Cedar Crossings

Based on observation and interview it was determined the facility failed to maintain a safe, clean and homelike environment on 1 of 1 facility and 1 of 2 resident dining rooms reviewed for environment. This placed residents at risk for tripping and living in an unkept and unhomelike environment. Findings include:

1. The facility's Homelike Environment Policy dated February 2021 outlined the following:
- Residents are provided with a safe, clean, comfortable and homelike environment.

Observations of the facility's dining rooms, hallways and resident rooms from 1/14/25 through 1/17/25 between the hours of 7:30 AM and 2:00 PM found the following issues:
-The flooring in the ECU (Enhanced Care Unit) dining room had an irregular half-circular portion of linoleum, approximately 9 inches long, 4 inches wide and 1.5 inches deep, missing on the left side of the dining room near the exit door which was a tripping hazard. In addition, there was approximately 5 feet in length of flooring with missing pieces of linoleum in the middle of the dining room. Several residents were observed ambulating independently in the dining room at all hours.
-The flooring immediately inside the ECU locked doors had an approximate 4 foot long, bubbled up and cracked section of linoleum.
-The shared television room on the ECU had large scrapes across the left wall.
-Room 41 had several black marks on the flooring in the center of the room.
-Room 43 had numerous vertical scrapes approximately 3 feet in length, along the wall across from the bed, and the door on the sink's cabinet had several scrapes approximately 1 foot in length.
-Room 46 had multiple black marks and scrapes in front of the bed nearest the door.
-The linoleum flooring in room 6 had an approximate 7 foot long crack down the center of the room.
-The wall behind the bed in room 9 had numerous scrape marks.

On 1/16/25 at 8:38 AM Staff 13 (CNA) stated the flooring in the ECU dining room was in the current condition for some time and was reported to maintenance in the past.

On 1/16/25 at 11:11 AM Staff 10 (Maintenance Director), during a facility walk-through, stated residents frequently ambulated independently in the ECU dining room and confirmed the flooring was a tripping hazard. Staff 10 reported there was no "warning" in place to notify residents of the tripping hazard. Staff 10 acknowledged the needed repairs in the identified resident rooms and shared spaces and stated it was his expectation that the facility was homelike and kept safe for all residents.

, 2. The facility's Homelike Environment Policy dated February 2021 outlined the following:
- Residents are provided with a safe, clean, comfortable and homelike environment.

Resident 68 was admitted to the facility in 11/2024 with a diagnosis of cerebral infarction (stroke).

A review of Resident 68's care plan revealed she/he only slept in her/his chair and it was her/his goal to sleep comfortably.

On 1/13/25 at 12:05 PM the temperature in Resident 68's room was cool and uncomfortably-cold air was felt blowing from the ceiling vent above her/his chair.

On 1/13/25 at 12:09 PM Resident 68 was observed sitting in her/his room in the lounge chair where she/he slept and spent most of her/his time during the day. She/he stated, "It's freezin' ass cold. And from midnight until 8:00 AM it gets even colder. The vent blows ice cold air."

On 1/16/25 at 7:36 AM Resident 68 was observed in her/his room sitting in her/his chair. She/he had multiple blankets covering her/his chest and lap. She/he wore a jacket under the blankets. The temperature in the room was observed to be uncomfortably cold and cold air blew from the ceiling vent over Resident 68's chair where she/he was seated. She/he reported, "It is always cold from midnight until about 8:00 AM. I put on extra blankets but it should be warmer in here." Resident 68 stated she/he told her/his caregivers the temperature in her/his room was too cold.

On 1/16/25 at 7:52 AM Staff 26 (CNA) confirmed Resiedent 68's room was cold and stated she adjusted the thermostat when she/he told her the room was cold. She said when she adjusted the thermostat her/his room became too warm. She reported it was difficult to regulate the temperature and said, "We try to fix it but it is hard."

On 1/16/25 at 12:30 PM Staff 10 (Maintenance Director) stated he checked the temperature in residents' rooms regularly. He reported Resident 68's room "was a little cold" and stated, "At night it gets cooler." He stated he adjusted the temperature for Resident 68 "several times" in the past three months. Staff 10 stated he planned to install locked cages covering the thermostats to prevent unauthorized individuals from changing temperatures or schedules. He added, "People try to be helpful but it can mess things up more if they change the temperature setting." Staff 10 stated, "The temperature should be comfortable all the time."

A review of Resident Grievance Forms revealed the residents in rooms near Resident 68's room also reported cold temperatures in their rooms.

On 1/17/25 at 9:40 AM Staff 2 (DNS) acknowledged the difficulty in regulating comfortable temperatures in residents' room and stated she was aware residents reported issues with their room temperatures being cool. She stated she expected temperatures to be comfortable for residents.

Based on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives for 2 of 2 sampled residents (#s 80 and 81) reviewed for hospitalizations. This placed residents at risk for lack of information regarding their options and rights. Findings include:

1. Resident 80 was admitted to the facility in 2/2024 with diagnoses including a stroke and difficulty with swallowing.

A review of Resident 80's health record revealed she/he was transferred to the hospital on 10/5/24.

No evidence was found in Resident 80's health record to indicate a transfer notice with appeal rights was provided in writing to the resident or their representative upon transfer to the hospital.

On 1/16/25 at 2:21 PM Staff 2 (DNS) stated transfer notifications with appeal rights were not being provided to residents or their representatives when they transferred to the hospital and it was her expectation that required notifications be provided to residents or their representatives when transferring to the hospital.

2. Resident 81 was admitted to the facility in 10/2024 with diagnoses including calculus (hard deposits) of the gallbladder and abdominal pain.

A review of Resident 81's health record revealed she/he was transferred to the hospital on 10/31/24.

No evidence was found in Resident 81's health record to indicate a transfer notice with appeal rights was provided in writing to the resident or their representative upon transfer to the hospital.

On 1/16/25 at 2:21 PM Staff 2 (DNS) stated transfer notifications with appeal rights were not being provided to residents or their representatives when they transferred to the hospital and it was her expectation that required notifications be provided to residents or their representatives when transferring to the hospital.

Based on interview and record review it was determined the facility failed to provide residents with a written bed hold notification, including reserved bed hold payment, at the time of transfer to the hospital for 2 of 2 sampled residents (#s 80 and 81) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include:

1. Resident 80 was admitted to the facility in 2/2024 with diagnoses including a stroke and difficulty with swallowing.

A review of Resident 80's health record revealed she/he was discharged to the hospital on 10/5/24.

No evidence was found in Resident 80's health record to indicate written notice of the facility's bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital on 10/5/24.

On 1/16/25 at 2:21 PM Staff 2 (DNS) confirmed a written bed hold policy including reserved payment was not provided to Resident 80 or their representative when the resident was transferred to the hospital on 10/5/24.

2. Resident 81 was admitted to the facility in 10/2024 with diagnoses including calculus (hard deposits) of the gallbladder and abdominal pain.

No evidence was found in Resident 81's health record to indicate written notice of the facility's bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital on 10/31/24.

On 1/16/25 at 2:21 PM Staff 2 (DNS) confirmed a written bed hold policy including reserved payment was not provided to Resident 81 or their representative when the resident was transferred to the hospital on 10/31/24.

Based on observation, interview, and record review it was determined the facility failed to provide care and treatment for 1 of 2 sampled residents (#56) reviewed for edema. This placed residents at risk for unmet needs. Findings include:

Resident 56 was admitted to the facility in 11/2024 with diagnoses including deep vein thrombosis (a blood clot that may cause pain and swelling) in the lower left leg, atrial fibrillation (an irregular, often rapid heart rate), and high blood pressure.

On 1/13/2025 at 10:37 AM, Resident 56 stated she/he had discomfort to her/his legs due to swelling. The resident was observed to have edema (swelling) in both feet. The resident stated a provider had ordered compression stockings for the edema about four weeks earlier but she/he did not receive the compression stockings. Compression stockings were not observed on her/his lower extremities.

On 1/16/25 at 12:07 PM, Staff 20 (RN) stated she was not aware of an order for compression stockings for Resident 56; however, she was able to locate an order for Tubigrip (a form of compression dressing) in a progress note dated 12/6/24.

On 1/16/25 at 1:30 PM, Staff 33 (LPN Resident Care Manager) stated the order for Tubigrip for compression had not been followed up on and was not implemented, due to an oversight.

On 1/17/25 at 12:59 PM Staff 2 (DNS) stated she expected the provider orders to be processed and implemented.

Based on observation, interview and record review it was determined the facility failed to ensure staff completed timely smoking assessments and smoking materials were stored safely for 3 of 3 sampled residents (#s 22, 50, and 60) reviewed for accidents. This placed residents at risk for accidents and smoking hazards. Findings include:

A Smoking Policy dated 8/2022 revealed the following:
-Resident smoking status is evaluated upon admission to ensure all residents are safe to smoke.
-A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff.
-No resident will be allowed to store any smoking materials in their room. All smoking material will be stored in a secured designated area (a lock box) accessible only to staff. If any smoking materials are seen on residents, please report to nurse or the social worker.
-If it is believed that residents are not compliant with locking up smoking materials and have them in their possession the IDT (interdisciplinary team) will be notified. IDT members will work with the resident to determine if smoking materials are being stored inappropriately and what interventions can be put in place to promote compliance.

1. Resident 22 was admitted to the facility in 10/2024 with diagnoses including chronic heart failure and diabetes.

A 10/23/24 Admission MDS revealed Resident 22 had a BIMS score of 13, which indicated the resident had moderate cognitive impairment.

A smoking assessment was completed on 10/25/24 and 1/13/25 which revealed Resident 22 was safe to smoke independently.

A care plan dated 6/27/24, and revised on 1/13/25, revealed Resident 22 was an independent smoker. No evidence was found indicating Resident 22's smoking materials needed to be locked up and stored safely.

Random observations from 1/13/25 through 1/17/25, revealed Resident 22 kept her/his lighter and cigarettes in her/his upper right jacket pocket, which was visible. Resident 22 was observed self-propelling in and out of the designated smoking area independently and her/his smoking materials were with her/him.

On 1/13/25 at 1:04 PM, Resident 22 stated she/he was allowed to smoke on her/his own, never turned in or locked up her/his smoking materials, and always kept them in her/his pocket.

On 1/15/25 at 10:37 AM, Staff 27 (CNA) and at 6:07 PM, Staff 28 (CNA) both stated Resident 22 was independent to smoke and did not need supervision. Staff 27 and Staff 28 stated Resident 22 did not turn in her/his smoking materials and kept them on her/him at all times. Staff 27 stated Resident 22 was supposed to keep her/his smoking materials locked up.

On 1/16/25 at 12:25 PM, Staff 2 (DNS) stated all residents who smoked were assessed upon admission, quarterly, and if a resident had a change of condition. Staff 2 stated all residents, whether supervised or unsupervised, were to keep smoking materials locked up when not out smoking.

On 1/17/25 at 1:40 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 1 stated residents who smoked were required to keep smoking materials locked up, but it was a bit challenging, and not all residents complied. Staff 1 stated that was something they continued to work on.

2. Resident 50 was admitted to the facility in 6/2024 with diagnoses including end stage kidney disease and diabetes.

A 11/24/24, Quarterly MDS revealed Resident 50 had a BIMS score of 15, which indicated the resident was cognitively intact.

A smoking assessment was completed on 9/27/24 and 1/13/25, which revealed Resident 50 was safe to smoke independently. No records were found to indicated Resident 22 had a smoking assessment upon her/his admission and the 1/13/25 quarterly smoking assessment was late.

A care plan dated 6/28/24, and revised on 12/26/24, revealed Resident 50 was an independent smoker. Resident 50 was to secure her/his smoking materials in a secure storage box.

Random observations from 1/13/25 through 1/17/25, revealed Resident 50 kept her/his lighter and cigarettes with her/him. Resident 50 was observed ambulating in and out of the designated smoking area independently and had her/his smoking materials with her/him.

On 1/13/25 at 1:04 PM, Resident 50 stated she/he was allowed to smoke on her/his own, she/he always kept her/his smoking materials with her/him, and she/he never secured them in a storage box.

On 1/14/25 at 2:40 PM, Staff 28 (CNA) stated Resident 50 was independent to smoke and the smoking materials were to be locked up. Staff 28 stated she was unsure if Resident 50 turned in her/his smoking materials.

On 1/15/25 at 5:42 AM, Staff 29 (CNA) and at 5:09 PM, Staff 30 (CMA) both stated Resident 50 was independent to smoke. Staff 29 stated she was unaware if smoking materials were to be locked up or kept with the resident. Staff 30 stated Resident 50 was supposed to keep her/his smoking materials locked up at the nurses station.

On 1/15/25 at 5:15 AM, Staff 25 (LPN) stated Resident 50 was an independent smoker, but all residents needed to be supervised. Staff 25 stated Resident 50 was supposed to keep her/his smoking materials at the nurses station, but was non-compliant.

On 1/16/25 at 12:25 PM, Staff 2 (DNS) stated all residents who smoked were assessed upon admission, quarterly, and if a resident had a change of condition. Staff 2 acknowledged Resident 50's smoking assessment was not timely. Staff 2 stated all residents, whether supervised or unsupervised, were to keep smoking materials locked up when not out smoking.

On 1/17/25 at 1:40 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 1 stated residents who smoked were required to keep smoking materials locked up, but it was a bit challenging, and not all residents complied. Staff 1 stated that was something they continued to work on.

3. Resident 60 was admitted to the facility in 8/2024 with diagnoses including schizoaffective (causing individuals to have hallucinations, embrace false beliefs, and experience depression or mania) disorder and kidney disease.

A 11/10/24 Quarterly MDS revealed Resident 60 had a BIMS score of 15, which indicated the resident was cognitively intact.

A smoking assessment was completed on 1/13/25, which revealed Resident 60 was safe to smoke independently.

A review of Resident 60's medical records revealed no care plan was initiated related to resident 60's smoking, and no initial smoking assessment was found or completed until 1/13/25.

On 1/14/25 at 2:40 PM, Staff 28 (CNA) stated Resident 60 was independent to smoke and the smoking materials were to be locked up. Staff 28 stated she was unsure if Resident 60 turned in her/his smoking materials.

On 1/14/25 at 2:33 PM, Resident 60 stated she/he was able to smoke on her/his own and family brought in her/his smoking materials. Resident 60 stated she/he did not secure any smoking materials in a secure lock box.

On 1/15/25 at 5:42 AM, Staff 29 (CNA) and at 5:09 PM, Staff 30 (CMA) both stated Resident 60 was independent to smoke. Staff 29 stated she was unaware if smoking materials were to be locked up or kept with the resident. Staff 30 stated Resident 60 was supposed to keep her/his smoking materials locked up at the nurses station.

On 1/16/25 at 8:39 AM, Staff 31 (LPN) stated Resident 60 was an independent smoker but could not speak to the current smoking policy because it was complicated and the smoking policy kept changing.

On 1/16/25 at 12:25 PM, Staff 2 (DNS) stated all residents who smoked were assessed upon admission, quarterly, and if a resident had a change of condition. Staff 2 acknowledged Resident 60's smoking assessment was not timely and there was nothing on Resident 60's care plan related to smoking. Staff 2 stated all residents, whether supervised or unsupervised, were to keep smoking materials locked up when not out smoking.

On 1/17/25 at 1:40 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 1 stated residents who smoked were required to keep smoking materials locked up, but it was a bit challenging, and not all residents complied. Staff 1 stated that was something they continued to work on.

Based on observation, interview and record review it was determined the facility failed to ensure resident respiratory services were in place and equipment was maintained for 1 of 2 sampled residents (#54) reviewed for respiratory care. This placed residents at risk for breathing complications. Findings include:

Resident 54 was admitted to the facility in 5/2024 with diagnoses including anxiety and depression.

A care plan dated 5/24/24, revealed Resident 54 had sleep apnea and utilized a CPAP/BIPAP machine. The device was to be cleaned, including the mask, tubing and head gear.

Random observations from 1/13/25 through 1/17/25 revealed Resident 54 utilized a BIPAP (a ventilator that helps people breathe by delivering pressurized air through a mask) machine adjacent to her/his bed on a nightstand. The BIPAP machine was dusty, and the tubing and mask were in a drawer covered with magazines and under a saltine cracker box.

On 1/13/25 at 8:08 AM, and 11:38 AM, and on 1/17/25 at 8:17 AM, Resident 54 stated she/he utilized a BIPAP machine at night. Resident 54 stated staff did not clean the device or ensure the BIPAP had distilled water in the machine for her/him to utilize.

A review of Resident 54's clinical record revealed no evidence of a physician's order for the use of the BIPAP machine. No evidence was found the facility staff were assisting the resident with placement or cleaning of Resident 54's BIPAP machine.

On 1/16/25 at 5:13 AM, Staff 32 (CNA), and at 7:32 AM, Staff 23 (LPN), and at 8:39 AM, Staff 31 (LPN) all stated Resident 54 had a BIPAP machine and the resident wore the device at night. Staff 31 stated night shift was responsible for cleaning the BIPAP machine. Staff 32 stated Resident 54 refused to wear the machine at times.

On 1/16/25 at 9:31 AM, Staff 3 (RNCM) entered the room and acknowledged Resident 54 had a BIPAP machine. The BIPAP device was on the nightstand, and the dispenser piece, which held the distilled water, was placed next to the BIPAP machine. Staff 3 stated it appeared the BIPAP machine seemed to have been cleaned. The tubing and mask was inside the drawer, while the machine itself was dusty, with no distilled water in the device or room. Staff 3 acknowledged she could not locate any orders for the BIPAP machine, and there was no indication the BIPAP was being cleaned appropriately.

Based on observation, interview and record review it was determined the facility failed to administer medications and ensure communication forms were completed accurately for 1 of 1 sampled resident (#50) reviewed for dialysis (a procedure which removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly). This placed residents at risk for lack of care and services, and potential medication side effects. Findings include:

Resident 50 was admitted in 6/2024 with diagnoses including end stage renal disease and diabetes.

a. A care plan dated 8/12/24 and revised on 1/17/25 revealed Resident 50 received dialysis related to renal failure. Resident 50 went out for dialysis at 5:00 AM on Tuesday, Thursday, and Saturday and returned at 2:00 PM.

A review of Resident 50's Physician Recapitulation Orders dated 12/8/24, revealed the following medications to be administered in the morning at 7:00 AM or 7:30 AM:

*Midodrine (a cardiovascular agent) 5 mg, administer every Tuesday, Thursday, and Saturday 20 minutes prior to dialysis to treat hypotension.
*Nephro-Vite Oral Tab 0.8 mg (B-Complex & Folic Acid), administer one tablet in the morning as a supplement.
*Sevelamer Carbonate (a phosphate binder) administer 800 mg three times daily for renal failure.
*Amlodipine Besylate (a calcium channel blocker), administer 10 mg for hypertension.
*Folic Acid (a B vitamin supplement), administer 400 mcg by mouth every day shift as a supplement.
*Carvedilol (a beta blocker), administer 25 mg every morning for hypertension.
*Losartan Potassium (a angiotensin receptor blocker), administer 50 mg every morning for hypertension.
*Omeprazole (a proton pump inhibitor), administer 40 mg by mouth twice times daily for heartburn.
*Prazosin (treats high blood pressure), administer 3 mg every morning for hypertension.
*Dicylomine (treats irritable bowel syndrome), administer 1 capsule by mouth.
*Metoclopramide (treats stomach problems), administer 1 tablet by mouth before meals for gastroparesis.
*Sucralfate (treats stomach problems) suspension administer 10 ml by mouth before meals for gastric protection.

A review of the MARs from 12/1/24 through 1/17/25 revealed 20 opportunities on dialysis days for Resident 50 to receive her/his medications before leaving for dialysis. There were multiple instances when the MARs indicated the resident was out of the facility and did not receive her/his medications or indicated they were administered.

On 1/15/25 at 5:15 AM, Staff 25 (LPN) stated Resident 50 attended dialysis on Tuesday, Thursday, and Saturday. The resident received an oxycodone (a pain medication) for her/his chronic pain, and did not receive any other medications until she/he returned to the facility, which was after 10:00 AM.

During a continuous observation on 1/16/25 from 5:00 AM through 5:40 AM Resident 50 was up, dressed, and stopped at the nurse's station. Staff 23 (LPN) administered a pain pill, handed Resident 50 the communication binder, and the resident sat in the front lobby until her/his ride arrived at 5:40 AM. Staff 23 stated the only medication administered to the resident prior to leaving for dialysis was the pain medication.

On 1/16/25 at 11:26 AM, Resident 50 returned from dialysis, and stated she/he went to dialysis routinely and took a pain medication prior to leaving the facility. Resident 50 stated she/he returned around lunch time and received her/his morning medications upon returning to the facility.

On 1/16/25 at 7:32 AM, Staff 23 (LPN) stated the resident only received pain medication before being sent to dialysis. Staff 23 stated the resident received her/his morning medications once she/he returned from dialysis.

On 1/16/25 at 1:28 PM, Staff 22 (LPN) stated Resident 50 did not receive her/his morning medications on dialysis days until the resident returned from the dialysis unit. Staff 22 stated this was a concern and the resident's medication times needed to be adjusted. Staff 22 stated the resident did not have any side effects due to the medications not being administered on dialysis days, to her knowledge.

On 1/17/25 at 9:51 AM, Staff 21 (CMA) stated when she arrived on shift, Resident 50 was gone for dialysis, and she saved the resident's medications until she/he returned from the dialysis center. Staff 21 stated she was told by a nurse to chart the medications as "out" or check off as administered because the medications would show late in the electronic system.

On 1/17/25 at 10:31 AM, Staff 3 (RNCM) and at 11:39 AM, Staff 2 (DNS) stated both were unaware Resident 50 did not receive her/his scheduled morning medications until after she/he returned from dialysis. Staff 3 stated staff were expected to seek clarification regarding Resident 50's medications on her/his dialysis days, and acknowledged multiple medications were either not given or received after the resident returned from dialysis.

b. A review of 15 Pre/Post Dialysis Communication forms from 12/24/24 through 1/16/25 revealed multiple instances when the dialysis forms were either inaccurate, not completed or not returned from the dialysis center.

On 1/15/25 at 5:15 AM, Staff 25 (LPN) stated Resident 50 attended dialysis on Tuesday, Thursday, and Saturday. The resident took a dialysis communication book with her/him to dialysis. Staff 25 stated the forms were to be completed and placed back in the communication book; however this did not always occur.

During a continuous observation on 1/16/25 from 5:00 AM through 5:40 AM, Resident 50 was up, dressed and stopped at the nurses station. Staff 23 (LPN) handed Resident 50 the communication binder and the resident sat in the front lobby until her/his ride arrived at 5:40 AM.

On 1/16/25 at 11:26 AM, Resident 50 was observed returning from her/his dialysis treatment and stated she/he took the communication binder prior to her/him leaving the facility on Tuesday, Thursday, and Saturday. Resident 50 returned to the facility, and the communication binder was in a basket on her/his front wheeled walker.

On 1/16/25 at 7:32 AM, Staff 23 (LPN) and at 1:28 PM, Staff 22 (LPN) both stated the communication binder forms were not always accurate or completed because they had two different forms available to use. Staff 22 stated the forms in the dialysis binder were to be transcribed and then given to medical records to upload in the electronic system.

On 1/17/25 at 9:31 AM, Staff 3 (RNCM) and at 11:39 AM, Staff 2 (DNS), both acknowledged the Dialysis Communication Forms were inaccurate. Staff 2 stated staff were expected to complete the dialysis form in the electronic system, print it out, and place the form in the dialysis communication binder. Staff were to ensure all information was compete and accurate.

Based on interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 5 of 9 sampled residents (#s 2, 8, 22, 26 and 57) reviewed for call light wait times and staffing. This placed residents at risk for lack of ADL care needs. Findings include:

a. Resident 26 was admitted to the facility in 2/2023 with diagnoses including morbid obesity and diabetes.

On 1/13/25 at 10:34 AM, Resident 26 stated call light response times took 45 minutes. Resident 26 stated she/he needed assistance with ADL care.

Resident 26's call light response logs from 1/1/25 through 1/14/25 revealed six times when the the response time was 16 to 30 minutes, and six times when the response time was greater than 30 minutes.

b. Resident 22 was admitted to the facility in 10/2024 with diagnoses including morbid obesity and right leg lower amputation.

On 1/13/25 at 1:00 PM, Resident 22 stated she/he needed assistance to change her/his brief and staff could take 30 minutes or up to an hour to respond to her/his call light. Resident 22 stated she/he sat in a wet and soiled brief on more than one occasion due to long call light response times.

Resident 22's call light response logs from 12/24/25 through 1/13/25 revealed seven times when the the response time was 16 to 30 minutes, and three times when the response time was greater than 30 minutes.

c. Resident 57 was admitted to the facility in 7/2024 with diagnoses including lung and brain cancer.

On 1/13/25 at 3:53 PM, Witness 3 (Complainant) stated Resident 57's call light was activated for 30 minutes or longer before the resident received assistance; and that happened on more than one occasion. Witness 3 stated the resident attempted to remove her/his own brief due to long call light response times.

Resident 57's call light response logs from 11/20/24 through 1/7/25 revealed six times when the the response time was 16 to 30 minutes.

d. Resident 2 was admitted to the facility in 4/2022 with diagnoses including diabetes.

On 1/14/25 at 10:30 AM, Resident 2 stated call light response times were long and she/he was not always changed timely. Resident 2 stated staff turned her/his call light off and indicated they would be back but did not return.

Resident 2's call light response logs from 12/24/25 through 1/13/25 revealed 16 times when the the response time was 16 to 30 minutes, and three times when the response time was greater than 30 minutes.

e. Resident 8 was admitted to the facility in 5/2024 with diagnoses including morbid obesity and diabetes.

On 1/14/25 at 10:48 AM, Resident 8 stated call light response times were excessively long; sometimes over two hours.

Resident 8's call light response logs from 12/24/25 through 1/13/25 revealed 17 times when the the response time was 16 to 30 minutes, and 10 times when the response time was greater than 30 minutes.

f. Interviews with staff revealed the following:
-On 1/14/24 at 2:50 PM, Staff 28 (CNA) stated call light response times were longer when the facility was short staffed, which occurred, on occasion.

-On 1/15/25 at 5:40 PM, Staff 38 (CNA) stated call light response times were longer to answer when the facility was short staffed which occurred occasionally. Staff 38 stated not all staff assisted with answering call lights.

-On 1/17/25 at 10:41 AM, Staff 39 (CNA) stated call light response times could be greater than 20 minutes when the facility was short staffed.

On 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated staff were expected to answer call lights under 20 minutes and all staff were responsible for answering call lights. Staff 1 and Staff 2 acknowledged the long call light response times for residents 2, 8, 22, 26 and 57.

g. A review of the facility's Direct Care Staff Daily Reports from 11/15/24 through 1/12/25 revealed the facility did not meet mandatory state minimum CNA ratios for one or more shifts on the following dates:

12/12/24: Day shift.
12/18/24: Day shift.
12/22/24: Day shift.
12/24/24: Day shift.
12/26/24: Day shift.
12/29/24: Day shift.
12/30/24: Day shift.

On 1/16/25 at 12:51 PM, Staff 7 (Staffing Coordinator) stated at times it was difficult to cover shifts, especially when staff called at the last moment. Staff 7 stated she tried her best to ensure the facility met the state CNA minimum ratio.

On 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 and Staff 2 acknowledged the above dates and stated the facility struggled at times meeting the state CNA minimum ratios.

h. A list was provided from 11/2024 through 1/2025, which revealed the facility fluctuated between four to five bariatric residents.

Review of the Direct Care Staff Daily Reports from 11/15/24 through 1/12/25 revealed the following dates when state bariatric staffing ratios were not met:

12/16/24: Day shift and Evening shift.
12/17/24: Day shift.
12/18/24: Day shift.
12/20/24: Day shift and Evening shift.
12/21/24: Evening shift.
12/22/24: Day shift.
12/24/24: Day shift and Evening shift.
12/25/24 Day shift.
12/26/24: Day shift.
12/28/24: Day shift and Evening shift.
12/29/24: Day shift.
12/30/24: Day shift.
12/31/24: Day shift.
1/1/25: Day shift and Evening shift.

On 1/16/25 at 12:51 PM, Staff 7 (Staffing Coordinator) stated at times it was difficult to cover shifts, especially when staff called at the last moment. Staff 7 stated she tried her best to ensure the facility meets the state bariatric minimum ratio but was not always successful.

On 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 and Staff 2 acknowledged the lack of coverage regarding the 14 days. Staff 1 and Staff 2 stated the facility struggled at times meeting the state bariatric minimum ratios.

Based on interview and record review it was determined the facility failed to ensure each CNA received annual performance reviews for 5 of 5 randomly selected CNAs (#s 14, 15, 16, 17, and 18) reviewed for staffing. This failure placed residents at risk for lack of care by competent staff. Findings include:

On 1/16/25 at 1:00 PM, Staff 2 (DNS) was asked for the annual performance reviews for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18.

A review of the personnel profile records for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18 revealed no annual performance reviews were completed.

On 1/16/25 at 1:22 PM, and 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 2 stated if there was nothing located in the personnel profile folders, the annual performance reviews were not completed. Staff 1 and Staff 2 acknowledged the annual performance reviews were not completed for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18.

Based on interview and record review it was determined the facility failed to ensure pharmacist recommendations were addressed for 1 of 5 sampled residents (#66) reviewed for unnecessary medications. This placed residents at risk for receiving ineffective or unnecessary medications. Findings include:

Resident 66 was admitted to the facility in 9/2024 with diagnoses including insomnia.

The 11/2024 Monthly Pharmacist Review of Resident 66's medication regimen revealed the following:
-On 11/27/24 the pharmacist's recommendation advised the prescriber to reassess Resident 66's Melatonin 1 mg at bedtime (helps regulate sleep) and determine if the resident would benefit from an increase to 3 mg due to Resident 66 sleeping between one and four hours per night.

Resident 66's clinical record revealed no indication the pharmacist's recommendation to increase the resident's Melatonin was addressed.

On 1/15/25 at 11:42 AM Staff 4 (RNCM) reported she did not receive any follow up to Resident 66's 11/27/24 pharmacist recommendation to increase the resident's Melatonin from 1 mg to 3 mg.

On 1/15/25 at 2:09 PM Staff 2 (DNS) confirmed the facility did not receive a response from Resident 66's provider regarding the 11/27/24 pharmacist's recommendation. Staff 2 reported the provider did not consistently respond to pharmacist recommendations which caused delays in follow up.

Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were secured and not expired for 3 of 4 medication carts reviewed for medication storage. This placed residents at risk for adverse medication effects. Findings include:

The facility's Storage of Medication Policy, dated November 2020, states the facility drugs and biologicals will be stored in locked compartments, drugs with missing, incomplete, improper, or incorrect labels would be returned to the pharmacy, and discontinued or outdated drugs would be returned or destroyed.

On 1/15/25 at 5:26 AM, during an observation of the Milo Hall diabetic/treatment cart assisted by Staff 23 (LPN) the following items were identified:

-Naloxone Nasal Spray Pharmacy Label had an expiration date of 12/12/24.
-Lantus (Glargine) insulin vial was opened. No open date was written on the supplied label. The pharmacy fill date was 11/11/24. This type of insulin had a 28-day use by date after opening.
-An unlabeled and opened bottle of insulin was found in a plastic cup in the cart with a resident name on it. There was no opened date on the vial.
-A Humulin Kwik Pen was found, it was unlabeled. The open date written on the pen was 11/05. This type of insulin had a 28-day use by date after opening.
-An unlabeled tube of Solosite Wound Treatment Gel with an expiration date 1/1/2025.

On 1/17/25 at 8:12 AM, The Hayden Hall medication cart was observed outside of the dining room, unlocked and unattended. Several staff members and a resident walked past the unlocked cart. At 8:24 AM Staff 5 (LPN Resident Care Manager) acknowledged the medication cart was unlocked and was to be secured when not in use.

On 1/17/25 at 8:30 AM, a review of the medication cart on Hayden Hall revealed a medication storage card containing Lorazepam 1 mg tablets for a resident who no longer had an order for the medication and three loose tablets of an unknown ingredient found in the bottom of the medication drawer. Staff 5 confirmed the medications should have been destroyed.

On 1/17/25 at 8:37 AM, an observation of the diabetic/treatment cart on Hayden Hall revealed multiple opened medicated creams and ointments with no opened dates written on the provided labels. Staff 5 was uncertain if open dates were required.

On 1/17/25 at 12:59 PM, during a review of the findings with Staff 2 (DNS), she stated she expected staff to properly store, label and destroy medications and biologicals according to the facility policy.

Based on observation, interview and record review it was determined the facility failed to provide dental services for 1 of 1 sampled resident (#36) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include:

Resident 36 was admitted to the facility in 1/2024 with diagnoses including dysphagia (inability to chew and swallow safely) and pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit.

A review of Resident 36's 11/9/24 Significant Change MDS revealed she/he had severe cognitive impairment, her/his own teeth that were not broken or decayed, did not wear dentures and required substantial to maximal physical assistance to perform oral hygiene.

A review of Resident 36's clinical record revealed no indication the resident was seen by a dentist since admission to the facility.

On 1/13/25 at 12:27 PM and 1/14/25 at 2:14 PM Resident 36 was observed to have jagged, broken and decayed teeth. She/he also had thick accumulations of oral secretions on her/his teeth and gums.

On 1/14/25 at 8:59 AM Witness 1 (Family Member) stated he noticed "a lot of buildup" on Resident 36's teeth. He also stated he thought the caregivers swabbed Resident 36's teeth rather than brushing them. He reported he told facility staff Resident 36 needed dental care but it was not provided.

On 1/17/25 at 8:23 AM Staff 19 (CNA) stated she swabbed Resident 36's teeth but did not use the sponge toothbrush much because Resident 36 was at risk of choking.

On 1/17/25 at 8:30 AM Staff 20 (RN) stated the caregivers tried to clean Resident 36's mouth but she never looked at her/his teeth closely. She also reported the last time a dentist visited the facility was "about a week ago" and stated the dentist did not see Resident 36.

On 1/17/25 at 9:32 AM Staff 2 (DNS) confirmed Resident 36's 11/9/24 MDS was inaccurate and she/he needed dental care. She added she expected dental needs to be identified timely.

Based on observation, interview and record review it was determined the facility failed to ensure waste was properly contained in dumpsters and the garbage storage area was maintained in a sanitary condition for 1 of 1 garbage area reviewed for kitchen sanitation. This placed residents at risk for potential exposure to pathogens related to the harborage and feeding of pests. Findings include:

The facility's Food-Related Garbage and Refuse Disposal Policy dated October 2017 outlined the following:
- Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests.
- Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

On 1/13/25 at 9:15 AM the outside dumpsters adjacent to the kitchen door to the parking lot were observed to be uncovered with garbage bags full of kitchen and resident care waste spilling over and covering the ground around the dumpsters. A minimum of 20 bags of garbage were piled on the ground in the parking lot in front of the dumpsters.

On 1/13/25 at 9:36 AM Staff 9 (Dietary Manager) acknowledged the garbage was on the ground rather than in the bins with the lids closed. She stated the garbage collection usually occured three times each week and the garbage overflowing the dumpsters accumulated since the previous week. She reported an additional dumpster was ordered to contain the additional garbage because the facility's garbage needed to be contained in closed dumpsters.

On 1/16/25 at 3:03 PM Staff 10 (Maintenance Director) stated he expected the facility's garbage to be contained within the dumpsters provided and an additional dumpster was being used to contain all of the garbage. He confirmed the facility's policy to maintain the area around the dumpsters clear of garbage bags and debris to limit its accessibility to pests. He stated staff was educated regarding the importance of keeping the garbage in the dumpsters with the lids closed and added the facility also had a tall bin to serve as an overflow dumpster.

On 1/17/25 at 9:40 AM Staff 2 (DNS) stated she expected the facility's garbage to be contained in the dumpsters.

2. Resident 49 was admitted to the facility in 12/2024 with diagnoses including chronic obstructive pulmonary disease.

A physician order from 12/20/24 included Resident 49 was to have a Foley catheter to assist with bladder elimination.

On 1/13/25 at 10:49 AM Resident 49 was observed in her/his room. Resident 49 was observed to have a catheter. No instructions regarding enhanced barrier precautions were observed outside of Resident 49's room.

On 1/13/25 at 12:15 PM Staff 41 (CNA) was observed entering and exiting Resident 49's room. Staff 41 stated they were providing hands on care to Resident 49 which included a brief change. Staff 41 stated gloves were worn but no additional PPE was worn when providing hands on care for Resident 49.

On 1/16/25 at 8:51 AM Staff 8 (Infection Preventionist) stated enhanced barrier precautions were to be followed when hands on care was provided to Resident 49 due to her/him having a Foley catheter. Staff 8 confirmed enhanced barrier precautions were not followed as required for Resident 49.

On 1/16/25 at 9:08 AM Staff 1 (Administrator) confirmed enhanced barrier precautions were to be followed with Resident 49 due to the use of a Foley catheter.



, Based on observation, interview and record review it was determined the facility failed to follow infection control practices for 2 of 4 sampled residents (#s 36 and 49) reviewed for infection control. This placed residents at risk for cross contamination. Findings include:

1. Resident 36 was admitted to the facility in 1/2024 with diagnoses including dysphagia (inability to chew and swallow safely) and pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit.

A review of Resident 36's 11/9/24 Significant Change MDS revealed she/he had severe cognitive impairment and required substantial to maximal physical assistance to complete toileting hygiene.

Resident 36's care plan and signed physician's orders indicated staff were to follow enhanced barrier precautions when providing her/him care that involved physical contact.

A sign posted on the outside of Resident 36's room outlined the following information and guidance:
- Everyone must clean their hands, including before entering and when leaving the room.
- Providers and staff must also wear gloves and a gown for changing linens, providing hygiene and changing briefs or assisting with toileting.

On 1/15/25 at 10:39 AM Resident 36 was observed to walk to the door of her/his room wearing a T-shirt and a brief. The brief was visibly soiled with a bowel movement. Staff 20 (RN) approached Resident 36 and accompanied her/him back to her/his bed. Staff 20 drew the curtain closed around the bed, exited the room and called for CNA assistance.

On 1/15/25 at 10:49 AM Staff 35 (CNA) entered Resident 36's room without donning a mask or gown from the PPE kit positioned in the hallway outside of Resident 36's room. Staff 35 performed hand hygiene and closed the door.

On 1/15/25 at 11:10 AM Staff 35 exited Resident 36's room. He reported he provided toileting hygiene assistance by changing her/his brief. He also stated he cleaned and changed "anything that could have been soiled including the sheets and [her/his] pillow case." Staff 35 stated he did not wear a gown to provide these cares but reported, "Normally I totally would wear a gown and gloves when doing it for him."

On 1/15/25 at 11:12 AM Staff 20 stated she expected all staff who provided hands-on care for Resident 36 to follow enhanced barrier precautions because she/he has a PEG tube (a feeding tube that is surgically inserted through the skin and stomach wall into the stomach).

On 1/17/25 at 9:45 AM Staff 2 (DNS) stated she expected staff to follow enhanced barrier precautions when providing any cares that could result in exposure to Resident 36's PEG tube.

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 5 of 5 randomly selected staff members (#s 14, 15, 16, 17, and 18) reviewed for in-service training. This placed residents at risk for lack of competent staff. Findings include:

On 1/16/25 at 1:00 PM, Staff 2 (DNS) was asked for a list of training hours for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18.

A review of the personal profile records for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18 revealed no training hours were completed.

On 1/16/25 at 1:22 PM, and 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 2 stated if there was nothing located in the personal profile folders, the 12 hours of in-service training annually was not completed. Staff 1 and Staff 2 acknowledged the 12 hour in-service training were not completed for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 7 of 59 sampled days reviewed for sufficient staffing. This placed residents at risk for delayed treatment. Findings include:

A review of the facility's Direct Care Staff Daily Reports from 11/15/24 through 1/12/25 revealed the facility did not meet mandatory state minimum CNA ratios for one or more shifts on the following dates:

12/12/24: Day shift.
12/18/24: Day shift.
12/22/24: Day shift.
12/24/24: Day shift.
12/26/24: Day shift.
12/29/24: Day shift.
12/30/24: Day shift.

On 1/16/25 at 12:51 PM, Staff 7 (Staffing Coordinator) stated at times it was difficult to cover shifts, especially when staff called at the last moment. Staff 7 stated she tried her best to ensure the facility met the state CNA minimum ratio.

On 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 and Staff 2 acknowledged the above dates and stated the facility struggled at times meeting the state CNA minimum ratios.

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing requirements were maintained for 14 of 59 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

A list was provided from 11/2024 through 1/2025, which revealed the facility fluctuated between four to five bariatric residents.

Review of the Direct Care Staff Daily Reports from 11/15/24 through 1/12/25 revealed the following dates when state bariatric staffing ratios were not met:

12/16/24: Day shift and Evening shift.
12/17/24: Day shift.
12/18/24: Day shift.
12/20/24: Day shift and Evening shift.
12/21/24: Evening shift.
12/22/24: Day shift.
12/24/24: Day shift and Evening shift.
12/25/24 Day shift.
12/26/24: Day shift.
12/28/24: Day shift and Evening shift.
12/29/24: Day shift.
12/30/24: Day shift.
12/31/24: Day shift.
1/1/25: Day shift and Evening shift.

On 1/16/25 at 12:51 PM, Staff 7 (Staffing Coordinator) stated at times it was difficult to cover shifts, especially when staff called at the last moment. Staff 7 stated she tried her best to ensure the facility meets the state bariatric minimum ratio but was not always successful.

On 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 and Staff 2 acknowledged the lack of coverage regarding the 14 days. Staff 1 and Staff 2 stated the facility struggled at times meeting the state bariatric minimum ratios.

OAR-411-087-0100: Physical Environment: Generally (housekeeping/maintenance)

Refer to F584
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OAR-411-088-0080: Notice Requirements

Refer to F623
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OAR-411-088-0060: Right to Readmission

Refer to F625
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OAR-411-086-0110: Nursing Services: Resident Care

Refer to F684, F695, F698
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OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care Smoking

Refer to F689
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OAR-411-086-0100: Nursing Services: Staffing

Refer to F725
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OAR-411-086-0310: Employee Orientation and In-Service Training

Refer to F730
********************
OAR-411-086-0260: Pharmaceutical Services

Refer to F756 and F761
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OAR-411-086-0210: Dental Services

Refer to F791
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OAR-411-086-0250: Dietary Services

Refer to F814
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OAR-411-086-0330: Infection Control and Universal Precautions

Refer to F880
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OAR-411-086-0310: Emplyoee Orientation and In-Service Training

Refer to F947
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Based on interview and record review it was determined the facility failed to provide bed rails needed for bed mobility for 1 of 3 sampled resident (#11) reviewed for environment. This placed residents at risk of ADL decline. Findings include:

Resident 11 admitted to the facility in 5/17/24, with diagnoses including chronic kidney disease with dialysis.

The Admission MDS dated 5/21/24 revealed Resident 11 had a BIMS score of 15, which indicated the resident was cognitively intact and required moderate assist with bed mobility.

A 6/28/24 public complaint indicated Resident 11 had requested bed rails to assist with bed mobility. Resident 11 had to use the headboard to reposition herself/himself in bed, and waited a couple of weeks to have bed rails placed on her/his bed.

A 5/17/24 nursing admission note indicated the Resident 11 requested side rails (bed rails).

A 5/29/24 Resident Grievance Form filed by Resident 11 revealed the resident wanted bed rails.

On 10/1/24 at 12:44 PM, Staff 9 (LPN) stated he recalled Resident 11 requested bed rails for bed mobility at the time of admission. Staff 9 stated he completed an assessment for the bed rails and requested an order from the physician.

On 10/1/24 at 2:22 PM, Staff 2 (DNS) stated a bed rail assessment was not completed for Resident 11. Staff 2 stated a physician order for the bed rail was started on 5/29/24.

On 10/1/24 at 2:40 PM, Staff 1 (Administrator) stated it was her expectation that if a resident requested bed rails a bed rail assessment would be completed, and a physician order would be obtained in a timely manner. Staff 1 acknowledged Resident 11 requested bed rails at the time of admission and did not receive the bed rails until 5/29/24.

Based on interview and record review it was determined the facility failed to permit a resident to return to the facility for 1 of 4 sampled residents (#9) reviewed for discharge. This placed residents at risk for being unhoused. Findings include:

Resident 9 admitted to the facility in 12/2023, with diagnoses including absence of right foot, heart failure and cocaine abuse.

The 12/27/23 Discharge Care Plan indicated Resident 9 was homeless, and stayed in her/his car or in motels.

A 3/4/24 Progress Note indicated Resident 9 was out of the facility at her/his mother's house.

A 3/5/24 Progress note indicated Resident 9 continued to be out of the facility. Staff left a voice message for a return call.

A 3/9/13 Progress Note indicated Resident 9 returned to the facility at approximately 4:30 AM and was out of the facility since 3/3/24. Staff 8 (RN) informed Resident 9 she/he was discharged per facility policy however Resident 9 went to her/his previous room and went to bed. Staff 8 placed a call the the on-call manager.

A 5/3/24 public complaint indicated upon Resident 9's return to the facility, she/he found her/his belongings locked up and was informed she/he was discharged as AMA (against medical advice). The complaint further alleged the resident was escorted out of the facility.

On 9/27/24 at 12:15 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated per review of Resident 9's documentation, Resident 9 was discharged AMA when she/he did not return to the facility when expected. Staff 1 verified the facility did not permit Resident 9 to return to the facility after she/he was late arriving from her/his therapeutic leave.

On 9/30/24 at 12:01 PM, Staff 3 (Previous Administrator) stated he was unable to recall the event.

On 9/30/24 at 12:34 PM, Staff 8 (RN) stated she was unable to recall the event.

Based on interview and record review it was determined the facility failed to ensure meals were provided for a discharge for 1 of 3 sampled residents (#5) reviewed for discharge. This placed residents at risk for unsafe discharge. Findings include:

Resident 5 admitted to the facility in 12/2023, with diagnoses including hypertension. Resident 5 discharged from the facility on 1/11/24.

The 1/10/24 Discharge Instructions indicated Resident 5 was to be discharged to another state on 1/11/24. There was no indication a meal was ordered or provided for the resident for the extended transport.

On 1/23/24 Witness 5 indicated Resident 5 was discharged from the facility and was transported to a nursing facility in another state.

The Progress notes revealed Resident 5 discharged from the facility on 1/11/24 at 10:15 AM and was expected to arrive at the new facility at 5:30 PM.

On 10/3/24 at 10:14 AM, Staff 10 (CNA) stated she observed Resident 5 discharge on 1/11/24. Staff 10 stated the resident was sent out by medical transport and a meal was not provided for the transport.

On 10/3/24 at 10:33 AM, Staff 1 (Administrator) acknowledged staff did not send a meal with Resident 5 for the extended transport to another state upon discharge.

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OAR 411-086-0360 - Resident Furnishings, Equipment

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

Refer to F660
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OAR 411-088-0060 - Right to Readmission

Refer to F626
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Based on interview and record review it was determined the facility failed to ensure optometry services were provided timely for 1 of 3 sampled residents (#5) reviewed for quality of care. This placed residents at risk for unmet optical needs. Findings include:

Resident 5 admitted to the facility in 3/2022 with diagnoses including congestive heart failure and diabetes mellitus.

Resident 5's initial care plan dated 4/5/22 revealed she/he had cataracts in both eyes. Interventions listed were to refer Resident 5 for an eye exam.

Resident 5's Admission MDS dated 4/7/22 revealed a CAA for visual function was triggered for cataracts.

A 6/17/23 progress note revealed Staff 13 (SSD) had spoken to Resident 5 about scheduling a vision appointment. There was no documentation any appointments were made by Staff 13.

On 7/9/24 at 1:59 PM, Resident 5 stated she/he made requests for an eye exam since she/he admitted to the facility but the facility did not schedule any opthamology appointments until recently.

On 7/17/24 at 11:15 AM, Staff 5 (RCM) acknowledged the facility had not made a timely vision appointment for Resident 5 after her/his admission to the facility.

Based on observation, interview and record review review it was determined the facility failed to ensure routine dental services were provided for 1 of 3 sampled residents (#5) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include:

Resident 5 admitted to the facility in 3/2022 with diagnoses including congestive heart failure and diabetes mellitus.

Resident 5's initial care plan dated 4/5/22 revealed she/he had dental care needs related to her/his edentulous (no natural teeth or tooth fragments only) status. Interventions listed were to obtain a dental consult.

Care conference notes dated 8/19/22 revealed Resident 5 requested a dental exam.

A 6/17/23 progress note revealed Staff 13 (SSD) had spoken to Resident 5 about scheduling a dental appointment. There was no documentation any appointments were made until new orders were issued on 8/31/23.

On 7/9/24 at 1:59 PM, Resident 5 was observed to be missing most of her/his natural teeth. She/he stated she/he requested to see a dentist since she/he admitted to the facility because she/he wanted dentures, but the facility had not scheduled any dental appointments.

On 7/17/24 at 11:15 AM, Staff 5 (RCM) acknowledged the facility had not made a timely dental appointment for Resident 5 after her/his admission to the facility.

*********************************************************
OAR 411-086-0110: Nursing Services: Resident Care

Refer to F684

********************************************************

OAR 411-086-0210: Dental Services

Refer to F791

*********************************************************

Based on interview and record review it was determined the facility failed to re-evaluate elopement risks and modify care plan interventions after ongoing elopement attempts and exit seeking behaviors for a resident with cognitive impairment and inability to effectively communicate her/his needs due to aphasia and CVA. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1's elopement from the facility on 6/12/24 and placed residents at risk for an unsafe elopement. Findings include:

The facility's 3/2019 Wandering and Elopement policy indicated the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The resident's care plan was to include strategies and interventions to maintain the resident's safety.

Resident 1 admitted to the facility in 4/2024, with diagnoses including stroke, dysphagia (difficulty swallowing) and aphasia (a language disorder which causes difficulty speaking).

Resident 1's 4/2024 Admission MDS: Section C - Cognitive Patterns and Section E - Behavior, revealed a BIMS score of 0, indicating severe cognitive impairment and she/he exhibited wandering behaviors one to three days during the resident's look back period of seven days.

Resident 1's Cognition CAA revealed she/he was unable to participate in the BIMS interview, experienced confusion and disorientation and the resident's care plan would address her/his cognitive deficits with the goal of preventing decline.

Resident 1's Progress Notes from 4/17/24 to 4/20/24 and on 4/24/24 revealed she/he exhibited exit seeking behaviors.

Resident 1's Provider Notes from 4/16/24 through 6/12/24 revealed the resident spoke "gibberish", was unable to remember her/his name and was an elopement risk due to her/his severe confusion, ability to independently ambulate, and exit seeking tendency.

Resident 1's care plan dated 4/22/24 revealed she/he had elopement and wandering behaviors. Interventions included: to anticipate her/his needs and wants, attempt to determine a routine while the resident was up and attempt to determine effective communication strategies.

Resident 1's SLP Therapy Note dated 6/6/24 revealed she/he had a lack of word comprehension, sentence comprehension, word finding, grammatical construction and reading levels were measured as severe due to her/his cognitive impairment.

On 6/12/24 at 10:45 AM, the facility submitted a FRI which revealed Resident 1 was last seen in the facility on 6/12/24 at 6:30 AM. At 7:45 AM, Resident 1 was not in her/his room and a search of the building and surrounding area was initiated. At 8:10 AM, the facility contacted law enforcement and reported the resident missing.

On 6/14/24 at 10:08 AM, Staff 1 (Administrator) stated the resident had not returned to the facility. Staff 1 stated as part of the investigation he had learned Resident 1 packed her/his belongings the night before, was watching the exits and was overheard by staff to state "I'm leaving." Staff 1 stated it was difficult to ascertain her/his cognitive level because the resident could not communicate and was primarily Spanish speaking. Staff 1 stated Resident 1 was care planned for elopement. Staff 1 stated he had observed Resident 1 in the parking lot on two previous occasions unsupervised and had gone outside to bring her/him back into the facility. Staff 1 stated previous elopement attempts and exit seeking behaviors by Resident 1 were not always charted by staff, which was a problem he was working on.

On 6/14/24 at 10:35 AM and 3:07 PM, Staff 3 (RCM) stated Resident 1 was exit seeking when she/he first admitted to the facility and was placed on alert charting at the time. She stated the resident was not on alert status when she/he eloped from the facility. Staff 3 stated she was only aware of one time the resident previously tried to leave the building and the resident was stopped at the front door by Staff 2 (DNS). Staff 3 stated she was not aware Resident 1 was actively exit seeking, stated the CNA's had not informed her of this and did not think the resident would try to elope. Staff 3 stated after the elopement on 6/12/24 she learned from staff Resident 1 had packed her/his bags and belongings and indicated she/he was leaving. Staff 3 acknowledged Resident 1 was not placed on alert charting.

On 6/14/24 at 11:47 AM, Staff 7 (CNA) stated she worked on Resident 1's unit on 6/12/24 but was not assigned to the resident that day. Staff 7 confirmed she had provided care for Resident 1 previously, did not know the resident was considered an elopement risk and did not recall any staff providing her information related to the resident's exit seeking behaviors.

On 6/14/24 at 12:17 PM, Staff 6 (CNA) stated on 6/12/24 she was Resident 1's CNA for day shift. Staff 6 stated she was aware the resident was an elopement risk and the resident "was constantly by the front door, side doors, trying to put the codes in (referring to the security doors) and was always pacing up and down the halls." Staff 6 stated she was not made aware by any night shift staff the resident had packed her/his bags and did not receive report when she started her shift at 6:00 AM because she could not locate the night shift CNA. Staff 6 stated she initially wasn't concerned about Resident 1's absence because the resident frequently went into a different unit to watch TV. Staff 6 stated she completed vital checks, and after about an hour went back to check on Resident 1 and was unable to locate her/him. She then checked all areas where the resident could have been, realized the resident was missing and notified another CNA and the charge nurse.

On 6/14/24 at 1:20 PM, Staff 9 (SLP) stated Resident 1 did not have the ability to let others know her/his wants and needs. She stated Resident 1 was only able to say a couple of "perseveratory phrases" but was unable to communicate any other way. Staff 9 stated Resident 1 spoke "word salad" most of the time and only could point at things such as the clock when she would check in with her/him about upcoming therapy appointments. Staff 9 stated the resident struggled with a communication board and was not able to communicate with words and spoke a combination of English and Spanish, but the communications usually did not make sense. Staff 9 stated she considered Resident 1 as cognitively impaired.

On 6/14/24 at 3:26 PM, Staff 8 (CNA) stated he was Resident 1's assigned CNA on 6/12/24 night shift. Staff 8 stated he recalled the resident went to bed around 2:00 AM and did not see the resident again until around 6:15 AM. Staff 8 stated he had not observed Resident 1 packing her/his bags the evening before the resident eloped and had not observed exit seeking behaviors. Staff 8 stated he had not given Staff 6 report when she arrived for her shift as he was providing care to another resident. Staff 8 acknowledged the resident had made statements of wanting to leave the facility when she/he first admitted.

On 6/14/24 at 3:49 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to re-evaluate elopement risk and modify care plan interventions after repeated exit seeking behaviors and elopement attempts to prevent an elopement which resulted in Resident 1's continued missing status.

On 6/14/24 at 5:45 PM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions:

-All current residents with cognitive impairment will have an elopement risk assessment completed on 6/14/24;
-Residents with an identified elopement risk will have care plans reviewed for effective interventions and updated as needed;
-Behavior monitors will be created and/or updated to reflect identified elopement risks and interventions;
-Weekly audits to be conducted of elopement risks for care plan, interventions and behavior monitor 4 times and twice a month;
-Audits will be brought to QAPI for review;
-Nursing staff were to update themselves regarding wandering protocol at the start of every shift;
-Residents with known elopement/wandering risks observed to be exit seeking would be monitored by staff, who were not to leave the resident and tell other staff to alert the charge nurse;
-Nurses were to chart any type of exit seeking behaviors;
-At the beginning of each shift, all care staff will do walking rounds and all residents must have visual checks completed by staff;
-Elopement risk assessments will be completed on admission, quarterly and with any behavioral changes.

The Plan of Correction would be completed by 5:00 PM on 6/17/24.

The IJ was removed on 6/17/24 at 12:00 PM, as confirmed by onsite verification by the survey team.

Based on interview and record review, it was determined the facility failed to develop and present a QAPI plan to the State Survey Agency (SSA) and failed to present documentation and evidence of an ongoing QAPI Program. This placed residents at risk of not receiving the care and services for optimal resident outcomes. Findings include:

A review of facility QAPI records presented by Staff 1 (Administrator) showed no evidence the facility had developed a QAPI plan. Staff 1 also acknowledged there was no ongoing QAPI program.

On 6/17/24 at 11:39 AM, Staff 1 (Administrator) acknowledged the facility had not developed a QAPI Plan.

Based on interview and record review it was determined the facility failed to have a quarterly QAA (Quality Assessment and Assurance) committee meeting and failed to include the Medical Director reviewed for quality assurance. This placed residents at risk of not receiving the care and services for optimal resident outcomes. Findings include:

A review of facility records presented by Staff 1 (Administrator) showed no evidence nor documentation the facility conducted quarterly QAA meetings and with no Medical Director involvement.

On 6/17/24 at 11:39 AM Staff 1 (Administrator) acknowledged the facility QAA committee had not met quarterly and the facility's Medical Director had no involvement.

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OAR 411-086-0140: Nursing Services - Problem
Resolution and Preventive Care

Refer to F689
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OAR 411-085-0220 - Quality Assurance

Refere to F865 & F868

Based on interview and record review, it was determined the facility failed to ensure a resident was spoken to in a dignified manner for 1 of 3 sampled residents (#2) reviewed for dignity. This placed residents at risk for decreased self-worth. Findings include:

Resident 2 was admitted to the facility in 3/2023 with diagnoses including fracture of the thoracic vertebra (spinal fracture) and anxiety disorder.

Resident 2's 4/3/23 Admission MDS identified the resident with no cognitive impairment.

Resident 2's 3/29/23 Care Plan identified the resident with a mood problem related to depression, paranoia, anxiety, and panic disorder.

A 2/27/24 Facility Investigation form indicated Resident 2 reported on 2/22/24 that Staff 10 (CNA) was witnessed being yelled at, which caused Resident 2 anxiety. Staff 10 was placed on administrative leave and upon completion of the facility's investigation was terminated.

On 3/19/24 at 12:53 PM, Resident 2 confirmed Staff 10 yelled at her/him and it made her/him anxious. Resident 2 confirmed this behavior was disrespectful and it frightened her/him. Resident 2 stated due to the level of anxiety that was experienced during the incident, she/he felt unsafe while in the facility and requested to be sent out to the hospital.

On 3/19/24 at 1:30 PM, Staff 10 confirmed the incident occurred with Resident 2 but denied all allegations of unprofessional behavior and misconduct.

On 3/22/24 at 11:41 AM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed Staff 10 did not speak to the resident in a dignified manner and Staff 10 was terminated.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services to maintain mobility with transfers for 1 of 4 sampled residents (#3) reviewed for ADL care. This placed residents at risk for unmet ADL needs. Findings include:

Resident 3 was admitted to the facility in 10/2023 with diagnoses including multiple sclerosis (a disease that damages the central nervous system) and paraplegia.

Resident 3's 10/25/23 Care Plan indicated the facility was to assist the resident with ADL's including locomotion and range of motion activities due to paraplegia that affects her/his lower extremities.

On 3/19/24 at 12:20 PM, Resident 3 stated that the facility didn't assist Resident 3 out of bed and did not provide her/him with her/his daily range of motion exercises due to lack of time the care staff had throughout the day.

On 3/19/24 at 12:40 PM, Staff 8 (CNA) confirmed care staff did not always have enough time to get Resident 3 out of bed or assist with her/his daily ADL care needs due to the number of tasks that needed to be completed throughout the day.

Observations from 3/19/24 to 3/22/24 from 10:00 AM to 4:00 PM observed Resident 3 had not received any range of motion and/or locomotion exercises.

A review of Resident 3's clinical record revealed no range of motion or ADL tasks were provided.

On 3/22/24 at 11:45 AM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 3's ADL and range of motion exercises were not provided.

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OAR 411-085-0310 Residents Rights: Generally

Refer to F557
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OAR 411-086-0110 - Nursing Services: Resident Care

Refer to F677

Based on interview and record review it was determined the facility failed to provide appropriate supervision and implement fall interventions to prevent a resident fall with injury for 1 of 5 sampled residents (#1) reviewed for accidents. This failure resulted in Resident 1 requiring hospitalization and placed all residents at risk for falls. Findings include:

Resident 1 was admitted to the facility in 2/2023 with diagnoses including congestive heart failure (chronic heart condition), Stage IV chronic kidney disease and a history of right lower leg amputation.

The facility's Personal Care Assistant Policy included the following information:

On the Floor: Personal Care Assistants will be assigned to a Mentor CNA on all shifts and work as a team to provide care to both the Personal Care Assistant's and the Mentor CNA's section.

Resident 1's 2/14/23 Admission MDS revealed a BIMS score of 15 (cognitively intact) and she/he had a fall with a fracture within the past six months prior to admission to the facility.

The 2/7/23 Care Plan indicated staff were to remind Resident 1 to use the call light for assistance and she/he required one-person extensive assist for ambulation and toileting.

A 2/7/23 Fall Risk evaluation indicated Resident 1 was at "Moderate Risk for Falling."

Resident 1's 3/2023 MAR revealed she/he received Apixaban (blood thinner) twice a day to treat atrial fibrillation (rapid heart rate).

A 3/8/23 Incident Report indicated Resident 1 fell at 5:09 PM in her/his room. The report lacked a description of how the fall occurred, whether the resident sustained any injuries or what steps were taken after the fall occurred. There was no witness statement by Staff 19 (Former Employee-PCA [Personal Care Assistant]) who was in the resident's room and witnessed the fall. The incident report included a statement by Staff 18 (Former Employee-CNA) who indicated Staff 19 told her she needed a nurse because Resident 1 fell and was on the floor. The report revealed Witness 25 (Nurse Practitioner) was notified on 3/9/23 at 9:12 AM, 16 hours after the resident's fall.

The resident's medical record did not include a fall assessment after the fall on 3/8/23.

An "Alert" progress note on 3/8/23 at 10:16 PM directed staff to "monitor for [signs and symptoms] of pain on back right sided scapula/flank [shoulder/lower back] area. Abrasion present and covered per [resident's] request to protect from rubbing on bedding."

A 3/9/23 progress note at 11:03 AM revealed Resident 1 had pain rated at "9/10" on the right side of her/his back and an abrasion with "hardness" noted when touched. The progress note indicated the resident had "dark purplish discoloration" behind her/his left knee and left upper arm with increased pain. Witness 25 (Nurse Practitioner) was notified of the resident's request to go to the ED (emergency department). Resident 1 was sent to the ED at 11:44 AM.

A 3/9/23 Hospital History and Physical revealed the following information: Resident 1 was admitted to the ED due to a fall with a hematoma (bruise that causes blood to collect and pool under the skin). The resident was diagnosed with acute blood loss from a large left chest wall hematoma sustained while on an oral blood thinner and hemorrhagic shock (injury to the body caused by internal or external bleeding)." The resident's hemoglobin (transports oxygen to body tissues) level was 6.1 (normal: 12 to 16) and her/his hematocrit (percent of red blood cells) was 20 percent (normal: 41 to 50 percent). The resident received transfusions of two units of PRBCs (packed red blood cells) in the ED and after admission to the hospital she/he received four additional units of PRBCs.

In an interview on 11/7/23 at 7:05 PM Resident 1 stated Staff 19 was the only staff in the room with her/him. The resident stated she/he told Staff 19 she/he "was wobbly" and thought she/he was going to fall and requested assistance. The resident stated she/he was in pain and concerned due to the "blood thinners" she/he was on. The resident stated the physician was not notified and nursing staff did not think she/he needed to go to the hospital. Resident 1 stated she/he was in the hospital for four weeks until discharge on 4/5/23.

During an interview on 11/9/23 at 12:24 PM Staff 20 (LPN) stated after Resident 1's fall she checked her/him for a head injury and observed an abrasion on her/his scapula that looked like a "rug burn." Staff 20 stated she did not do a fall assessment and did not recall the resident requesting to go to the hospital.

On 11/9/23 at 1:37 PM Staff 2 (DNS) stated she expected Staff 19 to get assistance for the resident for any transfers. Staff 2 acknowledged there was no fall assessment completed and Staff 25 was not notified timely after the resident's fall.

Based on interview and record review it was determined the facility failed to ensure medical records for each resident were complete for 1 of 5 sampled resident (#1) reviewed for accidents. This placed residents at risk for incomplete medical records. Findings include:

Resident 1 was admitted to the facility in 2/2023 with diagnoses including congestive heart failure (chronic heart condition), Stage IV chronic kidney disease and history of right lower leg amputation.

A 3/8/23 Incident Report indicated Resident 1 experienced a fall at 5:09 PM in her/his room.

The resident's medical record did not include a fall documentation in a progress note or a fall assessment on 3/8/23.

An "Alert" progress note on 3/8/23 at 10:16 PM (five hours after the fall) directed staff to "monitor for [signs and symptoms] of pain on back right sided scapula/flank [shoulder/lower back] area. The progress note did not indicate the resident experienced a fall.

On 11/9/23 at 12:24 PM Staff 20 (LPN) stated she checked Resident 1 after the 3/8/23 fall for a head injury and observed an abrasion on her/his scapula but did not document a fall assessment.

During an interview on 11/9/23 at 1:37 PM Staff 2 (DNS) acknowledged a fall assessment was not completed after Resident 1's fall.

Based on interview and record review it was determined the facility failed to ensure call lights were in good working order for 1 of 3 sampled residents (#3) reviewed for call lights. This placed residents at risk for unmet needs. Findings include:

Resident 7 admitted to the facility in April 2023 with diagnoses including stroke.

On 11/8/23 at 9:25 AM Witness 11 (Complainant) stated Resident 7's call light did not work and the issue was reported to staff daily until it was fixed.

A 5/1/23 Grievance Record indicated Resident 7's call light did not work for the first four days at the facility.

On 11/7/23 at 11:20 AM Staff 1 (Administrator) acknowledged Resident 7's call light did not work the first four days of her/his admission.

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OAR 411-086-0140 Nursing Services: Problem Resolution

Refer to F689
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OAR 411-086-0300 Clinical Records

Refer to F842
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OAR 411-087-0440 Electrical Systems: Alarm and Nurse Call Systems

Refer to F919
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