the CDC Infection Preventionist training by the time he assumed the position. A review of training certificates provided by Staff 5 revealed Staff 5 completed seven of the 23 modules and submodules included in the training. On 1/12/23 at 2:05 PM Staff 5 stated he planned to complete the remaining modules and submodules of the CDC Infection Preventionist training by the end of February 2023. On 1/19/23 at 1:40 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the facility lacked a certified infection preventionist.

F882 Infection Preventionist Qualifications/Role 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? No specific residents have been identified. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? ICP nurse as well as DNS and RCM’s have completed CDC train modules. ICP is studying to take the CIC exam. DNS and RCMs are also studying also with the option of taking the CIC exam. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Job description and corresponding competency for ICP will be reviewed with the ICP nurse every 90 days. Weekly Coaching Study Sessions: ACE Program Series and office hours will be taken by ICP, RCMs, and DNS. Infection control committee will meet bi-monthly. Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustain compliance: DNS with QAPI committee, Quarterly QA Committee, and Administrator oversight.

Based on interview and record review it was determined the facility failed to ensure provision of education related to risks and benefits, informed consent and the opportunity to receive administration of pneumococcal immunizations for 1 of 5 sampled residents (#55) reviewed for immunizations. This placed residents at risk for being uninformed of their healthcare options and for contracting infectious diseases. Findings include: Resident 55 was admitted to the facility in 2/2022 with diagnoses including calculus of bile duct with acute cholecystitis without obstruction (a condition characterized by stones in the pathway between the liver with the small intestine). No evidence was found in Resident 55's clinical record to indicate she/he was screened for appropriateness to receive a pneumococcal immunization, provided information related to the risks and benefits or provided the opportunity to consent to or decline the immunization. On 1/19/23 at 12:23 PM Staff 5 (RN/IP) confirmed the resident was not screened, provided education about the immunization, or provided the opportunity to receive or decline the immunization. On 1/19/23 at 1:40 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged these findings and provided no further information.

F883 Influenza and Pneumococcal Immunizations 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #55’s chart was audited, and no vaccine administration was found. Resident was educated on the pneumococcal vaccine including risks and benefits and informed consent and was offered the Vaccine. Resident refused multiple times. This has been documented in the resident’s chart. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? The Pneumococcal Vaccine Policy has been reviewed and updated. The ICP and the infection control committee have been in-serviced on this policy. A whole house audit was done and those residents that have not yet received the vaccine have been offered. Any residents who refuse will be reapproached and refusals will be documented in the residents’ chart. ICP and DNS have access to the Alert ISS system to record vaccines that have been administered in this facility and to document in the residents chart any vaccines that were administered at another location. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: ICP will report all new admit vaccination status to the Monday, Wednesday, and Friday clinical meeting. Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure correction and sustain compliance: ICP with DNS oversight

Based on interview and record review it was determined the facility failed to provide active supervision to staff working on a preliminary status basis for 9 of 14 staff (#s 4, 6, 7, 20, 25, 26, 27, 28 and 29) reviewed for background checks. This placed residents at risk for abuse. Findings include: On 1/17/23 at 10:46 AM Staff 36 (Staffing Coordinator) provided a current list of staff on preliminary status. Staff 36 reported the identified staff were considered on preliminary status while the facility waited for clearance of their background checks. Staff 36 stated she was aware employees on preliminary status were required to be on active supervision and confirmed the facility did not have a policy regarding active supervision or a system in place to provide active supervision to employees whose background checks were pending. On 1/18/23 at 8:22 AM Staff 13 (CNA) and 1/18/23 at 8:35 AM Staff 35 (CNA) both stated they were unaware of any staff requiring active supervision. On 1/18/23 at 11:19 AM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation. No further information was provided.

M143 Employees: Criminal Record Checks #1 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice: No specific residents were identified as affected. #2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected. #3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Facility has reviewed and updated its Abuse Prevention, Investigation, and Reporting Policy to include the process to ensure active supervision of all staff whose background checks are pending in preliminary status. Office Manager/Bookkeeper and Staffing Coordinator have been in-serviced to the updated policy and process. All Staff have been in-serviced to their part in the active supervision process. The Staffing Coordinator will keep a running list of staff on preliminary status and ensure timeclock area posting and Nurse station posting are up to date. #4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and deficiency does not recur. Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. #5 Title of Person Responsible to ensure correction and sustain compliance. Staffing Coordinator and Business Office Manager with oversight from QAPI Committee, Quarterly QA Committee and Administrator.

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight consecutive hours between the start of day shift and the end of evening shift for 12 of 100 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident care and services. Findings include: Review of the Direct Care Staff Daily Reports from 7/1/22 through 8/31/22 and 12/1/22 through 1/8/23 revealed for 12 of 100 days there was no designated RN charge nurse who worked for eight consecutive hours in the facility between the start of day shift and the end of evening shift. On 1/17/23 at 8:41 AM Staff 2 (DNS) confirmed the facility did not have RN coverage on the identified days.

M182 Nursing Services: Minimum Licensed Nurse Staff 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? No individual residents were named. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? RN coverage. We have a contract agency RN working 5 days a week. Our RN ICP and RCM’s will rotate through the remaining 2 days of the week. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Compliance will be reported to the bi-monthly QAPI committee for two months and Quarterly for two Quarters. Results of audits will be reported to and reviewed by Quarterly QA Committee for further recommendation including the need and frequency of continued audits. 5. Title of person responsible to ensure and sustain compliance. DNS with bi-monthly QAPI committee, Quarterly QA Committee, and Administrator oversight.

***************************** 411-085-0310 Residents' Rights: Generally Refer to F550 ***************************** OAR 411-085-0130 Nursing Services: Notification Refer to F580 ***************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F584 and F604 ***************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 and F657 ***************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677 ***************************** OAR 411-086-0230 Activity Services Refer to F679 ***************************** OAR 411-086-0110 Quality of Care: Nursing Services: Resident Care Refer to F684 ***************************** OAR 411-086-0140 Quality of Care: Nursing Services: Problem Resolution & Preventative Care Refer to F689, F690 and F757 ***************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F727 ***************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F759 ***************************** OAR 411-086-0250 Dietary Services Refer to F801 ***************************** OAR 411-086-0220 Rehabilitative Services Refer to F825 ***************************** OAR 411-085-0220 Quality Assurance Refer to F867 ***************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ***************************** OAR 411-085-0200 Licensee, Employees, Consultants (IP qualifications) Refer to F882 ***************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F883 *****************************

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 10/31/2022 and 11/06/2022, 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 ensure Staff 11 (CNA) followed professional standards of practice regarding the dietary needs for 1 of 3 sampled residents (#500) reviewed for accidents. This resulted in Resident 500 eating solid food and she/he choked, which resulted in her/his death in the facility. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in disciplinary action and additional care plan training with instructions to follow the resident's care plan for all staff who provided care. This incident was identified as meeting the criteria for past noncompliance. Findings include: Oregon Board of Nursing Rule 851-063-0030 Authorized Duties and Standards for Certified Nursing Assistant 1 (6) Standards of Care for Certified Nursing Assistants. In the process of client care the CNA shall consistently: (d) Follow the care plan as directed by the licensed nurse Oregon Board of Nursing Rule 851-063-0090 Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title "CNA," whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: 2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing assistant performance of duties. Actual injury need not be established. Resident 500 was admitted to the facility on 12/23/13 with diagnoses including Dysphagia (difficult to swallow) and dementia. Resident 500's MDS Quarterly dated 6/15/22 revealed a BIMS score of 3, indicating severe cognitive impairment. The dietary assessment dated 6/14/22 revealed Resident 500 was prescribed a mechanically altered diet which consisted of pureed foods and thickened liquids. She/he was edentulous (no teeth) and was dependent on staff for eating and supervision. A document titled "Gracelen Terrace CNA/NA Standards of Care" detailed expectations for resident care and safety, including to follow resident care plans. The document was signed by Staff 11 on 7/11/22. An 8/6/22 at 9:45 AM progress note by Staff 5 (RN) revealed on 8/5/22 around 8:55 PM she overheard other staff say "call the nurse," stood up and observed Resident 500 in her/his wheelchair choking. Staff 5 was informed the resident choked on a regular textured sandwich given to her/him by Staff 11. Staff 5 immediately began abdominal thrusts and instructed staff to call 911. 911 was called on 8/5/22 at 8:57 PM. A CNA assisted Staff 5 with back blows to Resident 500 and continued with abdominal thrusts. Resident 500 was unresponsive, placed on the floor and her/his airway was cleared. CPR was initiated and food particles came out of the resident's mouth. Emergency personnel on the phone continued to give instructions and CPR was continued until EMTs (Emergency Medical Technicians) arrived at 9:08 PM but Resident 500 did not regain a pulse. EMT's called the resident's time of death at 9:11 PM. The facility's 8/12/22 investigation summary and revealed the root cause of Resident 500's death was the care plan was not followed by Staff 11. Staff 11 made sandwiches for several residents and did not review food textures for Resident 500 or other residents prior to handing out the sandwiches. Resident 500 was given a sandwich by Staff 11, who left the resident unsupervised. Staff 11 was immediately counseled and placed on administrative leave following the incident. A statement written and signed by Staff 6 (Staffing Coordinator) on 8/8/22 revealed on Monday, 7/11/22 she met with Staff 11 at the facility to do orientation which included a review of CNA/NA standards of care, Kardex (plan of care), the one page care plan location and the master copy of the diet textures location. On 8/23/22 at 12:22 PM Staff 6 stated she was responsible for hiring and scheduling CNAs. Newly hired and agency staff were given orientation by Staff 6. Staff 6 revealed Staff 11 was agency staff from another state (Texas) and reported to the facility on 7/11/22. He filled out paperwork, was given access to the electronic medical record, given CNA standards of care, shown how to access the Kardex and other basic information. Staff 6 revealed Staff 11 read and signed the standards of care form. On 8/24/22 at 10:42 AM Staff 11 stated he met with Staff 6 on 7/11/22. He revealed Staff 6 gave him the paperwork with CNA duties, asked him if he knew how to access Kardex and the electronic medical records which he confirmed he knew. Staff 11 confirmed he made sandwiches on 8/5/22 and gave a sandwich to Resident 500. He went to another hall and upon return observed Resident 500 on the floor and observed staff performing CPR on Resident 500. Staff 11 confirmed he did not check anyone's care plan that night for diet textures, including Resident 500. On 8/24/22 at 1:15 PM, Staff 1 (Administrator) confirmed it was an expectation that facility staff reviewed resident care plans. The situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance for F689. 2. The noncompliance occurred after the exit date of the last standard recertification survey 1/21/22 and before the date of this survey 8/9/22. 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F689 as evidenced by: - No deficient practice was found at F689 with additional sampled residents. - Evidence the deficient practice was identified by the facility; the facility took immediate action to immediately suspend, counsel the staff responsible, trained all staff for care plan implementation and diet texture. The Diet Textures training material was signed by 38 staff and indicated the training was completed by 8/8/22. - Staff 1 confirmed Staff 11 will never be allowed to work in the facility and had not worked in facility since immediately following the 8/5/22 incident. Refer to F689

Based on interview and record review it was determined the facility failed to ensure physician orders and care planned interventions were followed for 1 of 3 sampled residents (#500) reviewed for dietary services. As a result of facility staff not following the care planned interventions related to diet textures, Resident 500 choked which resulted in her/his death. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in disciplinary action and additional care plan training with instructions to follow the resident's care plan for all staff who provided care. This incident was identified as meeting the criteria for past noncompliance. Findings include: Resident 500 admitted to the facility in 2013 with diagnoses including dementia and dysphasia (difficult speech). A 7/5/18 physician order directed Resident 500 to be given a regular diet, pureed texture with liquid consistency at mildly thick nectar. The 6/14/22 Dietary Assessment by Staff 13 (RD) indicated Resident 500 needed a puree diet texture. Resident 500 did not have any reports she/he choked, pocketed food (held in mouth) or any reported swallowing difficulty. The 6/15/22 Quarterly MDS identified Resident 500 BIMS score of 3 (severe cognitive impairment), required a mechanically altered diet and was totally dependent for eating with one person assistance. Resident 500's 8/5/22 care plan identified her/him as an aspiration risk (food or liquid may enter airway) and directed staff to provide pureed texture for food. An 8/6/22 at 9:45 AM progress note by Staff 5 (RN) revealed on 8/5/22 around 8:55 PM she overheard people in the hall say "call the nurse call the nurse". She immediately stood up and saw Resident 500 in the hall in her/his wheelchair choking. Staff 5 was informed the resident choked on a regular textured sandwich given to her/him by Staff 11 (CNA). Staff 5 immediately began abdominal thrusts and yelled to call 911. 911 was called on 8/5/22 at 8:57 PM. A CNA assisted her, and five back blows were given and abdominal thrusts continued. Resident 500 was unresponsive and was placed on the floor, the airway was cleared, CPR was initiated, food particles came out of the resident's mouth, emergency personnel on the phone gave instructions and CPR continued. No pulse was able to be attained on Resident 500, the crash cart was brought by a LPN with the connected defibrillator (provides electric thrust to restart the heart), instructions were given from the defibrillator to continue CPR shock to be given at that time. Staff 5 continued CPR, then Staff 7 (CNA) took over and continued CPR until EMS (Emergency Medical Services) arrived at 9:08 PM. EMS stopped the CPR for Resident 500. Resident 500 had no heart rate and the time of death was called on 8/5/22 at 9:11 PM. An 8/12/22 Incident Review/Summary progress note by Staff 3 (RNCM) summarized her investigation for the root cause of Resident 500's death was the care plan was not followed and Resident 500 was given a regular textured meat sandwich when she/he was to only have pureed texture. Resident 500 choked on the sandwich and was unable to cough, speak or call out for help due to the sandwich texture which prevented air to pass in the throat. Staff tried to intervene but were unable to dislodge the food. Staff 3, MD (Doctor of Medicine), and ARNP (Advanced Registered Nurse Practitioner) discussed Resident 500's comorbidities on 8/8/22 and 8/9/22. The MD and ARNP agreed Resident 500's death would be documented as "Accidental". On 8/23/22 at 12:22 PM Staff 6 (Staffing Coordinator) stated she was responsible for hiring and scheduling CNAs. New hires or agency staff were given orientation to the facility by Staff 6. Staff 6 revealed Staff 11 was an agency staff and started work at the facility on 7/11/22. He completed paperwork, was given access to the electronic medical record, given CNA standards of care, shown how to access the Kardex (care plan) and other basic information. Staff 6 revealed Staff 11 read and signed the standards of care form and was given a tour of the facility. On 8/23/22 at 1:00 PM Staff 5 confirmed the accuracy of her progress note written on 8/6/22. On 8/23/22 at 3:27 PM Staff 7 (CNA) stated he was working the evening of 8/5/22. He was outside a resident's room and heard another staff say his name loudly, observed Resident 500 in her/his wheelchair and a staff member giving her/him the Heimlich Maneuver (abdominal thrusts). Staff 7 picked Resident 500 up and began the Heimlich Maneuver. Staff 7 said to get the nurse and Staff 5 came over, told the staff to lie Resident 500 on the floor and started CPR. Staff 7 and Staff 5 rolled the resident over and swept out her/his mouth and observed pieces of the sandwich in her/his mouth. Staff 7 revealed the CPR was stopped when paramedics arrived and the time of death was called by EMTs. Staff 7 recalled Staff 11 gave out sandwiches to residents earlier in the night. Staff 7 observed a paper plate with a sandwich with bites missing from the sandwich located next to Resident 500. Staff 7 revealed resident care plans were kept at the nurse's station and on the tablets located in resident hallways. On 8/23/22 at 5:17 PM Staff 10 (Housekeeping) stated he was working in the hall where Resident 500 was seated in her/his wheelchair. The first time Resident 500 was observed, she/he did not have a sandwich. When Staff 10 returned a few minutes later, he observed Resident 500 to eat the regular textured sandwich with a couple of bites taken out of it. Staff 10 gave the resident a napkin, turned around and a couple of seconds later heard Resident 500 cough. Another housekeeping staff said the resident might be choking and Staff 10 revealed Resident 500 looked as if she/he were trying to spit the food out. One of the agency CNAs said to get the nurse, and Staff 10 stated he did at that time. Staff 10 revealed he was unaware of Resident 500's dietary needs as he worked in housekeeping. On 8/24/22 at 10:42 AM Staff 11 stated he worked the evening shift on 8/5/22. Staff 11 revealed a resident wanted a sandwich and he made sandwiches for everyone. Staff 11 confirmed he gave a regular textured sandwich to Resident 500. He went to another hall and upon return he observed Resident 500 on the floor and staff performing CPR. He ran down the hall and asked what was going on. Another staff said "someone gave her/him a sandwich" and Staff 11 told them he gave Resident 500 the sandwich. Staff 11 revealed he saw Resident 500 with a sandwich before at least twice and other staff said they also saw the resident with sandwiches before 8/5/22. Staff 11 revealed he was assigned the room where the resident resided but did not have Resident 500 on his roster. Staff 11 confirmed he did not check anyone's care plan that night, including Resident 500's. On 8/24/22 at 12:32 PM Staff 12 (CNA) stated she worked the evening shift on 8/5/22. She revealed after she saw Resident 500 on the floor, she asked Staff 11 what happened and he told her he gave Resident 500 a sandwich. Staff 12 asked Staff 11 why he gave a sandwich to Resident 500 because she/he was on a pureed diet. Staff 11 told her he didn't know that and nobody told him. Staff 12 revealed she never observed Resident 500 to eat sandwiches prior to 8/5/22 and nobody else who was present during the incident told her they observed Resident 500 eat regular textured sandwiches prior to 8/5/22. On 8/24/22 at 1:15 PM Staff 3 (RNCM) stated Resident 500 required extensive assist with dressing, transfers and needed supervision to eat to ensure Resident 500 would eat. She confirmed Resident 500 had been requiring eating assistance for several years. Staff 3 revealed she did not heard from staff Resident 500 was given solid food prior to 8/5/22. On 8/24/22 at 1:15 PM Staff 2 (DNS) stated new or agency CNAs were always given orientation to meet resident needs. She confirmed Staff 11 was given orientation when he started working at the facility, and it was an expectation staff would review and follow the resident care plans. On 8/24/22 at 1:15 PM Staff 1 (Administrator) confirmed it was an expectation facility staff reviewed and followed the resident care plans. On 8/24/22 at 1:15 PM Staff 3 confirmed Staff 11 did not follow Resident 500's care plan on 8/5/22. Staff 3 revealed the facility immediately took steps to counsel and suspend Staff 11. In addition, all staff attended a training on care plans and diet texture, which was completed on 8/8/22. On 8/23/22 and 8/24/22 Staff 3, Staff 4 (RNCM), Staff 5, Staff 7, Staff 8, Staff 9, and Staff 12 were interviewed and all expressed the standard of care was to review the care plan before they provided care, which included diet textures, for the residents. The situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance for F689. 2. The noncompliance occurred after the exit date of the last standard recertification survey 1/21/22 and before the date of this survey 8/9/22. 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F689 as evidenced by: - No deficient practice was found at F689 with additional sampled residents. - Evidence the deficient practice was identified by the facility; the facility took immediate action to immediately suspend, counsel the staff responsible, trained all staff for care plan implementation and diet texture. The Diet Textures training material was signed by 38 staff and indicated the training was completed by 8/8/22. - New forms were developed and/or revised for communication of diet textures, new signage was posted for resident diets and a training at the CNA meeting for diet textures and instruction to follow the care plan was completed. - DNS, RNCM, and CNA interviews indicated knowledge and awareness of diet textures and expectations to follow residents care plans.

****************************** OAR 411-086-0110 Quality of Care: Nursing Services: Resident Care Refer to F689 ****************************** , OAR 411-086-0100 Nursing Services: Resident Care Refer to F658 **********************************

Based on interview and record review it was determined the facility failed to ensure the resident's representative was informed of and participated in treatment decision making for 1 of 3 sampled residents (#4) reviewed for Physician Orders for Life Sustaining Treatment (POLST). This placed residents at risk for not being informed and not having choices honored. Findings include: Resident 4 was admitted to the facility in 12/2003 with diagnoses including dementia. Resident 4's annual MDS dated 10/13/21 revealed the resident was cognitively impaired and unable to make health care decisions for her/himself. On 12/2/21 at 10:42 PM Witness 2 (Complainant) reported she was Resident 4's legal guardian. She stated she received a new POLST for the resident dated 11/30/21 from Staff 17 (Social Services). The POLST section "documentation of who was present for discussion" indicated the POLST decisions were discussed with Witness 2, however Witness 2 stated she was never consulted. On 5/11/22 at 2:30 PM Staff 17 (Social Services) stated Resident 4's POLST was 10 years old. Staff 17 made a new POLST and stated she did not consult the resident's guardian. Staff 17 stated she wrote Witness 2's name on the POLST indicating Witness 2 had been notified. On 5/16/22 at 12:16 PM Staff 1 (Administrator) and Staff 3 (RNCM) confirmed Staff 17 should have discussed the new POLST with Resident 4's legal guardian in order for the guardian to make the decisions.

F522 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #4. Facility received a grievance on 1.11.22 that facility had not followed proper process on updating a POLST form for resident #4. (Facility had initiated an updated POLST based on the age of the POLST and a change in Guardian.) A formal grievance was initiated, the situation investigated and a Quality Assurance and Performance Improvement plan written. It was found that a POLST had been updated following an inaccurate process and the POLST was rescinded on 1.12.22. On 1.12.22 the process to update the POLST following appropriate process was initiated. Grievance was resolved on 1.14.22. Social Services Director, Resident Care Managers, Director of Nursing, Advanced Registered Nurse Practitioner and Medical Director (SSD, RCMs, DNS, ARNP, Medical Director) have been educated that facility staff if needed, may prepare an updated POLST but the signer of the POLST (MD, DO, NP, PA, ND) must have a direct conversation with the Resident, Guardian or Responsible Party, per Oregon POLST guidelines. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: All residents in facility with a POLST have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: SSD has an established baseline audit of all residents in facility and status of POLST. The POLST is discussed Quarterly in the resident Care Conference and as needed. Facility POLST policy has been reviewed and updated. SSD, RCMs, DNS, ARNP, Medical Director have been educated that facility staff if needed, may prepare an updated POLST but the signer of the POLST (MD, DO, NP, PA, ND) must have a direct conversation with the Resident, Guardian or Responsible Party, per Oregon POLST guidelines. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: SSD and Inter-Disciplinary Team (IDT) members will continue to report to Bi-Monthly Quality Assurance and Performance Improvement (QAPI) committee on audit results and any concerns related to POLSTs. Any concerns raised will be resolved through the QAPI committee as they occur or if needed through the facility grievance system. QAPI/Grievance results will be reported to Quarterly Quality Assurance (QA) Committee for further review and recommendation. 5. Title of person responsible and date of corrective action to be complete: SSD in collaboration with RCMS, ARNP, Medical Director, IDT, QAPI Committee with oversight of DNS and Administrator will ensure compliance.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from abuse for 10 of 11 sampled residents (#'s 6, 7, 8, 9, 10, 11, 12, 13, 15 and 16) reviewed for abuse. This placed residents at risk for abuse and psychosocial outcomes. Findings include: The facility's abuse prevention, investigation and reporting policy revised 3/2022 indicated each resident had the right to be free from abuse by anyone, including but not limited to facility staff, other residents...or by any other individual. 1. Resident 6 was admitted to the facility in 11/2020 with diagnoses including traumatic brain injury and dementia with delusions. Resident 6's Annual MDS dated 12/15/21 indicated cognitive impairment and behaviors which included targeting peers to elicit a response. Resident 6's care plan updated 1/17/22 indicated the resident had delusions, hallucinations, agitation and physical/verbal aggression towards others. An intervention initiated 5/27/21 instructed to monitor the resident when she/he was near other men and to keep the resident away from crowded areas. Resident 7 was admitted to the facility in 7/2021 with diagnoses including stroke and Lewy body dementia. Resident 7's Annual MDS dated 7/13/21 indicated severe cognitive impairment, hallucinations, delusions and aggressive/violent behaviors. Resident 7's care plan updated 3/29/22 indicated the resident was at risk for verbal/physical aggression/abuse with a history targeting peers and feared peers were trying to kill her/him. Interventions initiated 7/7/21 included 15 minute checks and not invading the resident's personal space. A facility incident investigation indicated on 1/16/22 Resident 7 was heard yelling in the hall while next to Resident 6 and was observed to hit Resident 6 in her/his face. The report indicated Resident 6 made an obscene gesture with a middle finger towards Resident 7. The facility incident investigation concluded abuse occurred. On 5/11/22 at 12:00 PM Staff 4 (RNCM) and on 5/11/22 at 2:00 PM Staff 2 (DNS) confirmed Resident 7 hit Resident 6 in the face on 1/16/22. On 5/16/22 at 11:52 AM Staff 1 (Administrator) confirmed resident to resident abuse between Resident 9 and Resident 10 was substantiated. 2. Resident 6 was admitted to the facility in 11/2020 with diagnoses including traumatic brain injury and dementia with delusions. Resident 6's Annual MDS dated 12/15/21 indicated cognitive impairment and behaviors including targeting peers to elicit a response. Resident 6's care plan updated 1/17/22 indicated the resident had delusions, hallucinations, agitation and a history of physical/verbal aggression towards other men. An intervention initiated 5/27/21 instructed to monitor the resident when she/he was near other men and to keep the resident away from crowded areas. Resident 8 was admitted to the facility in 2007 with diagnoses including paranoid schizophrenia and dementia with behaviors. Resident 8's Significant Change MDS dated 11/18/21 indicated the resident was severely cognitively impaired, had delusions and hallucinations, was easily agitated and would push other residents out of the way. Resident 8's Care Plan updated 3/14/22 indicated the resident had delusions, hallucinations and was at risk for verbal/physical aggression towards others. Interventions initiated 5/20/21 included 15 minute checks which were occurring. A facility investigation dated 10/4/21 indicated Resident 8 was observed to kicked Resident 6 while the two resident were passing each other, The facility concluded there was no physical or emotional injury which occurred. On 5/11/22 at 12:00 PM Staff 4 (RNCM) and on 5/11/22 at 2:00 PM Staff 2 (DNS) confirmed Resident 8 kicked Resident 6 on 10/4/21. 3. Resident 9 was admitted to the facility in 5/2020 with diagnoses including stroke and dementia. Resident 9's Annual MDS dated 5/25/21 indicated the resident was severely cognitively impaired and was only able to communicate with gestures. Resident 9's care plan indicated ineffective coping and risk for verbal/physical abuse which were initiated on 5/6/20. The intervention to redirect the resident away from peers who have intrusive behaviors was initiated 9/29/21. Another intervention was initiated on 12/31/21 to temporarily provide one-on-one caregiver during the shift and then to transition to 15 minute checks. Resident 10 was re-admitted to the facility in 2/2022 with diagnoses including Alzheimer's disease, hallucinations and delusions. Resident 10's Significant Change MDS dated 2/15/22 indicated the resident was severely cognitively impaired. Resident 10's care plan included interventions initiated on 12/29/21 for ineffective coping, disruptive behavior and potential for verbal/physical aggression. The care plan interventions were revised 2/10/22 to provide a one-on-one caregiver when needed after the resident's risk for verbal/physical aggression increased. The intervention to complete 15 minute checks and to redirect the resident from entering other residents' rooms were initiated 1/6/22 after the incident. A facility investigation dated 12/31/21 indicated Resident 9 and Resident 10 were seen in the community bathroom together. No staff witnessed when Resident 9 and Resident 10 each went into the bathroom and no staff witnessed Resident 9 hit Resident 10, however, when staff were called into the bathroom to separate the two residents, Resident 10 reported Resident 9 hit her/him in the jaw and her/his jaw hurt. The facility report concluded abuse without major injury occurred. On 5/16/22 at 11:52 AM Staff 1 (Administrator) confirmed resident to resident abuse occurred between Resident 9 and Resident 10. , 4. Resident 11 was admitted to the facility in 5/2013 with diagnoses including psychotic disorder with delusions and dementia with behavioral disturbance. Resident 11's MDS significant change in status assessment dated 2/2022 revealed the resident had severe cognitive impairment. Resident 11's care plan dated 4/2022 revealed she/he had ineffective coping and was at risk for verbal/physical aggression as well as visual and auditory hallucinations. Resident 12 was admitted to the facility on 1/2021 with diagnoses including bipolar disorder and Alzheimer's disease. Resident 12's MDS quarterly assessment dated 4/2022 revealed a BIMS score of 3, indicating severe cognitive impairment. Resident 12's care plan dated 10/2021 revealed she/he had ineffective coping and was at risk for elopement. The facility initiated a resident to resident abuse investigation on 10/28/21 which revealed the following: Staff 6 (CNA) heard a call for help from Resident 12's room. He observed Resident 11 on Resident 12's bed, punching Resident 12 in the legs and stomach. Staff removed Resident 11 from the room and assessed Resident 12 for injuries. Resident 12's shins were observed to have bruises and swelling as a result of being punched. Both residents were placed on alert charting and 15 minute checks initiated. Both residents were observed on 5/10/22 and 5/11/22. Neither resident was interviewed due to their cognitive impairment and inability to recall the incident. Staff 6 was not interviewed due to no longer working at the facility. On 5/13/22 at 10:36 AM, Staff 3 (RNCM) confirmed the incident had occurred and noted Resident 11 became aggressive prior to having a seizure. On 5/13/22 at 11:45 AM, Staff 1 (DNS) confirmed the incident occurred and the facility had substantiated abuse. 5. Resident 13 was admitted to the facility on 2/2021 with diagnoses including paranoid schizophrenia, unspecified dementia with behavioral disturbance and hallucinations. Resident 13's annual MDS assessment dated 2/2022 revealed a BIMS score of 9, indicating moderate cognitive impairment. Resident 13's care plan dated 2/2022 revealed she/he had ineffective coping and was at risk for verbal/physical aggression. Resident 11 was admitted to the facility on 5/2013 with diagnoses including psychotic disorder with delusions and dementia with behavioral disturbance. Resident 11's MDS significant change in status assessment dated 2/2022 revealed resident had severe cognitive impairment. Resident 11's care plan dated 4/2022 revealed she/he had ineffective coping and was at risk for verbal and physical aggression as well as visual and auditory hallucinations. On 4/3/22, the facility initiated a resident to resident abuse investigation which revealed the following: Staff 5 (LPN) was exiting a resident's room and heard loud voices in the hall. She observed Resident 11 in the center hall in her/his wheelchair attempting to go into the restroom. Resident 13 was in the same hall, seated in her/his wheelchair close to the bathroom door on one side of the hall. A treatment cart was located opposite Resident 13 on the other side of the hall, blocking Resident 11's access to the restroom. Resident 11 started yelling at Resident 13 and she/he told Resident 11 to "hold on" but did not move. Resident 11 waved her/his arms toward Resident 13 and struck her/him in the head before Staff 5 could intervene. Resident 13 was assessed for injuries and none were found. Resident 13 was observed in her/his room on 5/10/22 at 12:36 PM and refused to be interviewed. Resident 11 was observed in her/his room and in the facility hallways on 5/10/22 and 5/11/22. She/he was not interviewed due to her/his cognitive impairment and inability to recall the incident. Staff 5 was not available for an interview. On 5/13/22 at 10:25 AM, Staff 4 (RNCM) confirmed the incident occurred and stated Resident 11 experienced anxiety and irritability prior to a seizure. Resident 11 was impatient with Resident 13 due to wanting to use the restroom. Resident 13 did not move out of the way quickly enough which resulted in Resident 11 striking Resident 13 on the head with her/his fist. Staff 4 stated Resident 13 did not have any negative psychosocial outcomes as a result of the incident. On 5/13/22 at 12:03 PM, Staff 2 (DNS) confirmed the incident occurred and the facility had substantiated abuse. 6. Resident 15 was admitted to the facility on 10/2021 with diagnoses including vascular dementia. Resident 15's MDS quarterly assessment dated 4/2022 revealed a BIMS score of 10, indicating moderate cognitive impairment. Resident 15's care plan dated 4/2022 revealed she/he had inappropriate behavior, was resistant to treatment and care and was at risk for verbal/physical aggression. Resident 10 was admitted to the facility on 12/2021 with diagnoses including Alzheimer's disease, vascular dementia with behavioral disturbance and delusional disorder. Resident 10's MDS admission assessment dated 1/2022 revealed a BIMS score of 1, indicating severe cognitive impairment. Resident 10's care plan revealed she/he had ineffective coping and was at risk for verbal/physical aggression. The facility initiated a resident to resident abuse investigation on 2/10/22 which revealed the following: On 2/10/22 at 3:00 AM, Resident 10 was observed to be in Resident 15's bed by Staff 7 (CNA). Resident 10 was observed to strike Resident 15 on the arms, face, head and torso and attempted to bite Resident 15. Resident 10 also bit her/himself on the hands and arms. Staff 7 attempted to intervene. Resident 10 also attempted to strike and bite Staff 7. Resident 10 was moved to another room, where she/he continued to attempt self harm and was sent to the hospital for a psychiatric evaluation. Resident 15 was assessed for injuries, none were found and the resident did not complain of pain. Resident 15 was unable to be interviewed due to her/his cognitive impairment and inability to recall the incident. Resident 10 was not observed due to being discharged from the facility. Staff 7 was not interviewed due to no longer working at the facility. On 5/13/22 at 12:03 PM, Staff 4 (RNCM) stated the incident was the first time Resident 10 had displayed aggressive behaviors. She/he had just returned from the hospital and her/his behaviors were different after the hospitalization, with increased agitation and delusions. Staff 4 stated Resident 10 was not care planned for aggression prior to the incident. On 5/13/22 at 12:03 PM, Staff 2 (DNS) confirmed the incident occurred and the facility had substantiated abuse. 7. Resident 16 was admitted to the facility in 12/2020 with diagnoses including major depressive disorder, vascular dementia with behavioral disturbance and delusional disorder. Resident 16's MDS quarterly assessment dated 3/2022 revealed severe cognitive impairment and only spoke "word salad," meaning she/he was unable to verbally converse. Resident 16's care plan dated 1/2022 revealed she/he had ineffective coping and was at risk for verbal/physical aggression. Resident 4 was admitted to the facility in 12/2003 with diagnoses including vascular dementia with behavior disturbance and major depressive disorder. Resident 4's MDS quarterly assessment dated 4/2022 revealed a BIMS score of 6, indicating severe cognitive impairment. Resident 4's care plan dated 5/2022 revealed she/he had ineffective coping, demanding and anxious behaviors and was at risk for verbal/physical aggression. The facility initiated a resident to resident abuse investigation on 1/26/22 which revealed the following: On 1/26/22 at 11:10 AM, Staff 3 (RNCM) was in her office and heard raised voices across the hall. Staff 3 went to the resident's room and observed Resident 16 seated on the floor with her/his back to the wall. Resident 16 was in distress, crying, had blood on the side of her/his mouth and a cut on the right side of her/his upper lip. Resident 4 was seated on her/his bed and had blood on her/his right hand, which was bruised. Resident 4 initially denied hitting Resident 16 but then admitted she/he hit Resident 16 because she/he "was hollering." Resident 16 was assessed for injuries and sustained a cut to her/his upper lip and two areas of redness on the resident's right cheek were noted. Resident 16 was sent to the hospital for assessment, received stitches on her/his cut lip and was moved to a different room upon return to the facility. Both residents were observed in the facility on 5/10/22 and 5/11/22. Neither resident was interviewed due to their cognitive impairment and inability to recall the incident. On 5/11/22 at 12:39 PM, Staff 3 confirmed the incident had occurred and she had written the incident report. On 5/13/22 at 11:45 AM, Staff 1 (DNS) confirmed the incident occurred and the facility had substantiated abuse.

F600 1.How will corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident # 8, 9, 10 have been discharged. Resident # 6, 7, 11, 12, 13, 15, 16. Facility identified, reported and investigated each of these situations as they occurred. Residents were immediately protected by separating from each other and were placed on 15-minute checks or on 1-1 care if assessed as needed. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All aggressive residents and targeted residents have the potential to be affected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Facility utilizes a resident Master List system where aggressive, agitated residents and residents targeted are identified for staff to be mindful and aware and to follow resident care plans to prevent altercations. Frequency of Master List update has gone from monthly to weekly. Medications and medication times are reviewed as needed and at the Monthly Psychotropic Meeting with SSD, RCMs, DNS and Pharmacist for aggressor residents if needed for recommended adjustments. Facility continues efforts to staff Certified Nursing Assistants (CNA) levels one up from required ratios as staff are available. Facility has reduced resident census capacity in order to safely care for the current resident population with a focus on prevention and has streamlined the admission process to ensure only residents whose needs can safely be met are considered for admission. Charting kiosks have been moved away from the Nurse station to the hallways to ensure greater staff oversight throughout facility. Each shift now has a designated CNA lead available to assist CNAs as needed. CNA required meetings and Charge Nurse meetings are re-established to occur at least monthly, CNA and Charge Nurse job descriptions have been issued and educated to each Charge Nurse and CNA. CNA and Charge Nurse baseline evaluations have been completed. All Charge Nurses and CNAs have been educated to follow resident care plans and for Certified Nursing Assistants to seek assistance from CNA Lead and Charge Nurse when needed with challenging resident situations. Activities program is in QAPI review for effectiveness of engaging residents while continuing with Covid Infection Control prevention and safety measures. Facility has re-structured the Nursing education program to ensure RN directed education and oversight. Facility continues to follow QAPI plan to reduce unnecessary clutter, noise and activity in the hallways. Charge Nurse, Resident Care Manager, Director of Nursing Services, CNA Lead, CNA Staffing Coordinator, Administrative Staff Manager rounds will occur throughout the week on all shifts. DNS office is now located centrally close to the Nursing floor. Audit tool has been created to audit effectiveness of changes. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Results of audits of CNA staffing, CNA lead effectiveness, monthly CNA, Charge Nurse meetings and education, Activity program effectiveness, Rounds will be reported to Bi-Monthly QAPI and to results will Quarterly QA Committee for further review and recommendation. 5. Title of person responsible and date of corrective action to be complete: Certified Nursing Assistants are directly responsible to follow resident care plans with direct oversight of the Charge Nurse 1st, Resident Care Manager 2nd, Director of Nursing 3rd in collaboration with Administrative staff and overall oversight of Administrator.

Based on interview and record review it was determined the facility failed to protect residents' rights to be free from misappropriation of resident medication for 4 of 4 sampled residents (#s 11, 19, 20 and 21) reviewed for drug diversion. This placed residents at risk for narcotic drug diversion. Findings include: The facility's Reporting Suspicion of a Crime policy dated 3/11/22 included "drug diversion for personal gain or use" as a reportable crime to the state agency and law enforcement. On 4/13/22 a facility reported incident was received which indicated on 4/9/22 Staff 2 (DNS) was made aware of missing narcotic medication cards. On 4/9/22 Staff 2 (DNS) was made aware of missing narcotic medication cards. An immediate investigation was initiated to audit medication carts and medication rooms. It was determined the missing narcotic medication cards were not found and there was no documented evidence the medications were destroyed. The facility investigation substantiated misappropriation of resident medications. The residents who's medications went missing were Residents 11, 19, 20 and 21. None of those residents went without their narcotic medications and there were no negative outcomes. On 5/11/22 at 12:28 PM Staff 2 (DNS) stated the facility determined resident medications were stolen and no suspects were identified. The police were notified but they refused to investigate unless a suspect was identified. On 5/16/22 at 12:53 PM Staff 1 (Administrator) confirmed the crime of misappropriation of residents' medications occurred and there were no suspects.

F602 1. How will corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #11. Initial investigation identified this resident as potentially being affected. Through continued investigation, this resident was ruled out as being affected. Resident #19, #20, #21. Facility followed Reporting Suspicion of a Crime policy and reported to State agency DHS and the police that facility was missing resident medications (narcotics). Full investigation for each resident was conducted and it was substantiated that misappropriation of resident property/medications (narcotics) occurred. Investigation was unable to produce evidence determining the person or person(s) responsible for the missing medications (narcotics). Should evidence leading to the person or persons responsible come to light, facility will notify required State agencies (Department of Human Services (DHS), Oregon State Board of Nursing (OSBN)) and the Police. Any personnel found to have committed a crime shall be terminated. Medication receiving, storage/access, count process/records systems have been tightened to ensure access is available only to staff with a need to access. Increased oversight and audits by Nurse Managers and Pharmacy Nurse were implemented and will continue. Education to Certified Medication Aides (CMA), Medication Nurses, Charge Nurses and Nurse Managers (RN RCMs, RN DNS) has occurred and will continue as needed. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents on narcotic pain medications have the potential to be affected by this. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Pharmacy Nurse conducted a follow up audit after full initial investigation was completed of residents with narcotic medication orders. Pharmacy Nurse substantiated original findings and found no additional residents were affected. Nurse Managers (RN DNS, RN RCMs) will continue random Narcotic Count audits and Pharmacy Nurse will now audit resident narcotic count records going forward during regularly scheduled Pharmacy audits. Medication receiving, storage/access, count process/records systems have been tightened. Increased oversight and audits by Nurse Managers and Pharmacy Nurse were implemented and will continue. Education to Certified Medication Aides, Medication Nurses, Charge Nurses and Nurse Managers has occurred and will continue as needed. All med carts and the med room were rekeyed and only the CMA/med nurse on shift and the DNS have keys to the med carts. Only CMA/med nurse, Charge Nurse/treatment nurse, DNS, and RCMs have keys to the med room. The following policies were reviewed and updated if needed: Policies pertaining to Medication Orders and Administration, Substance Abuse policy (staff), Conduct and Behavior policy (Staff), Reporting Reasonable Suspicion of a Crime policy, Abuse policy, Package and Delivery Distribution policy and corresponding education has been provided to CMAs, Medication Nurses, Nurse Managers and Charge Nurses. Included in the education was detail on checking in narcotics, narcotic counts at the beginning and end of shift accounting for every single page and all cards and bottles per Pharmacy Controlled Substance Log Book instructions, narcotic destruction, who can have access to the keys and the carts, ordering narcotic refills from the pharmacy. Pharmacies have been requested to not send more than 1-2 cards at a time since the cards taken were the last ones in groups of multiple cards and were overflow cards. New narcotic books were started and all existing cards were transferred to the new books. Staff with access to narcotics were interviewed and investigation was unable to produce evidence determining the person or person (s) responsible for the missing medications (narcotics). Ongoing education will be provided as needed. Education folders are in each med cart for staff to refer to if they have questions. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: 2/3 narcotic shift change counts were monitored by RCM/DNS for a minimum of 4 weeks and then random checks will occur. Going forward Pharmacy Nurse will audit count records/process going forward during routine audits by Pharmacy Nurse. Results of audits will be reported to Bi-Monthly QAPI meeting and Quarterly QA Committee for further review and recommendation. 5. Title of person responsible and date of corrective action to be complete: Certified Medication Aides, Medication Nurses and Charge Nurses are directly responsible for compliance with oversight of the Director of Nursing Services and Pharmacy Nurse and overall oversight of Administrator.

Based on interview and record review it was determined the facility failed to provide ADL care for 1 of 3 sampled residents (#3) reviewed for ADLs. This place residents at risk for unmet needs. Findings include: Resident 3 was admitted to the facility in 9/2021 with diagnoses including stroke. Resident 3's Admission MDS dated 9/20/21 indicated the resident was cognitively intact and incontinent of bowel and bladder. Resident 3's 9/14/21 care plan indicated the resident was incontinent of bowel and bladder and dependent on staff to change her/his briefs. Interventions included incontinent care scheduled to be provided every 2-3 hours. An Incident Review/Summary completed by the facility indicated on 11/6/21 Resident 3 was left in an over-saturated brief for all of the night shift by Staff 20 (Former Staff-CNA). The facility's investigation concluded incontinent care was not provided. Staff 20 was not available for interview and no longer worked at the facility. On 5/11/22 at 2:00 PM Staff 2 (DNS) and on 5/16/22 at 11:52 AM Staff 1 (Administrator) confirmed Staff 20 (Former Staff-CNA) should not have left the resident in an over-saturated brief during the 11/6/21 night shift.

F677 1. How will corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #3. The staff CNA was immediately put on administrative leave pending investigation. Situation was found to be substantiated and she was offered a strict 30-day retraining program on Day shift with experienced CNA training and DNS/RCM oversight. CNA refused offer and employment was terminated. Resident care plan was reviewed and updated to ensure that resident has a male care giver or 2 female care givers during or around care-times due to resident sexually inappropriate behavior with female care-givers. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All dependent residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Each shift now has a designated CNA lead to be available for other CNAs as needed. Two NOC nurses will be scheduled as available for greater oversight and assistance. CNA required meetings are re-established to occur at least monthly, CNA and Charge Nurse job descriptions have been issued and educated to each Charge Nurse and CNA. CNA and Charge Nurse baseline evaluations have been completed. CNA Standards of Care has been re-reviewed with each CNA. All Charge Nurses and CNAs have been educated to follow resident care plans and for Certified Nursing Assistants to seek assistance from CNA Lead and Charge Nurse when assistance is needed with challenging resident situations. An audit tool has been created to monitor ADL care on all shifts. 4. indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Results of Audits of ADL care will be reported to Bi-Monthly QAPI meeting for 4 weeks and random ongoing audits of ADL care on all shifts including Evening and NOC and to Quarterly QA Committee for further review and recommendation. 5. Title of person responsible and date of corrective action to be complete: CNAs are directly responsible with chain of command oversight. 1st Charge Nurse. 2nd RCM, 3rd DNS and overall Administrator oversight.

Based on interview and record review it was determined the facility failed to provide appropriate assistive devices and adequate supervison to prevent accidents for 2 of 4 sampled residents (#s 17 and 18) reviewed for falls. This placed residents at risk for injury related to falls. Findings include: 1. Resident 17 was admitted to the facility in 12/2010 with diagnoses including dementia with behavioral disturbance and epilepsy. Resident 17's most recent MDS comprehensive assessment revealed a BIMS score of 0, which indicated severe cognitive impairment. Resident 17's care plan dated 1/2021 revealed she/he was totally dependent for all care areas, required a one person assist for bed mobility, dressing, bathing and toilet use and was a two person assist for transfers. The ADL care plan instructed staff to use a reclining shower chair for bathing. On 3/13/20 at 10:00 AM, the facility initiated an investigation which revealed the following: Resident 17 was in the shower room seated in a shower chair. Staff 10 (CNA) pulled the resident forward to wash her/his back and the resident fell forward due to losing her/his body positioning. Resident 17 fell to the floor and hit the side of her/his head on the floor, resulting in a lump approximately 1 cm in size to on the left side of her/his head. Resident 17 was placed on 15 minute checks and no further injuries were noted. The facility's investigation concluded the wrong shower chair was used and Resident 17 should of been in a reclining shower chair. Immediate counseling was provided to Staff 10 for not following the resident's care plan and using the incorrect shower chair. Resident 17 was not observed due to discharge. Staff 10 was not available for an interview. On 5/13/22 at 11:50 AM, Staff 2 (DNS) and Staff 4 (RNCM) were interviewed and confirmed the incident occurred and the resident's care plan was not followed. 2. Resident 18 was admitted to the facility in 4/2021 with diagnoses including conversion disorder with seizures or convulsion, hypokalemia (blood levels below normal for potassium) and anemia. Resident 18's MDS admission assessment dated 5/2021 revealed a BIMS score of 0 which indicated severe cognitive impairment. Resident 18's care plan dated 4/2021 revealed she/he was totally dependent for all care areas and required two person assist with bed mobility, transfers, dressing and toileting. Resident 18's fall care area assessment revealed she/he was at high risk for falls related to cognitive impairment, use of psychtropic medications, visual deficit, weakness and respiratory impairment. On 6/23/21, the facility initiated an injury of unknown source investigation which revealed the following: On 6/23/21 at 1:15 AM, Resident 18 was receiving personal care from Staff 8 (CNA). Resident 18 was in bed and Staff 8 moved the bed away from the wall in order to turn the resident and complete the personal care. Resident 18 rolled toward the wall as she/he was being turned by Staff 8 and continued to roll off the bed, which was in a high position. Resident 18 fell approximately three to four feet from the bed to the floor. The fall mat was on the opposite side of the bed and the bolster to the outer edge of the bed was not in place due to the resident receiving incontinent care. Staff 9 (LPN) was summoned to Resident 18's room and assessed her/him. Staff 8 told Staff 9 she was unable to prevent Resident 18 from rolling off the bed while she was turning the resident. No visible injuries were found and the facility sent Resident 18 to the hospital due to the possibility of internal injury. Immediate counseling was provided to Staff 8 for not following the care plan for two person assist with all bed mobility and incontinent cares. Resident 18 was not observed due to discharge. Staff 8 and Staff 9 were not interviewed due to no longer working at the facility. On 5/13/22 at 10:10 AM, Staff 3 (RNCM) confirmed the incident occurred and stated Resident 18 did not have any injuries from the fall. Staff 3 stated the fall was avoidable due to the care plan not being followed. On 5/13/22 at 12:00 PM, Staff 2 (DNS) confirmed the incident occurred and it was an expectation that staff follow resident care plans.

F689 1. How will corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #17 has been discharged. Employee was immediately counselled to follow care plan regarding using the correct shower chair. Resident #18 has been discharged. Employee was immediately counselled to follow care plan for 2-person assist with all bed mobility and incontinent cares. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents care planned for specific shower chairs and 2-person assist with bed mobility and incontinent care have the potential to be affected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Facility has developed a simplified paper ADL version of the current electronic Kardex Care Plan. Facility has reviewed and updated its Using the Care Plan policy to include a simplified paper ADL version of the current electronic Kardex Care Plan for All Staff including CNAs to utilize. Facility has reviewed and updated its CNA/NA Standards of Care Guideline that all CNA/NA are trained to upon hire. CNAs, Charge Nurses, RCMs, DNS have been in-serviced to these policy changes. CNAs, Charge Nurses, RCMs, DNS have been in-serviced to follow resident care plans for shower chairs and 2-person assist with bed mobility and incontinent care. An audit tool has been created to monitor assistive devices and 2-person assist with bed mobility and incontinent care. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Random weekly audits of assistive devices and 2-person care will occur to ensure care plans are being followed for appropriate shower chairs being used and 2-person assist bed mobility and incontinent care will be conducted for a minimum of 4 weeks and random on-going audits. Nurse Management Team and Charge Nurses will conduct these audits. Results of Audits will be reported to Bi-Monthly QAPI committee for review and recommendation and to Quarterly QA Committee for further review and recommendation. 5. Title of person responsible and date of corrective action to be complete: CNAs are directly responsible with oversight from chain of command. 1st Charge Nurse, 2nd RCM, 3rd DNS and overall oversight of Administrator.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#2) reviewed for pharmaceutical services. This placed residents at risk for adverse side effects of medication. Findings include: Resident 2 was admitted to the facility in 12/2021 with diagnoses including bipolar disorder. A 12/16/21 physician order indicated Resident 2 was to receive lithium (a mood stabilizer) 450 MG twice daily. A 1/27/22 note to Resident 2 s' attending physician by the consulting pharmacist revealed a recommendation for baseline labs for Resident 2's lithium medication. On 2/1/22 the facility physician signed and agreed to the lithium baseline lab recommendation. A 2/8/22 lab request form revealed Resident 2's lithium labs were not ordered. On 5/16/22 at 10:40 AM, Staff 4 (RNCM) confirmed the lithium labs for Resident 2 were not completed per the physician's order. Staff 4 stated it was her expectation that the nurse would have followed the physician order and requested the lithium labs .

F770 1. How will corrective action be accomplished for those residents found to have been affected by the deficient practice: Resident #2. Labs were drawn on 2.12.22 via Hospital visit. Physician orders for on-going lab draws are now on TAR. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents requiring lab draws have the potential to be affected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: An audit of all existing standing lab orders has occurred to ensure lab orders are on TAR and results have been received and are documented on the TAR. Weekly clinical review meeting audits that all new Physician orders for labs have a corresponding lab slip and are placed on the TAR by reviewing New Physician Order Listing and Lab slip and clinical review meeting follow up tool. Charge Nurses, RCMs, DNS have been in-serviced to this process. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Results of audits for Physician Order Listing and Lab slips on the TAR and completed along with clinical review meeting follow up tool will be reported to Bi-Monthly QAPI for a minimum of 4 weeks or until Committee has determined compliance is sustained. Results of compliance will be reported to Quarterly QA Committee for further review and recommendation. 5. Title of person responsible and date of corrective action to be complete: Charge Nurses are directly responsible to ensure of compliance with chain of command oversight: 1st RCM 2nd DNS and overall Administrator oversight.

***************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F552 ***************************** OAR 411-085-0360 Free from Abuse, Neglect and Exploitation: Abuse Refer to F600 and F602 ***************************** OAR 411-086-0100 Nursing Services: Resident Care Quality of Care: Nursing Services: Resident Care Refer to F677 ***************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care Refer to F689 ***************************** OAR 411-086-0010 Laboratory Services: Administrator Refer to F770 *****************************

Based on observation, interview and record review it was determined the facility failed to ensure residents were covered in a dignified manner while being escorted to the shower for 2 of 2 sampled residents (#s 29 and 40) whom were reviewed for dignity. This placed residents at risk for private body parts to be exposed to others in a communal setting. Findings include: 1. The facility's Quality of Life - Dignity policy revised August 2009 revealed "10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures". Resident 40 was admitted to the facility in 11/2021 with diagnoses including dementia. The 11/2021 Admission MDS revealed Resident 40 was severely cognitively impaired. On 1/12/22 at 2:52 PM Staff 5 (CNA) was observed pushing Resident 40 in a shower chair on the East Hall towards the shower room. Resident 40 had a blanket draped across the front of her/his body, however the resident's backside, including her/his buttocks, was completely visible. As Staff 5 and Resident 40 approached the shower room door, approximately 45 feet from the resident's room, Staff 5 stopped and adjusted the resident's blanket to cover the resident's exposed body parts. On 1/12/22 at 3:16 PM Staff 5 confirmed the resident's backside was exposed and she stopped in front of the shower door to cover the resident. On 1/13/22 at 4:25 PM Staff 2 (DNS) stated she expected staff to ensure all residents were completely covered and their backsides not exposed when taken down a hall to take a shower. On 1/13/22 at 4:31 PM Staff 1 (Administrator) was informed of the incident in which Resident 40's backside was exposed and confirmed residents were to be fully covered and their backsides not exposed while being escorted to the shower room. 2. Resident 29 was admitted to the facility in 5/2017 with diagnoses including Alzheimer's disease and dementia. The 5/2021 Annual MDS revealed Resident 29 was severly cognitive impaired. On 1/12/22 at approximately 4:00 PM Staff 6 (Nurse Aide) was observed pushing Resident 29 from her/his room in a shower chair. The resident had the front of her/him wrapped in a blanket and the back side of the resident was fully exposed. The resident remained exposed as she/he was escorted down the Central Hall to the shower room on the East Hall. Several residents and staff were in the hallway. Staff 6 did not appear to notice the resident's backside was exposed. On 1/13/22 at 3:55 PM Staff 6 stated he would cover residents with a gown and a shower blanket, tucking the shower blanket under and behind the resident to cover their backside from being exposed. Staff 6 confirmed he took Resident 29 to the shower on 1/12/22 and stated he felt horrible as he was not aware the resident's buttocks and backside were exposed and visible to others. On 1/13/22 at 4:25 PM Staff 2 (DNS) stated she expected staff to ensure all residents were completely covered and their backsides not exposed when taken down a hall to take a shower. On 1/13/22 at 4:31 PM Staff 1 (Administrator) was informed of the incident in which Resident 29's backside was exposed and confirmed residents were to be fully covered and their backsides not exposed while being escorted to the shower room.

F 550 Resident Rights/Exercise of Rights 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. Resident #29. Upon Surveyor notification to Administration, a facility grievance form was initiated with immediate follow up in-service to Nursing staff to prevent further occurrences. Resident #40. Upon Surveyor notification to Administration, a facility grievance form was initiated with immediate follow up in-service to Nursing staff to prevent further occurrences. 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents who are assisted to the shower room have the potential to be affected. Upon Surveyor notification to Administration, a facility grievance form was initiated with immediate follow up in-service to Nursing staff to prevent further occurrences. Facility Quality of Life  Dignity policy has been reviewed and updated. Nursing staff have been re-educated to policy including specifically dignity during transport to the shower. New hires will be oriented upon hire to facility Dignity Policy and on-going all Nursing staff will be in-serviced quarterly and as needed. All Staff have been educated to policy to assist in identifying and reporting to Charge Nurse or Nurse Managers so immediate correction of any situations observed going forward will occur. An observation audit tool has been created for administrative staff or designee to conduct random shower audits each week to ensure policy is followed. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. Facility Quality of Life  Dignity policy has been reviewed and updated. Nursing staff have been re-educated to policy including specifically dignity during transport to the shower. New hires will be oriented upon hire to facility Dignity Policy and on-going all Nursing staff will be in-serviced quarterly and as needed. All Staff have been educated to policy to assist in identifying and reporting to Charge Nurse or Nurse Managers so immediate correction of any situations observed going forward will occur. An observation audit tool has been created for administrative staff or designee to conduct random shower audits each week to ensure policy is followed. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. Observation audit of shower transport process will occur randomly at least 3 times a week for a minimum of 4 weeks and on-going as determined by the bi-monthly QAPI committee. Results of audits will be reported to and reviewed by QAPI Committee bi-monthly and Quarterly Assurance Committee Quarterly until it is determined staff are proficient in practice. 5. The Director of Nursing with oversight from Administrator will ensure compliance.

Based on interview and record review it was determined the facility failed to obtain information and periodically review advance directives for 4 of 4 sampled residents (#s 8, 9, 30 and 44) reviewed for advanced directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 30 was admitted to the facility in 11/2018 with diagnoses including heart failure and dementia. Resident 30's quarterly MDS dated 11/3/21 indicated the resident was severly cognitvely impaired. There was no documentation found in Resident 30's clinical record to indicate if Resident 30 had an advance directive or not. On 1/12/22 at 3:15 PM Staff 14 (Medical Records) stated she could not locate any information related to Resident 30's advance directive status in the resident's clinical record. On 1/20/22 at 5:54 PM Staff 1 (Administrator) confirmed the facility did not document Resident 30's advance directive outcome and understood the importance of assuring appropriate documentation was in place regarding advance directives. 2. Resident 44 was admitted to the facility in 4/2018 with diagnoses including stroke and diabetes. Resident 44's quarterly MDS dated 10/20/21 indicated the resident had no cognitive impairment. There was no documentation found in Resident 44's clinical record to indicate if Resident 44 had an advance directive or not. On 1/12/22 at 3:15 PM Staff 14 (Medical Records) stated she could not locate any information related to Resident 44's advance directive status in the resident's clinical record. On 1/20/22 at 5:54 PM Staff 1 (Administrator) confirmed the facility did not document Resident 44's advance directive outcome and understood the importance of assuring appropriate documentation was in place regarding advance directives. , 3. Resident 8 was admitted to the facility in 12/2020 with diagnoses including Parkinson's disease and dementia. Resident 8's Annual MDS dated 12/29/21 indicated the resident was severly cognitively impaired. There was no documentation found in Resident 8's clinical record to indicate if Resident 8 had an advance directive or not. On 1/12/22 at 3:15 PM, Staff 14 (Medical Records) stated she could not locate any information related to Resident 8's advance directive status in the resident's clinical record. On 1/20/22 at 5:54 PM, Staff 1 (Administrator) confirmed the facility did not document Resident 8's advance directive outcome and understood the importance of assuring appropriate documentation was in place regarding advance directives. 4. Resident 9 was admitted to the facility 12/2020 with diagnoses including Parkinson's disease, dementia with behavioral disturbance and urinary retention. Resident 9's Annual MDS dated 12/29/21 indicated the resident was severly cognitively impaired. There was no documentation found in Resident 9's clinical record to indicate if Resident 9 had an advance directive or not. On 1/12/22 at 3:15 PM Staff 14 (Medical Records) stated she could not locate any information related to Resident 9's advance directive status in the resident's clinical record. On 1/20/22 at 5:54 PM Staff 1 (Administrator) confirmed the facility did not document Resident 9's advance directive outcome and understood the importance of assuring appropriate documentation was in place regarding advance directives.

F 578 Request/Refuse/Discontinue Treatment; Formulate Advance Directives. 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. Resident #8. The resident has a Healthcare Power of Attorney in place. Both resident and HPOA have been informed and provided written information that resident has the option to formulate an advance directive and facility accepts and requests any existing advance directive. This education with resident/HPOA along with outcome of education to formulate or provide an advance directive has been documented. Resident #9. The resident is their own responsible party with uninvolved family members. The resident has been informed and provided written information that they have the option to formulate an advance directive and facility accepts and requests any existing advance directive. This education with resident along with outcome of education to formulate or provide an advance directive has been documented. Resident #30. The resident is their own responsible party with an involved spouse. The resident and involved spouse have been informed and provided written information that they have the option to formulate an advance directive and facility accepts and requests any existing advance directive. This education with resident and involved spouse along with outcome of education to formulate or provide an advance directive has been documented. Resident #44. The resident is their own responsible party. The resident has been informed and provided written information that they have the option to formulate an advance directive and facility accepts and requests any existing advance directive. This education with resident along with outcome of education to formulate or provide an advance directive has been documented 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents have the potential to be affected. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. Facility Advance Directive policy has been reviewed and updated. Social Services Director, Activity Director and Nurse Management Team have been in-serviced to this policy. A full house audit has been completed of all resident electronic and paper charts for the existence of Advance Directives and documentation has been made in each resident electronic chart identifying this. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. Through scheduled Quarterly reviews (to include care conferences and quarterly notes) and as needed (significant change in condition) SSD will follow up with each resident offering Advanced Directive education and documenting the outcome of this education. New residents will be educated upon admission to their choice to formulate advance directives. Advance Directive education and status will be audited quarterly and reported to Quarterly QA Committee for further review and recommendation. 5. Social Services Director with oversight from Administrator will ensure compliance.

Based interview and record review it was determined the facility failed to ensure residents were free from abuse from staff and other residents for 4 of 5 sampled residents (#s 1, 17, 23 and 41) reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. The facility abuse policy updated 5/2021 indicated each resident has the right to be free from abuse by anyone and the facility will ensure all residents be free from abuse. Resident 1 was readmitted to the facility in 12/2021 with diagnoses including Huntington's disease, dementia with behavioral disturbances, anxiety and delusions. Resident 1's Admission MDS dated 12/29/21 indicated the resident's BIMS score was 7 (severely cognitively impaired) and the resident had difficult behaviors including disruption to the environment and exit seeking. Resident 1's care plan updated 11/18/21 included interventions for cognitive loss, impulsivity, wandering, exit-seeking and resistance to care. A FRI dated 8/29/21 revealed Staff 11 (CNA) pushed Resident 1 aggressively in her/his wheelchair with enough momentum to cause the resident to fall from the wheelchair. An assessment of the resident for injury indicated a reddened area on the resident's right shoulder. A facility investigation report dated 8/29/21 included witness statements and indicated Staff 11 (CNA) pushed Resident 1 in her/his wheelchair into her/his room with enough force to cause the resident to fall from the wheelchair. The report indicated the resident hit her/his head on a bed frame, had no visible head injuries but had an abrasion to her/his left shoulder. The facility substantiated abuse. The CNA was suspended then later put on probation. Review of Resident 1's clinical record revealed the resident had no signs of major injury, pain or psychological harm and did not need hospitalization for the 8/29/21 incident. On 1/11/22 at 7:36 AM Staff 11 (CNA) stated Resident 1 tried to hit another resident so Staff 11 pulled Resident 1 towards her/his room. The resident put her/his feet down to prevent going into the room and the resident's foot caught on the wheel causing the resident to fall out of the wheelchair. Staff 11 did not think he abused Resident 1. On 1/12/22 at 2:30 PM Staff 13 (CNA) stated she witnessed Staff 11 aggressively push Resident 1 in her/his wheelchair into the resident's room resulting in the resident falling out of the wheelchair and hitting her/his head. On 1/12/22 at 6:51 PM Witness 4 (Complainant) stated Staff 11 forcibly threw Resident 1 out of her/his wheelchair into the resident's room, left the resident on the floor and walked away. On 1/18/22 at 3:59 PM Staff 4 (RNCM) and on 1/20/22 at 6:05 PM Staff 1 (Administrator) confirmed staff to resident abuse was substantiated. , 2. Resident 17 was admitted to the facility in 7/2021 with diagnoses including dementia with Lewy bodies (a type of dementia in which clumps of protein are in the cells of the brain and can affect behavior and mood). The 7/2021 Admission MDS revealed Resident 17 had a BIMS of 7 (severely cognitively impaired) and she/he was coded for behaviors including hallucinations, delusions and wandering. Resident 17's care plan dated 7/7/21 revealed she/he had ineffective coping behaviors and was at risk for verbal and physical aggression. Resident 41 was admitted to the facility in 12/2003 with diagnoses including dementia. The 10/2021 Annual MDS revealed Resident 41 had a BIMS of 12 (moderately cognitively impaired) and she/he was coded for physical behaviors towards others. Resident 41's revised care plan dated 10/29/17 revealed she/he had ineffective coping behaviors including dementia and was at risk for verbal and physical aggression. Resident 41 was also care planned for auditory and visual hallucinations and delusions. On 10/21/21 a FRI revealed a resident to resident physical altercation between Residents 17 and 41 on 10/21/21. The FRI indicated uncertainty as to how the altercation started; however staff witnessed Residents 17 and 41 hitting each other. The facility's investigation revealed uncertainty as to how the altercation started, however staff witnessed Residents 17 and 41 hitting each other. The facility substantiated abuse. On 1/18/22 at 9:01 AM Witness 1 (Anonymous) stated Resident 17 hit other residents as a result of her/his dementia diagnosis. On 1/18/22 at 4:01 PM Staff 8 (Social Services Manager) confirmed she witnessed a physical altercation between Residents 17 and 41 in 10/2021, in which both residents hit each other. On 1/19/22 at 10:42 AM Staff 2 (DNS) confirmed the physical abuse incident between Residents 17 and 41 happened and it was not clear as to who initiated the event. She stated both resident's were placed on alert and supervision interventions were implemented. On 1/19/22 at 11:13 AM Staff 20 (CNA) acknowledged she was a witness to the physical altercation between Residents 17 and 41 on 10/21/21. She was unable to determine how the incident started but did see the residents hitting each other. On 1/20/22 at 12:16 PM Staff 1 (Administrator) acknoweldge the physical altercation occured between Residents 17 and 41. On 1/20/22 at 1:19 PM Staff 3 (RNCM) confirmed the physical altercation between Residents 17 and 41 occured and neither suffered any psychosocial harm. , 3. Resident 15 was admitted to the facility in 12/2020 with chronic obstructive pulmonary disease (lung disease making it difficult to breathe), major depressive disorder and hemiplegia/hemiparesis (muscle weakness or loss of function of one side of the body) following a stroke. Resident 15's 10/13/21 Quarterly MDS revealed a BIMS score of 13 (no cognitive impairment). A review of Resident 15's clinical record indicated the resident no longer resided in the facility. Resident 23 was admitted to the facility in 10/2021 with diagnoses including diabetes, dementia with behavioral disturbance and major depressive disorder. Resident 23's 10/24/21 Quarterly MDS revealed Resident 23 was coded as having severely impaired cognition. An 11/16/21 FRI indicated Resident 15 was heard making derogatory and offensive comments to Resident 23 regarding her/his spouse which resulted in Resident 23 becoming agitated. A Facility Investigation, dated 11/16/21, indicated staff heard Resident 15 using derogatory language and inappropriate comments directed towards Resident 23. Resident 15 was counseled to stop using rude, threatening and abusive language. Staff 3 (RNCM) completed a thorough investigation and substantiated that Resident 15 was verbally abusive to Resident 23. On 1/10/22 at 12:29 PM, Resident 23 was interviewed and unable to recall any interactions with Resident 15. On 1/13/22 at 2:05 PM, Staff 2 (DNS) and Staff 3 (RNCM) confirmed verbal abuse between Residents 15 and 23 occurred.

F 600 Free from Abuse and Neglect 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. Resident #1. Staff member was immediately placed on Administrative Leave. Upon return to work, staff member was placed in a 30 day re-training/probation program Monday-Friday on Day shift working 1 on 1 with an experienced CNA trainer with DNS RN and RCM RN oversight. Oregon State Board of Nursing (OSBN) was notified for further review and possible monitoring. Resident #17. Resident was immediately separated from resident #41 and assigned on a 1-1 caregiver. Resident #23. Resident #15 was moved to another hall. Resident Master List (Residents with a history of being aggressive toward other residents) was updated. Resident #41. Resident was immediately separated from resident #17. Resident #17 was immediately assigned a 1-1 caregiver. Resident Master List (Residents with a history of being aggressive toward other residents) was updated. 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. Resident to Resident: All ambulatory residents have the potential to be affected. Staff to Resident: All residents have the potential to be affected. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. Facility Abuse Policy has been reviewed and updated. Facility staff have been in-serviced to facility Abuse Policy, Mandatory Reporter Policy and Notice of Right and Responsibilities of staff on Reporting of Reasonable Suspicion of a Crime (F608). Nursing staff have been in-serviced Resident Master List (Residents with a history of being aggressive toward other residents). Resident Care Managers (RCM) will assess each resident quarterly using the aggression assessment tool (UDA) in accordance with previous plan of correction in 2021 and as scheduled upon admission, within 72 hours of admission, 30 days after admission, quarterly and PRN. RCMs will utilize the findings in the aggression assessment and behaviors noted when resident mood is identified as aggressive to update residents care plans with resident behaviors and interventions. Facility will continue to utilize the Resident Master List system (Residents with a history of being aggressive toward other residents) to notify nursing staff of residents identified as being aggressive towards other residents. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. The Resident Master List system will be audited and updated by the 15th of each month by the RCM and/or designee ongoing. Administrative staff and/or designee staff will conduct random weekly observation and interview audits each week for at least 4 weeks and on-going as determined by the QAPI committee to ensure staff understand staff to resident abuse, resident to resident abuse and the resident master list system. Results of audits will be reported to the bi-monthly QAPI committee and the quarterly QA Committee for further review and recommendation. 5. The Director of Nursing with oversight from Administrator will ensure compliance.

Based on observation, interview and record review it was determined the facility failed to post a conspicuous notice of employee rights to file a complaint with the State Survey Agency and failed to include examples of suspected crimes for reporting in the facility's abuse policy. This placed staff at risk for not being informed of their rights related to reporting suspicion of crimes and under reporting of alleged crimes. Findings include: The facility's Abuse Prevention, Investigation, Reporting Policy, last updated 5/20/21, did not include examples of crimes that should be reported such as rape, manslaughter, drug diversion for personal use or gain, identity theft, etc. On 1/18/22 at 1:53 PM, during concurrent observation and interview, Staff 8 (Social Services Manager) and surveyor toured the breakroom, central hallway and staff entrance. No posting of employee rights for reporting reasonable suspicion of crimes without retaliation was located. Staff 8 reported she had no idea what the sign looked like or where it might be located in the facility. On 1/18/22 at 1:58 PM, Staff 1 (Administrator) was informed Staff 8 and surveyor were unable to locate the sign regarding employee rights for reporting crimes without retalitation. On 1/20/22 at 3:06 PM, Staff 1 (Administrator) acknowledged no posted signage was observed regarding employee rights related to retaliation against employees for reporting a suspected crime and the abuse policy did not identify or include examples of crimes that should be reported.

F 608 Reporting of Reasonable Suspicion of a Crime 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. No specific Residents were identified. 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents have the potential to be affected. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. Facility Abuse policy has been reviewed and updated. All staff have been in-serviced to this updated policy. A notice has been posted including employee rights and responsibilities of reporting of reasonable suspicion of a crime in the employee breakroom, by the employee time clock and in new hire orientation packet. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. Periodic rounds by administrative team will identify that postings remain in place. Results of periodic rounds will be reported to quarterly QA committee for further review and recommendation. 5. Administrator with QA Committee oversight will ensure compliance.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 5 sampled residents (#s 40 and 44) reviewed for medications. This placed residents at risk of unmet needs. Findings include: 1. Resident 44 was admitted to the facility in 4/2018 with diagnoses including stroke and diabetes. A physician order dated 9/28/21 for routine Novolog (a fast-acting insulin) was to be administered three times a day and indicated to hold when blood sugars were below 90. Resident 44's Diabetic Administration Records from 12/12/21 through 1/12/22 revealed the resident's routine Novolog was held during the following days and times when the resident's blood sugar was above 90: 12/22/21 7:00 AM and 11:00 AM 12/23/22 4:00 PM 12/26/21 7:00 AM 12/28/21 7:00 AM 12/29/21 7:00 AM 12/30/21 7:00 AM 12/31/21 4:00 PM 1/2/22 7:00 AM and 4:00 PM 1/4/22 7:00 AM and 4:00 PM 1/8/22 7:00 AM 1/9/22 4:00 PM 1/12/22 7:00 AM and 4:00 PM On 1/20/22 at 9:06 AM Staff 9 (RN) stated he sometimes held the Resident 44's routine Novolog when her/his blood sugar was over 90 depending on what the resident ate or did not eat, in order to avoid hypoglycemia. Progress notes reviewed from 12/12/21 through 1/12/22 revealed when the routine Novolog was held for blood sugars over 90, there was no rationale documented and the resident's physician was not notified. On 1/20/21 at 12:45 PM Staff 2 (DNS) confirmed the physician order instructed to hold the routine Novolog when the resident's blood sugars were over 90 and the order was not always followed. She stated the rationale for holding Resident 44's Novolog was not documented in the resident's clinical record. , 2. Resident 40 was admitted to the facility in 11/2021 with diagnoses including congestive heart failure. Resident 40's 11/24/21 Admission MDS revealed a BIMS score of 2 indicating severe cognitive impairment. An 11/18/21 physician's order indicated Resident 40 was prescribed Carvedilol (a medication used to treat heart failure) 3.125 mg, one tablet twice a day with meals, hold for systolic blood pressure (SBP) less than 100 and heart rate (HR) less than 60. A review of Resident 40's 12/2021 and 1/2022 MAR indicated she/he received Carvedilol twice a day; however, there was no evidence in Resident 40's clinical record staff were monitoring SBP or HR prior to administering the resident's Carvedilol. On 1/20/22 at 8:01 AM, Staff 18 (LPN) stated she was unaware Resident 40 received any medications that required her to check SBP or HR prior to administration. Staff 18 stated such parameters were typically defined and documented on resident's MARS; however, Resident 40 had no location on their MAR that triggered her to monitor or document SBP and HR. Staff 18 stated unless staff were familiar with Resident 40's medication regimen, they would not be aware to check SBP or HR and there was no way to tell if the medication had been given according to the physician's orders. On 1/18/22 at 8:34 AM, Staff 3 (RNCM) stated parameters for Resident 40's SBP and HR should have been on the resident's MAR at the time the orders were processed. Staff 3 reported there was no evidence in Resident 40's clinical record the Carvedilol was administered according to the physician's orders. On 1/20/22 at 10:30 AM, Staff 2 (DNS) acknowledged the facility's failure to follow physician orders.

F 684 Quality of Care 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. Resident #40. Documentation boxes were added to resident MAR in order to document that blood pressure and pulse were taken prior to medication administration. Certified Medication Aides (CMAs) and Medication Nurses have been educated to ensure there is a place to document blood pressure and pulse prior to administration and administer per Physician orders related to parameters. Resident #44. LN’s have been educated to follow parameters of Physician Orders. If LN determines parameters are not safe to follow, LN will seek clarification from Physician for further orders and document in progress notes. 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents with parameters on medication orders are at risk for this deficient practice. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. Facility has reviewed and updated Medication Administration and Physician Order policies and has in-serviced all CMAs, Medication Nurses and Charge Nurses to updated policies and procedures specifically to order entry, monitoring, administering and documenting outlined parameters per Physician orders. Audit tool to be used will be PCC reports on MAR and DAR documentation. Clinical review meeting will review at least weekly, all new orders to ensure accuracy of input into electronic system. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. MAR and DAR documentation audit will occur daily Monday through Friday for a minimum of 4 weeks. Clinical review meeting will occur at least weekly to monitor order entry accuracy, and documentation of parameters are being followed. Results of audits and Clinical review meetings will be reported to bi-monthly QAPI meeting and Quarterly QA Committee until further notice as determined by QAPI/QA Committees. 5. The Director of Nursing with oversight from Administrator will ensure compliance.

Based on interview and record review it was determined the facility failed to ensure a resident received Restorative Services for 1 of 3 sampled residents (# 40) reviewed for Restorative Services. This placed residents at risk for decreased independence. Findings include: Resident 40 was admitted to the facility in 11/2021 with diagnoses including dementia with behavioral disturbance, delusional disorder and traumatic subdural hemorrhage (a head injury resulting in blood between the brain and it's outermost covering). Resident 40's 11/24/21 Admission MDS indicated she/he required two people for assistance with walking in the room, had upper extremity impairment on both sides and staff believed Resident 40 was capable of increased independence. Resident 40's 12/3/21 Physician Orders for Restorative Services indicated the following: -Restorative ROM 3-5 times per week; -Ambulate with Restorative Nursing Team 3 to 5 times per week. Resident 40's 12/2/21 Restorative Care Plan indicated the resident was to receive restorative ambulation and ROM with the facility restorative team 3 to 5 times per week. The 12/2021 and 1/2022 Restorative Treatment Record indicated Resident 40 was to ambulate with Restorative Nursing for muscle strengthening and improved weight bearing and receive ROM for muscle weakness, improved strength and joint flexibility 3 to 5 times per week every day shift Monday through Friday. Resident 40's Restorative Treatment Record revealed she/he received Restorative Nursing Services as follows: -12/6 through 12/10: ambulation and ROM received twice; -12/13 through 12/17: ambulation received one time and ROM received three times; -12/20 through 12/24: ambulation was not received and ROM was received one time; -12/27 through 12/31: ambulation and ROM were received one time; -1/3 through 1/7: ambulation was not received and ROM was received one time. On 1/12/22 at 2:16 PM, Staff 15 (RA/CNA) stated RA staff were not always able to perform Restorative Services but they tried to see Resident 40 at least one or two times per week. Staff 15 reported RA staff were frequently asked to work on the floor as CNAs. On 1/12/22 at 3:32 PM and 1/14/22 at 11:11 AM, Staff 5 (CNA) and Staff 19 (CNA) reported CNA staff did not provide Restorative Services to residents and Restorative Services for Resident 40 were performed by RA staff. On 1/18/22 at 3:04 PM, Staff 4 (RNCM) confirmed Resident 40 did not receive Restorative Services as ordered. On 1/20/22 at 3:06 PM, Staff 1 (Administrator) acknowledged the facility's failure to provide Restorative Services as ordered.

F 688 Increase/Prevent Decrease in ROM/Mobility 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. Resident #40. Restorative CNAs and Certified CNAs have been re-educated to ensure documentation is completed prior to end of shift for all Restorative activities completed. 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents have the potential to be affected. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. Restorative Program Policy has been reviewed and updated. CNAs, RAs and Charge Nurses and Nurse Managers have been educated to this policy. Electronic audit tool will be utilized to ensure documentation occurs. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. Electronic audit will occur daily Monday through Friday for a minimum of 4 weeks and on-going as determined by bi-monthly QAPI committee. Clinical review meeting will occur at least weekly to monitor that restorative services documentation occurs daily. Clinical review meeting is an on-going meeting. Results of audits and Clinical review meetings will be reported to bi-monthly QAPI meeting and Quarterly QA Committee until further notice as determined by QAPI/QA Committees. 5. The Director of Nursing or designee RN with oversight from DNS and Administrator will ensure compliance.

Based on observation, interview and record review it was determined the facility failed to provide care and services related to catheter care for 1 of 1 sampled resident (# 9) reviewed for urinary catheter care. This placed residents at risk for unmet catheter needs. Findings include: Resident 9 was admitted to the facility in 12/2020 with diagnoses including Parkinson's disease, urinary retention, benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms and history of urinary tract infections. Resident 9's Progress Notes indicated on 11/15/21, Resident 9 was sent to the emergency room for evaluation after a fall, was diagnosed with urinary retention, a catheter was placed and Resident 9 returned to the facility on 11/16/21 with a catheter. The 12/29/21 Annual MDS indicated Resident 9 used an indwelling catheter due to inability to void related to benign prostatic hyperplasia. The 12/29/21 Urinary Incontinence and Indwelling Catheter CAA indicated the need for catheter care as follows: -Catheter care with soap and water every shift. -Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended, rather, change indwelling catheters or drainage bags as indicated for infection, obstruction or when the closed system is compromised. -Indwelling catheter per physician order. -Maintain closed catheter drainage system/secure catheter tubing to prevent pulling/trauma. -See TAR for catheter maintenance schedule and clinical indicators for changing foley catheter, tubing and drainage bag. A review of Resident 9's clinical record indicated there were no physician orders for care and services of Resident 9's catheter, no care plan was in place and no catheter TAR was located. There was no evidence found in the clinical record to indicate Resident 9's catheter, drainage bag and drainage tubing was being routinely monitored, maintained and cleaned or changed when necessary. Observations of Resident 9 from 1/10/22 through 1/20/22 revealed the resident used a catheter. Multiple observations on 1/11/22 between the hours of 8:30 AM and 1:30 PM revealed the catheter drainage bag to be extremely full. On 1/12/22 at 1:09 PM, Staff 24 (CNA) revealed staff utilized a smaller catheter drainage bag because the larger catheter drainage bags were not in stock, therefore, the catheter bag needed to be emptied more frequently. On 1/13/22 at 4:03 PM, Staff 25 (LPN) stated there were no physician orders regarding Resident 9's catheter care and services in the resident's clinical record prior to 1/13/22 but the CNAs were aware the standard of care was to clean the catheter. On 1/18/22 at 10:19 AM, Staff 3 (RNCM) confirmed there were no catheter care and service physician orders, care plan and TAR in Resident 9's clinical record and these would be expected for resident's who required catheters. On 1/20/22 at 12:59 PM, Staff 2 (DNS) stated on 1/11/22, she observed Resident 9's catheter drainage bag was extremely full, notified the nurse it was not acceptable for the bag to be that full and asked her to empty the bag. Staff 2 confirmed there were no catheter care or service physician orders, care plan and TAR.

F 690 Bowel/Bladder Incontinence, Catheter, UTI 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. Resident #9. Physician orders have been obtained, Care Plan is in place, Catheter Care is on Treatment Administration Record (TAR). 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents who have a catheter or the potential to have a catheter based on diagnoses and medications that could contribute to urinary retention. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. Catheter care policy has been reviewed and updated. Update includes that residents will receive a physical assessment upon re-entry that identifies if an indwelling foley catheter is present. If present, orders will be obtained from physician for care and maintenance of catheter, a care plan will be initiated to reflect the same and TAR will be in place to reflect the same. Nursing Departments has been in-serviced to follow this policy. Electronic record audit will be reviewed in Clinical Meeting at least weekly to ensure documentation is in place. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. Upon admission, re-admission resident will be assessed for presence of indwelling catheter and ensure that physician orders, care plan, and TAR are in place. Clinical meeting will review at least weekly, all admissions and re-admissions for presence of an indwelling catheter and to ensure all orders, care plan and treatments are in place. Results of compliance will be reported to bi-monthly QAPI and Quarterly QA committee. 5. The Director of Nursing with oversight from Administrator will ensure compliance.

Based on interview and record review it was determined the facility failed to ensure an RN worked eight consecutive hours between the start of the dayshift and the end of the night shift as a charge nurse for 18 out of 72 days reviewed for staffing. This placed residents at risk for unmet needs. Findings include: The facility's Direct Care Staff Daily Reports from 11/1/21 through 1/11/22 revealed the following days where no RN worked eight consecutive hours as a charge nurse: -11/1, 11/7, 11/22, 11/28, 11/29, 12/3, 12/4, 12/6, 12/11, 12/18, 12/19, 12/25, 12/26, 12/31, 1/3, 1/9, 1/10 and 1/11. On 1/20/21 at 10:20 AM, Staff 2 (DNS) stated she was aware of the lack of RN coverage and confirmed the facility's failure to ensure an RN worked eight consecutive hours as a charge nurse on the days reviewed. Staff 2 stated the facility only had one RN who worked as a charge nurse at this time.

F 727 RN 8 Hrs/7days/Wk, Full Time DON 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. No specific resident identified. 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents have the potential to be affected. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. The facility submitted a waiver for the RN coverage requirement requesting the ability to designate an LPN charge nurse with RCM RN oversight while continuing efforts to fill the RN charge nurse positions open. Facility continues advertising with competitive market wages and sign on bonus to fill the RN charge nurse positions open. Facility continues submitting requests for RN coverage from 7 agency staffing agencies. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. Facility conducts bi-weekly QAPI staffing reviews including monitoring of any new applicants for the RN positions open and monitoring of daily assignment sheets to ensure an RCM RN is noted as oversight for LPN designated charge nurse on days where an RN charge nurse is not available to schedule. Results of compliance will be reported to bi-weekly QAPI and Quarterly QA committee. 5. The Director of Nursing with Administrator oversight will ensure compliance.

Based on interview and record review it was determined the facility failed to process physician laboratory orders timely and accurately for 1 of 5 sampled residents (#44) reviewed for medications. This placed residents at risk of unmet needs. Findings include: Resident 44 was admitted to the facility in 4/2018 with diagnoses including congestive heart failure, kidney disease, diabetes and hypothyroidism. A physician order dated 4/26/21 indicated Resident 44 was to have labs completed for CBC (complete blood count), CMP (complete metabolic panel), lipid panel (measures fats and fatty substances), TSH (thyroid function) level and valproic acid (used to determine if anti-seizure medication is at a therapeutic level) every 6 months (April/October). A physician order dated 4/24/18 indicated Resident 44 was to have a lab completed for Hgb A1C level (a test to evaluate diabetes) every 3 months (Jan/April/July/Oct). A progress note by Staff 4 (RNCM) dated 11/17/21 indicated the CBC, CMP and valproic acid level lab was last completed on 5/11/21, the lipid panel was last completed on 7/6/21, the TSH level was last completed on 6/22/21 and the last AIC was completed in May 2021. The lab orders were not on Resident 33's TAR. There was no evidence in the resident's clinical chart to indicate any labs were completed after these dates. The last lab located in the resident's clinical record was completed on 7/6/21 and was only for a lipid panel. There was no documentation any other ordered labs were completed after 7/6/21 through the time of this investigation. On 1/20/22 at 11:45 AM Staff 4 (RNCM) confirmed labs were not completed as ordered.

F 770 Laboratory Services 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. Resident #44. Resident lab draw orders are in place, TAR has been updated to reflect that requisition form has been completed and sent to the lab, charge nurse has followed up to ensure labs have been drawn, TAR has been updated to reflect that results of lab draws have been received, critical values were called to Physician or routine values were reviewed by Physician on weekly visit. 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents requiring lab draws at certain intervals have the potential to be affected. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. Facility Lab policy has been reviewed and updated. All Charge Nurses have been in-serviced to this policy. Electronic audit of TAR completion will be utilized. Weekly audit of compliance will occur via weekly Clinical Review meeting of new orders. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. Weekly electronic audit of TAR completion will be completed for a minimum of 4 weeks and on-going as determined by the bi-monthly QAPI committee. Weekly Clinical meeting will review all lab orders and follow up. This is an on-going Clinical meeting. Compliance will be reported to bi-monthly QAPI and Quarterly QA until it is determined proficient practice is in place. 5. The Director of Nursing or designee with oversight of the Administrator will ensure compliance.

Based on interview and record review it was determined the facility failed to ensure risk and benefit education (consents) related to immunizations were completed for 5 of 5 sampled residents (#s 1, 2, 30, 37 and 47) and failed to determine immunizations were completed for 2 of 5 sampled residents (#s 37 and 47) reviewed for infection control. This placed residents at risk for lack of knowledge for immunizations and at risk for infections. Findings include: 1. The facility's Influenza and Pnuemococcal Vaccinations policy dated 4/10/18 indicated the facility is responsible to provide residents or their representatives education on the benefits and possible side effects of influenza and pneumococcal vaccines and to offer the vaccines if appropriate. The residents' medical record will include documentation the resident was provided education regarding the benefits and potential side effects of the vaccinations and will show the resident either received the vaccination or did not receive the vaccination because of medical contraindication or refusal. The following residents were reviewed for influenza, pneumococcal and COVID immunizations: Resident 1 was admitted to the facility in 12/2018 with diagnoses including Huntington's disease. The resident's clinical record indicated she/he was given the influenza vaccine on 10/26/21, however the only consent found for this vaccination was dated 9/12/19. Resident 1 declined COVID vaccinations (dates unknown), however no declinations were found in the resident's clinical record to show the resident was educated about the risk and benefits. Resident 2 was admitted to the facility in 9/2021 with diagnoses including stroke. Resident 2 received the influenza vaccine on 10/27/21, however no consent was found in the resident's clinical record. Resident 2 declined COVID vaccinations (dates unknown), however no declinations were found in the resident's clinical record to show the resident was educated about the risk and benefits. Resident 30 was admitted to the facility in 11/2018 with diagnoses including stroke. Resident 30 received the influenza vaccination on 10/26/21, however the last consent found in the resident's clinical record was signed in 2018. Resident 30 received the pneumococcal polysaccharide vaccine (PPSV23) on 12/3/18, however no consent was found in the resident's clinical records. Resident 37 was admitted to the facility in 2/2021 with diagnoses including schizoaffective disorder. The resident received the influenza vaccination on 10/27/21, however no consent was found in the resident's clinical record. Resident 37's representative declined COVID vaccinations (dates unknown), however no declination was found in the resident's clinical record to show the representative or the resident were educated about the risk and benefits. Resident 47 was admitted to the facility in 2/2021 with diagnoses including schizophrenia. The resident received the influenza vaccine on 10/29/21, however the only consent found in the resident's clinical record was in the admission packet and was signed on 5/11/21. The resident declined the COVID vaccinations (dates unknown), however no declinations were found in the resident's clinical record. On 1/18/22 at 10:42 AM Staff 10 (LPN/Infection Preventionist) confirmed the consents discussed above for Residents 1, 2, 30, 37 and 47 could not be found. On 1/18/22 at Staff 14 (Medical Records) stated she did not find the consents discussed above for Residents 1, 2, 30, 37 and 47 in their clinical records. On 1/20/22 at 6:00 PM Staff 1 (Administrator) stated she understood and had no additional information. 2. The facility's Influenza and Pnuemococcal Vaccinations policy dated 4/10/18 indicated immunizations for pneumocococcal disease will be offered to every resident unless medically contraindicated. Resident 37 was admitted in 2/2021 with diagnoses including schizoaffective disorder. Resident 37's clinical record revealed the resident received the pneumococcal polysaccharide vaccine (PPSV23) on 1/29/14. Since the resident was over 65 years old, there was no evidence the resident was offered the pneumococcal conjugate vaccine (Prevnar 13) and no documentation to indicate the vaccine was contraindicated. Resident 47 was admitted to the facility in 2/2021 with diagnoses including schizophrenia. Resident 47's clinical record did not contain documentation the resident was offered or received either of the pneumococcal vaccines. On 1/20/22 at 6:00 PM Staff 1 (Administrator) stated she understood and had no additional information.

F 883 Influenza and Pneumococcal Immunizations 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. Resident #1. Facility received a verbal consent for the 10.26.21 influenza vaccine. Facility has since gotten written consent from the resident. Facility received a verbal declination for the COVID vaccine. Facility has re-approached resident and has written documentation of consent or refusal. Written consents/declinations are uploaded into resident electronic clinical record. Resident #2. Facility received a verbal consent for the 10.27.21 influenza vaccine and has since gotten written consent from the resident. Facility has re-approached resident and physician and has written documentation of consent, refusal or medical exemption for COVID vaccine. Written consents/declinations are uploaded into resident electronic clinical record. Resident #30. Facility received a verbal consent for the 10.26.21 influenza vaccine and has since gotten written consent from the HPOA. Facility has since gotten written consent from the HPOA for the pneumococcal vaccine given on 12.3.18. Written consents/declinations are uploaded into resident electronic clinical record. Written consents/declinations are uploaded into resident electronic clinical record. Resident #37. Facility received a verbal consent from both resident and Guardian for the 10.27.21 influenza vaccine and has since gotten written consent from the resident/Guardian. Facility has re-approached resident (Guardian already consented) and has written documentation of consent or refusal of COVID vaccine. Written consents/declinations are uploaded into resident electronic clinical record. Resident #47. Facility received a verbal consent from resident and Guardian for the 10.29.21 influenza vaccine and has since gotten written consent or refusal of COVID vaccine from resident/Guardian. Written consents/declinations are uploaded into resident electronic clinical record. 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents have the potential to be affected. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. Facility vaccine policy has been reviewed and updated to include that annual written consents/declinations will be completed prior to administration of vaccines and uploaded into each resident clinical record. Nurse Management Team including Infection Preventionist has been in-serviced to updated policy which includes an annual written consent or declination and documentation to be uploaded into each resident electronic clinical record. An audit tool has been created to audit documented consents, declinations and availability in chart for all current residents. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. Full house audit for documented consents, declinations and availability in chart has been completed for the current resident population. Per updated policy, only documented consents will have vaccines administered. Those refusing or with medical exemption will have declination documented at time refusal or exemption is received. Audit report from electronic record system will be run monthly to verify documentation on file. Review of new admission vaccination status and status of current resident population will occur via weekly clinical meeting. 5. The Infection Control Prevention Nurse with oversight of the DNS and Administrator will ensure compliance.

Based on interview and record review it was determined the facility failed to document COVID-19 test results in each individual resident's clinical record. This placed residents and staff at risk for incorrect and imprecise COVID-19 surveillance and tracking information. Findings include: On 1/13/22 at 4:50 PM Staff 10 (LPN/Infection Control Preventionist) stated the lab used by the facility for COVID testing of residents sent the test results to her and she was the only staff able to access the information. Staff 10 stated the lab results were not uploaded into each individual resident's clinical record where other staff could obtain the residents' COVID testing status. On 1/18/22 at 10:52 AM Staff 10 confirmed the facility did not upload the results of residents' COVID tests into their individual clinical records. On 1/20/22 at 6:00 PM Staff 1 (Administrator) stated she understood and had no additional information.

F 886 COVID-19 Testing-Residents & Staff 1. Corrective actions to be accomplished for those residents found to have been affected by the deficient practice. No specific residents identified. 2. Identification of other residents with potential to be affected by the same deficient practice and corrective actions to be taken. All residents have the potential to be affected. 3. Measures to be put in place or systemic changes that will be made to ensure that the deficient practice does not recur. COVID testing policy has been reviewed and updated to include uploading documented COVID test results into each resident’s clinical record in addition to ICP Nurse, Medical Records Director and Direct of Nursing have access to Lab Portal test results and Antigen Rapid Test results folder. 4. Monitoring of corrective actions to ensure that the deficient practice does not recur. Audit report from electronic record system will be run monthly to verify documentation on file. Results of audits will be reported to bi-monthly QAPI and Quarterly QA Committee on-going. 5. Infection Prevention Nurse and Medical Records Director with oversight of DNS and Administrator will ensure compliance.

***************************** OAR 411-085-0310 Resident Rights: Residents' Rights: Generally Refer to F550 ***************************** OAR 411-086-0040 Resident Rights: Admission of Residents Refer to F578 ***************************** OAR 411-085-0360 Freedom from Abuse, Neglect, and Exploitation: Abuse Refer to F600 and F608 ***************************** OAR 411-086-0110 Quality of Care: Nursing Services: Resident Care Refer to F684 ***************************** OAR 411-086-0140 Quality of Care: Nursing Services: Problem Resolution & Preventative Care Refer to F688 and F690 ***************************** OAR 411-086-0100 Nursing Services: Staffing Refer to F727 ***************************** OAR 411-086-0010 Laboratory Services: Administrator Refer to F770 ***************************** OAR 411-086-0140 Infection Control: Nursing Services: Problem Resolution & Preventative Care Refer to F883 ***************************** OAR 411-086-0330 Infection Control: Infection Control and Universal Precautions Refer to F886 *****************************

Based on interview and record review it was determined the facility failed to meet the minimum required certified nursing assistant (CNA) staffing ratio for 9 out of 15 days reviewed for sufficient staffing. This placed residents at risk for delayed care. Findings include: Per Oregon Administrative Rule (OAR) 411-086-0100 (temporary rule), the facility was required to have one CNA for every 8.5 residents during day shift, one CNA for every 12 residents during evening shift, and one CNA for every 18 residents during night shift. The Direct Care Staff Daily Reports and Shift Assignment Sheets from 9/12/21 through 9/26/21 revealed the following days when the required state minimum CNA staffing ratios were not met for one or more shifts: - 9/12/21 - 9/14/21 - 9/15/21 - 9/17/21 - 9/19/21 - 9/20/21 - 9/22/21 - 9/25/21 - 9/26/21 On 9/28/21 at 2:25 PM Staff 1 (Administrator) confirmed the identified CNA shortages.

M183 SS=E OAR 411-086-0100(5) Nursing Services: Minimum CNA Staffing. 1. How facility will correct deficient practice as it relates to specific residents affected. No specific residents identified as affected. 2. How facility will identify other residents having the potential to be affected and what corrective action will be taken. All residents have the potential to be affected. 3. What measures will be put in place or what systemic changes will be made to ensure that deficient practice does not recur. Root cause analysis for days under staffing ratio on 9.12.21, 9.14.21, 9.15.21, 9.17.21, 9.19.21, 9.20.21, 9.22.21, 9.25.21 and 9.26.21 found that all shifts were scheduled to required ratio except one shift was scheduled one staff person under. 28 call-in’s were found in the 9 days under staffing ratio; 13 shifts were staff members who were on Quarantine for being a direct exposure to a positive Covid case at home or in the community and 15 shifts were under staffing ratio due to staff call ins (injury off the job, injury on the job, day care issues, parental care issues, illness, children ill, mental health). 7 of the 9 days found under ratio did not capture all CNAs working: 3 shifts had 1 staff member not in the staffing ratio numbers due to being mentored and 4 shifts had 2 CNAs not in the staffing ratio numbers due to being mentored. Subsequent review with DHS Staffing Policy Analyst found that these mentored CNAs could have been counted in the staffing ratio numbers because they were providing direct care for residents working alongside a more experienced CNA. Facility Attendance Policy has been reviewed an updated to include a perfect attendance incentive program and clarified counsel/disciplinary action process for excessive absences. Staffing Coordinator, Director of Nursing (DNS) and Administrator have been and will continue daily staffing review (audit tool has been created) and a minimum weekly and more frequent if needed staffing meeting to review status of staffing and submit requests to contracted agencies to fill open CNA shifts (audit tool has been created). CNAs and Nursing Administrative staff have been in-serviced to the updated Attendance Policy. CNA Staffing Coordinator, Payroll staff, DNS and Administrator have been in-serviced on Oregon Nursing Assistant Staffing & NATCEP Reimbursement Reporting & Enforcement Guide and the ability to capture orientation or mentoring situations in the staffing ratio numbers on the Direct Care Staff Daily Report when criteria met. Any questionable situation will be reviewed with DHS Staffing Policy Analyst case by case to see if a unique situation is allowable or not. CNA Staffing Coordinator will continue to utilize agency staff as needed to cover shifts. CNA Staffing Coordinator will continue to attempt to cover call-ins as they occur with facility staff and agency staff. CNA Staffing Coordinator will continue to track call-ins on individual tracking sheets as call-ins occur. CNA Staffing Coordinator will summarize excessive call-ins on spreadsheet for DNS weekly review (Audit tool has been created). Facility will continue to mitigate a short shift by utilizing all available support staff to ensure resident needs are being met-Nurse, CMA, Feeding Assistant, Hospitality Aide and Administrative Nursing staff to support the efforts of the CNAs. DNS will audit weekly attendance spreadsheet and follow up with documented counsel/disciplinary actions. Facility continues to follow a QAPI (Quality Assurance and Performance Improvement) plan already in place on CNA staffing challenges: CNA wages were adjusted to above market wages on 8.1.21, tracking of CNA attendance began on 7.1.21 with corresponding Director of Nursing (DNS) counseling of staff with attendance issues, Nursing staff in-service to attendance policy in July, CNA Staffing Coordinator was hired in June, facility has contracts with 7 staffing agencies, facility employs Hospitality Aides as needed, has various staff who have completed the feeding assistant training to assist as needed, continues to have support staff (Nurses, CMAs, Hospitality Aides, Feeding Assistants and Administrative Nursing staff) support the floor when CNA staffing is under ratio, continues hiring qualified CNA staff, continues training infection control practices to staff to assist their safety while at home or in the community to prevent being direct exposures to Covid positive cases resulting in loss of work for necessary Quarantine. 4. How corrective actions will be monitored to ensure deficient practice will not recur, i.e., what quality assurance program will be put in place. Daily Monday-Friday audit of Daily Staffing Ratios input into DHS Excel Direct Care Staff Daily Report. Daily, weekly and more frequent (if needed) staffing reviews/audits by CNA staffing coordinator, Director of Nursing and Administrator to monitor and correct staffing levels. Utilization of DHS Staffing Policy Analyst as needed to clarify if unique staffing situations are allowable toward CNA staffing ratios. Documented Attendance tracking of each CNA with call-ins to be reviewed by DNS weekly. Documented Employee counseling/disciplinary action for excessive attendance issues will be audited weekly by DNS. Results of audits will be reported to and reviewed by weekly QAPI committee and Quarterly Quality Assurance Committee until further notice as determined by QAPI/QA Committee. 5. Title of person responsible for correction of deficiency. C.N.A. Staffing Coordinator and Director of Nursing will be responsible for correction with overall assistance and oversight of Administrator, CEO and Owner.

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 08/16/2021 and 08/22/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to ensure residents were free from staff to resident and resident to resident abuse for 3 of 16 sampled residents (#s 7, 16 and 22) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility abuse policy updated 5/2019 indicated each resident has the right to be free from abuse by anyone and the facility will ensure all residents be free from abuse. 1. Resident 16 was admitted to the facility in 4/2020 with diagnoses including dementia with behaviors, anxiety and heart failure. Resident 16's Admission MDS dated 4/16/20 indicated the resident had moderately impaired cognition, impulsive behavior and the ability to verbalize needs. Resident 16's care plan, updated 3/24/21, included interventions for cognitive loss, impulsivity and resistance to care. A facility investigation report dated 4/8/21 revealed on 4/8/21 Staff 33 (Former CNA) verbally mocked Resident 16, displayed a negative attitude toward the resident, used profanity in the presence of the resident and failed to act in a professional manner when responding to Resident 16's behavior. Staff 33 was immediately placed on administrative leave. On 7/30/21 at 2:55 PM Staff 1 (Administrator) confirmed the facility substantiated the staff to resident verbal abuse. Review of Resident 16's clinical record revealed the resident had no signs of psychological harm from the 4/8/21 incident. 2. Resident 22 was admitted to the facility in 12/2003 with diagnoses including dementia and anxiety. Resident 22's annual MDS dated 10/4/2020 indicated the resident was cognitively impaired and needed to be acknowledged and respected. The facility incident investigation dated 5/25/21, included staff witness statements and indicated on 5/22/21 a staff member overheard Staff 33 (Former CNA) tell Resident 22 if he/she touched the snack cart one more time, he would break her/his fingers. An assessment of the resident indicated the resident denied any physical or psychological distress from the incident. The facility investigation concluded Staff 33 did verbally abuse the resident. Staff 33's employment was terminated. Resident 22's care plan included interventions dated 10/12/2018 for hoarding food and interventions dated 10/29/2017 to gently redirect the resident when the resident made inappropriate actions and to assess for hunger. On 7/30/21 at 2:30 PM Staff 3 (RNCM) stated the conclusion of the investigation was Staff 33 did verbally abuse Resident 22. On 8/9/21 at 3:08 PM Staff 1 (Administrator) confirmed the interaction between Staff 33 and Resident 22 was verbal abuse. , 3. Resident 7 admitted to the facility in 2017 with diagnoses including dementia. According to progress notes and a facility incident report dated 6/26/21, Resident 7 was "assaulted" by another resident in the facility when the other resident struck Resident 7 with a cane. Resident 7 sustained a three cm skin tear during the incident. The incident was witnessed by Staff 32 (CNA). No other injury was observed and Resident 7 did not appear to be emotionally affected by the incident. On 8/4/21 at 3:09 PM Staff 32 stated he saw a resident strike Resident 7 with a cane and he did not observe Resident 7 do anything to provoke the other resident. On 8/5/21 at 1:42 PM Staff 1 (Administrator) stated Resident 7 was the victim of unprovoked aggression by another resident, which constituted physical abuse of Resident 7.

F600 Free from Abuse and Neglect. Facility failed to ensure residents were free from staff to resident and resident to resident abuse. 1. How facility will correct deficient practice as it relates to specific residents affected. Resident #16: Resident is discharged. Resident #22: Staff CNA was terminated. Resident#7: Resident #8 cane was removed, was assigned a 1:1 caregiver and is in active discharge planning for more appropriate placement. 2. How facility will identify other residents having the potential to be affected and what corrective action will be taken. All residents are at potential risk related to this citation. Facility continues with on-going aggression assessments for all residents; upon admission, within 72 hours of admission, 30 days after admission, quarterly and PRN with the goal to identify potential risk of causing harm to others. A hard copy master list of resident population identifying residents with a history of being aggressive toward other residents and residents, who are targets, will be kept in the Alert book at each nurse station. The master list will be audited and updated by the 15th of each month by the RCM and/or designee. Nursing staff will be in-serviced by Staff Development Nurse to refrain from using profanity, to act in a professional and positive manner, to not react in a negative manner or with gestures and facial expressions that might be taken as negative or disrespectful or threaten bodily harm, even in a joking manner. Nursing staff will be in-serviced by Staff Development Nurse to the master list of residents with a history of aggression toward other residents and residents with a history of being targeted by the residents with a history of aggression toward other residents and to refer to resident care plans for acceptable interventions. 3. What measures will be put in place or what systemic changes will be made to ensure that deficient practice does not recur. Resident Care Managers (RCM) will assess each resident quarterly using the aggression assessment tool (UDA) in accordance with previous Plan of Correction of 2021 and as scheduled upon admission, within 72 hours of admission, 30 days after admission, quarterly and PRN. RCMs will utilize the findings in the aggression assessment and behaviors noted when resident mood is identified as aggressive to update residents care plans with resident behaviors and interventions. A new system to notify nursing staff of residents identified as being aggressive towards other residents has been implemented as follows: A hard copy master list of resident population identifying residents with a history of being aggressive toward other residents and residents, who are targets, will be kept in the Alert book at each Nurse station. This master list will be audited and updated by the 15h of each month by the RCM and/or designee. Nursing staff will be in-serviced by Staff Development Nurse to refrain from using profanity, to act in a professional and positive manner, to not react in a negative manner or with gestures and facial expressions that might be taken as negative or disrespectful or threaten bodily harm, even in a joking manner. Nursing staff will be in-serviced by Staff Development Nurse to the master list of residents with a history of aggression toward other residents and residents with a history of being targeted by the residents with a history of aggression toward other residents and to refer to resident care plans for acceptable interventions. Audit tool has been created. 4. How corrective actions will be monitored to ensure deficient practice will not recur, i.e., what quality assurance program will be put in place. Administrative Staff and/or designee staff will conduct random weekly observation and interview audits to ensure staff understand staff to resident abuse, resident to resident abuse, the master list system and the care plan system. A hard copy master list of resident population identifying residents with a history of being aggressive toward other residents and residents, who are targets, will be kept in the Alert book at each Nurse station. This master list will be audited and updated by the 15h of each month by the RCM and/or designee. Results of audits will be reviewed by QAPI committee weekly and Quality Assurance Committee Quarterly until further notice as determined by QAPI/QA Committee. 5. Title of person responsible for correction of deficiency. The Director of Nursing with oversight from Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to adequately monitor resident's skin and follow physician orders for wound care for 3 of 4 sampled residents (#s 7, 21 and 25) reviewed for wound care. This placed residents at risk for new or worsening wounds. Findings include: 1. Resident 25 admitted to the facility in 3/2020 with diagnoses including dementia and diabetes. The resident's 9/9/20 Care Plan related to skin integrity indicated an intervention of "care partner to notify nursing staff of any new skin concern found when providing care or showers such as bruises, rashes, skin tears, or other skin issues." A 10/14/20 Wound Assessment revealed a right heel suspected deep tissue injury (a type of subcutaneous tissue damage from pressure) healed. A 10/16/20 Wound Assessment revealed a left heel suspected deep tissue injury also healed. A review of the resident's 11/2020, 12/2020 and 1/2021 TAR revealed nursing staff documented they applied cream to both the resident's left and right heels every morning and every evening prophylactically. No documentation was found in Resident 25's electronic medical record to indicate concerns with the resident's skin until 1/7/21. On 1/7/21 a progress note indicated the resident had a recurrence of eschar (black, leathery dead tissue) to the right heel with odor. On 8/12/21 at 9:46 AM Staff 3 (RNCM) reported when she entered Resident 25's room to assess her/his respiratory status on 1/7/21 she could tell there was an odor and observed the wound. She stated staff did not inform her of the wound. Staff 3 could not speak to how staff documented they applied cream to both of Resident 25's heels twice a day yet did not identify or report the wound. 2. Resident 21 admitted to the facility in 6/2021 for wound care of surgical wounds. The 6/15/21 Nurse to Nurse Checklist for Transition of Care revealed wound care instructions for four wounds to be completed three times per week on Monday, Wednesday and Friday. The document indicated an outside community nurse would provide the wound care on one of the days and the facility would provide the wound care on two days. A 6/18/21 physician order instructed staff to provide wound care in the mornings every Monday and Friday before the resident got out of bed. A review of the 6/2021 TAR revealed wound care was not done on Monday 6/21/21. The corresponding documentation entered at 2:01 PM revealed the day shift nurse was unable to complete on time due to time constraints and the resident transferred to her/his wheelchair prior to the nurse's availability. The documentation indicated the wound care would be provided on evening shift. Additional documentation related to the wound care at 7:15 PM on 6/21/21 revealed the wound care was not able to be completed during the nurse's shift because the resident would not transfer out of her/his chair and back into the bed. On 8/12/21 at 9:37 AM Staff 2 (Interim DNS) confirmed Resident 21 did not receive wound care on 6/21/21. , 3. Resident 7 admitted to the facility in 2017 with diagnoses including dementia. According to progress notes dated 6/26/21, Resident 7 sustained a three cm skin tear when the resident was struck with another resident's cane. The progress note indicated treatment orders were in place for the skin tear. A review of the resident's clinical record revealed no evidence of an assessment of the wound, treatment orders for the wound or consistent monitoring of the wound. During interviews on 8/5/21 and 8/6/21 Staff 1 (Administrator) acknowledged there was no assessment of Resident 7's skin tear and no evidence to indicate ongoing treatment or monitoring of the wound.

F684 Quality of Care. Facility failed to adequately monitor residents skin and follow physician orders for wound care. 1. How facility will correct deficient practice as it relates to specific residents affected. Resident #25 has been discharged. Resident #21 has been discharged. Resident #7. Any identified skin concerns will be monitored via the new system created from this plan of correction. 2. How facility will identify other residents having the potential to be affected and what corrective action will be taken. All residents are at potential risk related to this citation. A whole house skin check will occur by RCM to identify any potential new skin problems. If any new skin problems are identified, resident MD and family/guardian will be notified. Charge Nurse will conduct weekly skin checks and document completion on weekly skin check form. Completed weekly skin check form will be turned into RCM for review, assessment and if needed, continued follow up. Charge nurse will complete a risk management report for any new, significant skin problems found during weekly skin checks, will notify Physician and will update treatment administration record (TAR) with any new Physician orders received or with house, standing order if instructed by Physician. Charge Nurse will place resident on alert charting. RCM will review the skin check forms turned in by the Charge Nurse and cross check that the TAR has been updated, Physician and family/guardian have been notified and alert charting initiated. RCM will ensure the resident care plan has been updated and that skin problem is being monitored weekly until healed. RCM will audit this process weekly. The weekly skin check form will be signed by Charge Nurse and RCM when completed and scanned into the electronic chart. The hard copy completed skin check form will be kept in a binder at each nurse station to be used as a resource for staff to know what skin problems have already been identified. 3. What measures will be put in place or what systemic changes will be made to ensure that deficient practice does not recur. A weekly skin check system managed by the Charge Nurse has been implemented. The Charge Nurse will check resident skin weekly when resident receives a shower. Any new skin problems identified will be captured on a skin check form with detailed information on new open areas. Charge Nurse will sign off on TAR that weekly skin check is completed. Completed weekly skin check form will be turned into RCM for review, assessment and if needed, continued follow up. Charge nurse will complete a risk management report for any new, significant skin problems found during weekly skin checks, will notify Physician and will update treatment administration record (TAR) with any new Physician orders received or with house, standing order if instructed by Physician. Charge Nurse will place resident on alert charting. RCM will review the skin check forms turned in by the Charge Nurse and cross check that the TAR has been updated and Physician and family/guardian have been notified and resident has been placed on alert charting. RCM will ensure the resident care plan has been updated and that skin problem is being monitored weekly until healed. RCM will audit this process weekly. The weekly skin check form will be signed by Charge Nurse and RCM when completed and scanned into the electronic chart. The hard copy completed skin check form will be kept in a binder at each nurse station to be used as a resource for staff to know what skin problems have already been identified. When a resident refuses a treatment per Physician orders, the Charge Nurse will notify the Primary Care Physician (PCP) on the same day of the treatment refusal. This will allow the PCP office the option to attempt to perform the treatment themselves. Nursing staff have been in-serviced to not utilize a prior Physician order for a newly identified skin problem and to initiate a new treatment on the TAR that corresponds with the onset of the new skin problem when a Risk Management report has been initiated for a new, significant skin problem. Weekly audit form has been created for RCM weekly audit. 4. How corrective actions will be monitored to ensure deficient practice will not recur, i.e., what quality assurance program will be put in place. RCM will review the weekly skin check forms and complete assessments for any Risk Management reports initiated by Charge Nurse for new, significant skin problems found. If RCM finds in weekly review, a new significant skin problem where the Risk Management report has not been initiated, RCM will initiate this process. RCM will ensure MD and guardian/family have been notified, treatment orders are in place and care plan is followed. The weekly audit by RCM will be turned in to Director of Nursing (DNS) for review and signature. The DNS will then turn in weekly audit to Administrator for review and signature. Results of audits will be reviewed by QAPI committee weekly and Quality Assurance Committee Quarterly until further notice as determined by QAPI/QA Committee. 5. Title of person responsible for correction of deficiency. The Director of Nursing with oversight from Administrator is responsible to ensure compliance.

Based on interview and record review it was determined the facility failed to ensure residents were free from accidents for 1 of 5 residents reviewed for falls (#16). This placed residents at risk for injuries. Findings included: Resident 16 was admitted to the facility in 4/2020 with diagnoses including dementia with behaviors, liver disease and heart failure. Resident 16's Admission MDS dated 4/16/20 indicated the resident had moderate cognitive impairment and was at risk for falls. The resident was care planned for impulsive behaviors. Resident 16's care plan, updated 3/24/21, had fall interventions which included the assistance of two staff for transferring. A facility incident investigation started on 4/8/21 and concluded on 4/12/21 indicated Resident 16 fell in the bathroom on 4/8/21 while one CNA assisted the resident to transfer off the toilet to a wheelchair. The investigation concluded the fall was preventable because the care plan to provide two people for transferring was not followed. Resident 16 sustained two small abrasions from the occurrence. A Facility Report Incident dated 4/13/21 indicated on 4/8/21 Resident 16 was being assisted in the bathroom by one CNA when the resident fell to the floor. It was reported the care plan instructed two people to assist with transfers. The report concluded the resident's care plan for transfers was not followed. On 8/9/21 at 3:00 PM Staff 1 (Administrator) confirmed the fall was avoidable and the care plan was not followed.

F689 Free of Accident Hazards/Supervision/Devices. Facility failed to ensure residents were free from accidents. 1. How facility will correct deficient practice as it relates to specific residents affected. Resident #16 has been discharged. 2. How facility will identify other residents having the potential to be affected and what corrective action will be taken. All residents are at potential risk related to this citation. Restorative Nursing Assistants with Director of Nursing review and oversight, have completed re-evaluations of all residents for current, appropriate resident transfer status. Care plans have been updated as needed by RCM. 3. What measures will be put in place or what systemic changes will be made to ensure that deficient practice does not recur. Nursing staff have been in-serviced by Staff Development Nurse and Restorative Nursing Assistants to transfer status of resident population including residents who are Independent, 1 person assist, 2 person assist, mechanical lift (mechanical lift includes sling and sit to stand lifts and are 2 person transfers) transfers. Nursing staff have been in-serviced by Staff Development Nurse on expectations of following resident care plans. Weekly audit tool for monitoring has been created. 4. How corrective actions will be monitored to ensure deficient practice will not recur, i.e., what quality assurance program will be put in place. A weekly audit of nursing staff knowledge of education received on transfer status of residents will be conducted by DNS, RCM, SDC or designated Charge Nurse. Results of audits will be reviewed by QAPI committee weekly and Quality Assurance Committee Quarterly until further notice as determined by QAPI/QA Committee. 5. Title of person responsible for correction of deficiency. The Director of Nursing with oversight from Administrator is responsible to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure the appropriate diet texture was followed for 1 of 3 sampled residents (#13) reviewed for resident safety. This placed residents at risk for choking. Findings include: Resident 13 was admitted to the facility in 8/2018 with diagnoses including Huntington's Disease (nerve cell break down in the brain) and dementia. A 9/10/19 Physician Diet Order revealed Resident 13 was ordered a pureed texture diet with thin liquids. A 9/11/2019 updated care plan indicated Resident 13 received a pureed diet, was at risk for aspiration (food or fluids in the airways), required one-person supervision at meals and assist with eating when needed. A 9/13/20 progress note revealed Resident 13 was fed a regular textured meal and choked on a piece of pasta in the soup. On 7/29/21 at 2:45 PM Staff 16 (CNA) stated she fed Resident 13 during the incident on 9/13/20, observed her/him choking and reported the incident to the nurse. On 8/4/21 at 4:19 PM Staff 3 (RNCM) confirmed the care plan for Resident 13 was not followed. An investigation was initiated and the facility identified system failures in the identification and delivery of the correct plated meal to residents. The facility created a plan of correction after the incident on 9/13/20 which included the following: *On 9/28/20 all facility staff were provided education related to dietary textures, food temperatures and care plans. *A system was implemented to daily check alert charting for diet changes, update the resident diet list and label each meal with a permanent pen with the resident's name and diet. *Dining observations on 7/29/21 confirmed the establish meal identification system was in place and accurate . *On-going weekly meal audits are completed by the Dietary Manager or Dietitian to verify meal temperatures and accurate meals are served for random residents for each meal texture prepared. Audits are reviewed by Staff 1 (Administrator) and kept in a binder.

***************************** OAR 411-085-0360 Abuse Refer to F600 ***************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ****************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689 ****************************** OAR 411-086-0250 Dietary Services Refer to F805 ******************************