Marquis Tualatin Post Acute Rehab

Based on interview and record review it was determined the facility failed to prevent misappropriation of financial resources by Staff 7 (Former Agency CNA) for 1 of 1 sampled resident (#145) reviewed for misappropriation of property. This placed residents at risk for misuse of personal funds. Findings include:

The facility's 5/2010 Misappropriation of Property- Lost Items policy specified misappropriation of resident property as the patterned or deliberate exploitation of a resident's belongings or money without the resident's consent.

Resident 145 was admitted to the facility in 10/2024 with diagnoses including right femur fracture (a break in the thigh bone).

The 10/16/24 Admission MDS indicated Resident 145 was cognitively intact.

Resident 145 discharged from the facility on 11/2/24.

A 12/4/24 FRI indicated on 12/4/24 Witness 1 (Family) reported to Staff 1 (Administrator) a fraudulent check was written from Resident 145's check book while a resident at the facility. The check was made out to Staff 7 while she/he was a resident On 12/4/24 Staff 1 contacted local law enforcement, and a report was made. It was noted Staff 7 would not return to work at the facility.

The 12/10/24 facility investigation indicated Staff 7 was assigned as Resident 145's CNA on 11/3/24, 11/7/24, 11/8/24, and 11/9/24. Staff 7 was asked not to return to the facility on 11/15/24 due to declining to take care of residents in her assigned section. On 11/9/24 the fraudulent check was cashed, and it was noted Resident 145's signature was forged. The Oregon Board of Nursing was notified of Staff 7's misconduct and law enforcement was also notified. The facility investigation concluded that abuse occurred but was limited to Resident 145.

On 2/26/25 at 1:57 PM Witness 1 stated the fraudulent check was written to Staff 7 for $2,000. Witness 1 stated the signature on the check was not Resident 145's.

On 2/26/25, 2/27/25 and 2/28/25 attempts to contact Staff 7 were unsuccessful.

On 2/27/25 at 9:53 AM Resident 145 stated she/he first became aware of the fraudulent check when the monthly bank statement was received. Resident 145 stated her/his check book was kept in the nightstand drawer next to the bed at the facility. Resident 145 stated she/he never offered staff money, staff never asked her/him for money and there were no pre-signed checks in the check book. Resident 145 stated she/he did not sign the check made out to Staff 7 for $2,000.

On 2/28/25 at 9:14 AM and 10:55 AM Staff 1 acknowledged Resident 145's misappropriation of funds and indicated there were no other reports of misappropriation of property.

Based on interview and record review it was determined the facility failed to thoroughly investigate alleged misappropriation of property for 1 of 1 sampled resident (#145) reviewed for abuse. This placed residents at risk for misuse of personal funds. Findings include:

The facility's 5/2010 Misappropriation of Property- Lost Items policy specified when an incident of misappropriation of resident property was reported, the administrator would appoint a staff member to investigate the incident. The investigation would consist of the following:
-An interview with the resident.
-An interview with the employee(s) accused of taking the resident's property.
-A review of the resident's personal inventory record to determine if missing items were recorded on the report.
-Interviews with staff members (on all shifts as applicable) having contact with the resident.

Resident 145 was admitted to the facility in 10/2024 with diagnoses including right femur fracture (a break in the thigh bone).

The 10/16/24 Admission MDS indicated Resident 145 was cognitively intact.

Resident 145 discharged from the facility on 11/2/24.

A 12/4/24 FRI indicated on 12/4/24 Witness 1 (Family) reported to Staff 1 (Administrator) a fraudulent check was written from Resident 145's check book while she/he resided at the facility. The check was made out to Staff 7 (Former Agency CNA). On 12/4/24 Staff 1 contacted local law enforcement, and a report was made. It was noted Staff 7 would not return to work at the facility.

The 12/10/24 facility investigation indicated Staff 7 was assigned as Resident 145's CNA on 11/3/24, 11/7/24, 11/8/24, and 11/9/24. Staff 7 was asked not to return to the facility on 11/15/24 due to declining to take care of residents in her assigned section. On 11/9/24 the fraudulent check was cashed, and it was noted Resident 145's signature was forged. The Oregon Board of Nursing was notified of Staff 7's misconduct, law enforcement was also notified. The facility investigation concluded that abuse occurred but was limited to Resident 145.

The facility's investigation included an interview with Staff 8 (CNA) and Staff 9 (CNA) who worked with Staff 7 on several shifts and two residents who resided on the same hallway as Resident 145.

Review of the facility's 12/10/24 investigation revealed it was not thorough and did not address the following:
-An interview with the resident.
-An interview with the employee(s) accused of taking the resident's property.
-A review of the resident's personal inventory record to determine if missing items were recorded on the report.
-Interviews with staff members (on all shifts as applicable) having contact with the resident.

On 2/28/25 at 9:14 AM and 10:55 AM Staff 1 acknowledged Resident 145 and Staff 7 were not interviewed as part of the investigation. Staff 1 stated Resident 145's personal inventory record could not be found and staff members who had contact with Resident 145 were not interviewed. Staff 1 verified the facility investigation was not thorough.

Based on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 1 of 4 medication and treatment carts reviewed for safe medication storage. This placed residents at risk for unauthorized access to medications. Findings include:

The facility's 5/2010 Security of Medication Cart Policy specified the following:
-The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.
-The medication cart must be securely locked at all times when out of the nurse's view.

a. On 2/26/25 at 11:38 AM, the medication cart adjacent to the nursing station entered A-hall was unlocked and unattended. At 11:40 AM Staff 6 (RN) entered the A-hallway with a different medication and treatment cart. As Staff 6 passed by the unlocked and unattended cart she was observed to push in the lock on the cart to secure it and kept walking. Staff 6 went to a resident's room nearby and Staff 5 (RN) was observed to exit that same resident's room.

During an interview with Staff 5 and Staff 6 on 2/26/25 at 11:42 AM Staff 5 stated he did leave the medication and treatment cart unlocked and it should have been locked when he was out of sight of the cart. Staff 6 confirmed she locked the cart as she walked by.

b. On 2/26/25 at 12:29 PM, the medication cart adjacent to the nursing station on the A-hall was unlocked and unattended. At 12:31 PM Staff 5 approached the medication and treatment cart, and was observed to have pushed in the lock on the cart to secure it.

On 2/26/25 at 12:32 PM Staff 5 acknowledged he left the medication and treatment cart unlocked and was out of sight.

On 2/26/25 at 12:45 PM Staff 2 (DNS) was notified the medication and treatment cart on the A-hall was left unlocked and unattended with the contents accessible to unauthorized staff and residents on two separate occasions by the same staff member. Staff 2 acknowledged the cart was to be locked when unattended.

Based on interview and record review it was determined the facility failed to ensure minimum state CNA staffing ratios were met for 4 of 29 days and failed to ensure no more than 25 percent of the nursing assistants were uncertified nursing assistants for 15 of 29 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

a. A review of the facility's Direct Care Staff Daily Reports from 1/25/25 through 2/23/25 revealed the facility did not meet mandatory minimum CNA ratios for one or more shifts on the following dates:

-1/26/25
-2/14/25
-2/16/25
-2/18/25

On 2/26/25 at 11:51 AM Staff 3 (Staffing Coordinator) acknowledged the facility did not meet the required CNA ratio for the identified dates.

b. A review of the facility's Direct Care Staff Daily Reports from 1/25/25 through 2/23/25 revealed the facility failed to ensure no more than 25 percent of the nursing assistants were uncertified nursing assistants on the following dates:

-1/28/25
-1/29/25
-1/30/25
-2/4/25
-2/6/25
-2/7/25
-2/11/25
-2/12/25
-2/13/25
-2/14/25
-2/16/25
-2/17/25
-2/18/25
-2/19/25
-2/20/25

On 2/26/25 at 11:51 AM Staff 3 (Staffing Coordinator) acknowledged the facility did not ensure no more than 25 percent of the nursing assistants were uncertified nursing assistants for the identified dates.

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OAR 411-085-0360 Abuse

Refer to F602 and F610
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OAR 411-086-0260 Pharmaceutical Services

Refer to F761
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Based on interview and record review the facility failed to notify a resident's representative of a fall for 1 of 3 sampled residents (#1) reviewed for falls. This placed resident representatives at risk for being uninformed of resident accidents. Findings include:

Resident 1 was admitted to the facility in 11/2023 with diagnoses including BPH (benign prostatic hyperplasia) and depression.

Resident 1's Admission Record revealed Witness 15 (Family Member) was Resident 1's resident representative and emergency contact. No information was found in the clinical record to indicate Witness 15 signed paperwork as Resident 1's resident representative.

On 6/5/24 at 12:48 PM Witness 15 stated Resident 1 fell at the facility on the morning of 12/3/23, and no one from the facility contacted Witness 15 regarding the incident.

On 6/6/24 at 11:22 AM Staff 12 (LPN) stated she did not contact the family after Resident 1's fall because the resident was her/his own representative.

On 6/6/24 at 12:47 PM Staff 4 (RNCM) stated Witness 15 should have been notified of the fall if Witness 15 was Resident 1's resident representative.

On 6/7/24 at 10:15 AM Staff 3 (Admissions Director) stated she reviewed all admission paperwork with residents and family members. Staff 3 stated Witness 15 was Resident 1's resident representative. Staff 3 stated Resident 1 appointed Witness 15 to be her/his resident representative. Staff 3 stated she was present and there was a verbal agreement, but no paperwork signed during the admission process. Staff 3 stated she ensured the information was entered into the resident's medical record.

On 6/7/24 at 10:52 AM Staff 2 (Administrator) acknowledged Witness 15 was Resident 1's representative and should have been notified regarding Resident 1's fall on 12/3/23.

Refer to F689

Based on interview and record review it was determined the facility failed to ensure residents received care plan interventions for safe transfer and failed to ensure residents were monitored after a fall for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for latent injury. Findings include:

Resident 1 was admitted to the facility in 11/2023 with diagnoses including BPH (benign prostatic hyperplasia) and depression.

A review of the resident's care plan, dated 11/28/23, indicated Resident 1 required a two-person mechanical lift with transfers, wore non skid socks when out of bed, and the call light was to be within reach.

a. A Fall/Post Fall Assessment and Investigation dated 12/3/24 revealed the following:
-At 9:45 AM, Resident 1 was found on the floor next to the left side of her/his bed by Staff 12 (LPN).
-The resident was previously sitting in her/his wheelchair and Staff 12 heard Resident 1 calling for help.
-Resident 1 stated she/he became dizzy and fell forward out of the wheelchair.
-The resident was toileted at 7:00 AM and was last observed at 8:30 AM while eating breakfast. The resident received her/his medications, and was offered fluids.
-Staff 12 assessed the resident, who denied pain and her/his range of motion was within normal limits. The resident was injured with a bruise to the left side of her/his forehead. A neurological (assessing mental status and level of consciousness, pupillary response, motor strength, sensation, and gait) assessment was completed. The resident was assisted back into bed. No abuse or neglect was identified.
-The investigation indicated Resident 1 was her/his own responsible party and was marked as no requirement to notify others. The Resident Representative section was blank.

No information was found in Resident 1's clinical record to indicate she/he was monitored for latent injuries after the 12/3/23 fall.

On 6/5/24 at 12:48 PM Witness 15 (Family Member) stated Resident 1 fell at the facility on the morning of 12/3/23. Witness 15 stated the facility did not monitor the resident appropriately prior to and after the resident fell out of her/his wheelchair.

On 6/6/24 at 11:22 AM Staff 12 stated she recalled when Resident 1 fell out of her/his wheelchair due to dizziness on 12/3/24. Staff 12 stated the resident sustained a bruise to her/his left forehead. Staff 12 stated she did not contact Witness 15 but notified the physician. Staff 12 stated Resident 1 was to be placed on alert charting to monitor for latent injury, but she did not recall if this occurred or not.

On 6/6/24 at 12:47 PM Staff 4 (RNCM) stated she expected staff to place Resident 1 on 72-hour alert charting to monitor for latent injury. Staff 4 acknowledged and verified Resident 1 was not placed on alert charting from her/his fall on 12/3/24.

On 6/7/24 at 10:52 AM Staff 2 (Administrator) acknowledged Resident 1 was not placed on alert charting after the fall on 12/3/24 to monitor for latent injuries

b. On 6/5/24 at 12:48 PM, Witness 15 (Family Member) stated an incident occurred during an evening visit with Resident 1 on an unknown date. Witness 15 stated he observed two CNAs using a mechanical lift to transfer Resident 1. The CNA operating the lift was in a hurry, which caused the mechanical lift to strike Resident 1's head as the two CNAs lowered the resident into the wheelchair. Witness 15 stated the CNA guiding Resident 1's legs yelled at the other CNA to slow down, but the CNA operating the mechanical lift did not listen, which resulted in Resident 1's head being struck. Witness 15 stated after the CNAs placed Resident 1 in the wheelchair, both CNAs left the room without assessing the resident for potential injuries. Witness 15 stated Resident 1 was not a complainer, and did not call out in pain, but staff should have reported the incident to a nurse so the resident could be evaluated.

On 6/5/24 at 4:33 PM Staff 10 (Agency CNA) stated she recalled transferring Resident 1 with another CNA using a mechanical lift. The CNA operating the lift was not paying attention and moving quickly. Staff 10 stated she was guiding Resident 1's feet and hollered at the other CNA to slow down, but the CNA operating the lift did not listen, and the lift struck Resident 1 in the head. Staff 10 stated she asked Resident 1 if she/he was hurt, and the resident said she/he was not hurt. Staff 10 stated she did not report the incident to a nurse and acknowledged the incident should have been reported to rule out an injury.

On 6/6/24 at 12:47 PM Staff 4 (RNCM) stated she was unaware Resident 1 was struck in the head while being transferred with a mechanical lift. Staff 4 stated she expected staff to report any incident involving a potential injury to the charge nurse right away to ensure an assessment was completed.

On 6/7/24 at 10:52 AM Staff 2 (Administrator) acknowledged the findings and stated CNAs were to report any potential injury with a mechanical lift to a charge nurse so the resident could be assessed appropriately.

Based on interview and record review it was determined the facility failed to provide appropriate catheter care for a resident's urinary catheter for 1 of 3 sampled residents (#1) reviewed for catheter care. This placed residents at increased risk for infection. Findings include:

Resident 1 was admitted to the facility in 11/2023 with diagnoses including BPH (benign prostatic hyperplasia) and hematuria (blood in the urine).

A Nursing Admission Assessment, dated 11/28/23 at 9:19 AM, revealed Resident 1 admitted due to urosepsis (a urinary tract infection which spreads to the kidneys) with hematuria. The resident had a urinary catheter with a large amount of hematuria present. The resident was at risk for functional incontinence related to weakness, impaired mobility, and dependence on staff to meet mobility and toileting needs. Resident 1 was care planned for staff assistance with toileting, used a large brief, received daily urinary catheter care, and skilled therapy services to promote toileting safety and mobility.

A review of the resident's care plan, dated 11/28/23, indicated the presence of a urinary catheter. The care plan indicated staff were to provide catheter care with soap and water every day and were to monitor for signs and symptoms of infection.

A 12/2/23 Skilled Nursing Progress Note revealed Resident 1 was alert but disoriented, was able to follow simple instructions and cooperative with care and services. The urinary catheter was in place with adequate output. Hematuria was noted around the genital area.

A 12/5/23 Progress Note revealed at the beginning of evening shift Resident 1 had a temperature of 99.3. The resident's temperature was taken again at 6:00 PM and was 102.2. Tylenol was given, and the physician was called. Due to the resident's current symptoms and history, it was decided the resident would be sent out to the hospital for further evaluation. Resident 1 had a urinary analysis collected and the results were a high white blood cell count.

A Lab Results Report dated 12/5/23 revealed Resident 1's white blood cell count was elevated.

On 12/7/23 a public complaint was received from Witness 16 (Complainant), alleging Resident 1 arrived at the hospital on 12/5/23 with a catheter and UTI. When the catheter was removed, it was leaking and caused pain, accompanied by dark cloudy urine. Additionally, there were also sores on the resident's genitalia.

On 6/5/24 and 6/6/24 attempts were made to reach Witness 16 but were unsuccessful.

On 6/5/24 at 12:48 PM Witness 15 (Family Member) stated the facility did not provide adequate catheter care for Resident 1. Witness 15 stated the resident was sent to the hospital on 12/5/23, and hospital staff observed and reported to Witness 15 that Resident 1 had blood and discharge coming from the genitalia. Witness 15 stated hospital staff reported Resident 1 had erosion at the catheter entry point which indicated possible improper positioning of the catheter. Witness 15 stated the situation was gruesome and "upsetting."

On 6/5/24 at 2:32 PM Staff 9 (CNA) stated Resident 1 required daily catheter care to maintain cleanliness and prevent infection. Staff 9 expressed concerns that residents did not receive appropriate catheter care in 11/2023 and 12/2023. Staff 9 stated agency staff did not consistently provide appropriate ADL care.

On 6/5/24 at 4:33 PM Staff 10 (Agency CNA) stated Resident 1 had a catheter, and she emptied the catheter bag at the end of her shift but did not provide any other care related to the catheter, such as cleaning the catheter or providing peri care.

On 6/6/24 at 10:26 AM Staff 11 (CNA) stated Resident 1 was alert and oriented but had some baseline confusion. Staff 11 stated she provided catheter care and the resident's catheter, was uncomfortable and caused "tugging." Staff 11 recalled the resident had redness and blood coming out of the tip of the resident's genitalia a few times and she informed the nurse. Staff 11 stated a skin protective barrier was applied to the tender, red area. Staff 11 stated catheter care was to be performed once daily using soap and water.

On 6/6/24 at 10:46 AM Staff 7 (LPN) stated Resident 1 required catheter care provided by CNA staff. Staff 7 stated catheter care was not always provided adequately and depended on which CNAs were working. Staff 7 expressed concerns about a lack of appropriate catheter care in 11/2023 and 12/2023 due to staff unfamiliarity with the residents.

On 6/6/24 at 11:48 AM Staff 8 (LPN) stated Resident 1 was confused at baseline and admitted with a catheter and hematuria. Staff 8 stated catheter care was provided during day shift. Staff 8 stated she assumed CNAs provided catheter care and expected CNAs to review Resident 1's care plan prior to starting their shift. Staff 8 recalled Resident 1 had dried blood on the tip of her/his genitalia, and the area was red but did not appear painful. Staff 8 stated she did not remove the stat lock (stabilization device and support) to the catheter but provided the resident with a little more "slack" in the tubing that inserted into her/his genitalia. Staff 8 stated the resident was not alert enough to respond to questions.

On 6/6/24 at 12:47 PM Staff 4 (RNCM) acknowledged Resident 1 was not provided with appropriate catheter care. Staff 4 stated staff were expected to provide appropriate catheter care to residents and to report any new concerns to herself or the physician.

On 6/7/24 at 10:27 AM Staff 5 (Regional Nurse Consultant) and at 10:52 AM Staff 2 (Administrator) stated all CNA staff were expected to know and provide daily catheter care once daily with soap and water. Staff 5 stated if staff were unable to provide catheter care, they were to report to the charge nurse to ensure residents' received appropriate catheter care. Staff 2 acknowledged Resident 1 was not provided with appropriate catheter care.

OAR-411-086-0310: Nursing Services: Notification

Refer to F580
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OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care

Refer to F689 and F690
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Based on interview and record review it was determined the facility failed to ensure reference checks were completed for 5 of 5 newly hired facility staff (#s 17, 18, 19, 20, and 21). This placed residents at risk for abuse. Findings include:

A review of the facility's new hires in the past four months revealed the following:
-Staff 17 (CNA) was hired on 6/21/23.
-Staff 18 (CNA) was hired on 8/10/23.
-Staff 19 (Receptionist) was hired on 8/22/23.
-Staff 20 (LPN) was hired on 8/25/23.
-Staff 21 (Maintenance Assistant) was hired on 8/30/23.

A review of the identified staff members' personnel files revealed reference checks were not completed for Staff 17, 18, 19, 20, and 21.

On 10/4/23 at 9:21 AM Staff 16 (HR Director) and Staff 15 (HR Assistant) indicated they attempted to obtain reference checks for the identified staff members but they did not hear back from the contacts.

On 10/5/23 at 10:03 AM Staff 1 (Administrator) stated reference checks were not completed for the identified staff members.

Based on interview and record review it was determined the facility failed to inform residents, resident representatives and families by five PM the next calendar day following the occurrence of a suspected or confirmed COVID-19 infection. This placed residents, resident representatives and families at risk for not being informed of the facility's COVID-19 outbreak status. Findings include:

Review of COVID-19 Line Listing tracking records from 11/2022 revealed two staff members were found to be COVID-19 positive on 11/17/22.

Review of COVID-19 Updates notification records from 11/2022 revealed the first notification of two positive COVID-19 staff members was not sent out until 11/19/22.

On 2/1/23 at 12:37 PM Staff 1 (Administrator) confirmed a delay occurrred in notifications provided to residents, resident representatives and families of potential exposure to COVID-19.

OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F885
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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 09/12/2022 and 09/18/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an advance directive for 4 of 5 residents (#s 5, 8, 13, and 22) reviewed for advance directives. This placed residents at risk for not having their health care preferences honored. Findings include:

Records reviewed for Residents 5, 8, 13, and 22 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive.

On 8/10/22 at 10:53 AM Staff 3 (Admissions Director) stated the facility did not have a process for discussing advance directives with residents upon admission to the facility. Staff 3 was unable to provide documentation to verify residents were notified of their right to formulate an advance directive.

On 8/10/22 at 11:03 AM Staff 4 (Social Services) stated she would ask about a POLST (Physician Orders for Life Sustaining Treatment) and advance directive upon admission to the facility. Staff 4 stated she asked new admissions if they had an advance directive and if they had any questions to let her know. No documentation was found in Resident 5, 8, 13, or 22's medical records or social services notes to verify the facility offered, assisted, obtained or periodically reviewed advance directives.

On 8/10/22 at 12:27 PM Staff 1 (Administrator) stated it was her expectation for staff to go over advance directives upon admission and she would provide education to Staff 3 and Staff 4.

Based on observation and interview it was determined the facility failed to maintain a clean and homelike environment on 2 of 2 halls due to soiled, stained flooring and damaged wall surfaces reviewed for environment. This placed residents at risk of an unkempt and non-homelike environment. Findings include:

Resident 5 was admitted to the facility in 2020 with a diagnosis including dementia. Resident 5 resided in Room 125-B.

On 8/8/22 at 2:51 PM Witness 2 (Family) stated the floor in the resident's room was dirty.

Observations of 125-B's floor on 8/8/22 through 8/10/22 revealed crumb debris scattered on the floor and under the bed along with a sock, a tube of lotion, a wadded napkin and a broken handle from a coffee cup. The wall behind Resident 5's bed had exposed, crumbling plaster.

Observation on 8/11/22 at 9:47 AM revealed Resident 5's floor was swept of the crumb debris but the sock, tube of lotion, wadded napkin remained on the floor.

Observations of resident rooms on 8/8/22 through 8/12/22 identified the following:
Hall A room 105, 109, 110, 112 and 113 had stained and soiled carpet.
Hall B room 122, 126, 127, 128, 129 and 133 had stained and soiled carpet.

On 8/11/22 at 1:36 PM Staff 13 (Maintenance Assistant) stated he was aware of the exposed plaster in Room 125-B. Staff 13 stated he could not complete the wall repair while Resident 5 was in the room due to the fumes.

On 8/12/22 at 10:11 AM Staff 17 (Housekeeping Supervisor) stated housekeeping staff provide daily cleaning of resident's floors, including vacuuming and sweeping. Staff 17 stated all staff, including CNAs and nurses should pick up items off resident's floors.

On 8/12/22 at 12:39 PM Staff 1 (Administrator) stated housekeepers provided daily floor care to all residents' rooms and all staff should help keep resident rooms tidy including picking up items off resident's floors. Staff 1 acknowledged the stained and soiled carpet.

Based on interview and record review it was determined the facility failed to ensure bowel care was appropriately provided to 1 of 5 sampled residents (#17) reviewed for medications. This placed residents at risk for bowel complications. Findings include:

Resident 17 was admitted to the facility in 2021 with diagnoses including Parkinson's disease (central nervous system disorder), pancreatitis (inflammation and swelling of the pancreas) and dementia.

The 6/26/22 Annual MDS revealed the resident had a BIMS of three (severe cognitive impairment) and was incontinent of bowel with no constipation present.

The resident's 5/18/21 Care Plan lacked information regarding her/his multiple three to five day periods without having a documented BM (bowel movement).

Resident 17's medical record revealed the following PRN bowel care protocol:

-Miralax Powder (osmotic type laxative, holds water in the stool) daily every morning, or PRN bowel care for no BM (bowel movement) in 48 hours.

-Senna (stimulant laxative, increases intestinal activity) daily at HS, or PRN bowel care for no BM in 48 hours.

-Dulcolax Suppository (stimulant laxative) PRN bowel care if no BM when the Miralax or Senna are not effective within 24 hours.

-Docusate Sodium (combination of stool softener and laxative) every 24 hours PRN for bowel care.

-Tap water enema (used to stimulate a BM), if Dulcolax suppository does not yield at least medium stool results within eight hours, may repeat one time PRN for bowel care.

Resident 17's 5/2022 through 8/2022 MAR/TARs and medical record revealed the following information:

*May 2022:
5/11/22 at 10:25 PM through 5/14/22 at 9:34 PM: three days (nine shifts) without a documented BM.

5/30/22 at 4:46 AM through 6/3/22 at 1:09 PM: four days (14 shifts) without a documented BM.

Bowel care medications provided:

-Docusate Sodium:
5/11/22 at 11:07 AM, results noted as "I" (Ineffective).
5/22/22 at 11:55 AM, results note as "U" (Unknown).

-Senna:
5/15/22 at 12:02 PM, results noted as "I."
5/16/22 at 9:58 AM, results noted as "E" (Effective).
5/19/22 at 12:37 PM, results noted as "E."

*June 2022:
6/3/22 at 8:58 PM through 6/7/22 at 9:27 PM: four days (13 shifts) without a documented BM.

6/8/22 at 9:18 PM through 6/12/22 at 11:15 PM: four days (13 shifts) without a documented BM.

6/18/22 at 1:54 PM through 6/22/22 at 8:30 PM: four days (12 shifts) without a documented BM.

6/23/22 at 8:58 AM through 6/27/22 at 5:30 AM: four days (13 shifts) without a documented BM.

Bowel care medications provided:

-Docusate Sodium:
6/1/22 at 2:52 PM, results noted as "I."
6/2/22 at 8:12 PM, results noted as "I."
6/7/22 at 1:38 PM, results noted as "I."
6/21/22 at 1:25 PM, results noted as "I."
6/25/22 at 9:28 PM, results noted as "refused."
6/26/22 at 9:28 AM, results noted as "I."

-Senna:
6/2/22 at 12:15 PM, results noted as "I."
6/6/22 at 8:50 AM, results noted as "I."
6/11/22 at 8:26 AM, results noted as "I."
6/12/22 at 8:18 AM, results noted as "I."
6/21/22 at 9:56 PM, results noted as "I."
6/22/22 at 8:43 AM, results noted as "I."
6/25/22 at 8:28 AM, results noted as "I."

-Dulcolax Suppository:
6/12/22 at 7:22 PM, results noted as "U."
6/22/22 at 7:04 PM, results noted as "E."

*July 2022:
7/2/22 at 9:42 PM through 7/7/22 at 1:31 PM: five days (15 shifts) without a documented BM.

Bowel care medications provided:

-Senna:
7/5/22 at 1:22 PM, results noted as "I."
7/6/22 at 12:21 PM, results noted as "I."
7/7/22 at 1:10 PM, results noted as "I."
7/19/22 at 9:31 AM, results noted as "I."
7/20/22 at 8:49 AM, results noted as "I."

-Dulcolax Suppository:
7/6/22 at 12:27 PM, noted as resident "refused."
7/7/22 at 1:10 PM, noted as resident "refused."
7/8/22 at 6:56 PM, results noted as "U."
7/20/22 at 3:57 AM, results noted as "E."
7/25/22 at 12:10 PM, results noted as "E."

-Miralax Powder:
17 gm; PRN:
7/7/22 at 1:10 PM, results noted as "I."

*August:
8/7/22 at 8:21 PM through 8/11/22 4:38 PM: four days (12 shifts) without a documented BM.

Bowel care medications provided:

-Senna:
8/6/22 at 8:27 AM, results were documented as "E."
8/11/22 at 12:50 PM, results were documented "E."

-Miralax:
8/11/22 at 12:50 PM, results were documented as "E."

From 5/11/22 through 8/11/22 Resident 17 experienced multiple periods of three to five days without having a documented BM. The resident's PRN bowel care medications were not administered according to the physician's protocol and there was a lack of follow up provided when the medications were documented as ineffective or the results were unknown.

On 8/12/22 at 9:54 AM Staff 22 (Licensed Nurse) stated when residents have a BM it was documented in the Task system and when a resident did not have a BM it was reported to the charge nurse.

On 8/12/22 at 9:57 AM Staff 8 (LPN) acknowledged Resident 17 was not having regular BMs and required PRN bowel care. Staff 8 stated their system triggered an alert if a resident went 48 hours without a BM, so Miralax was offered and a bowel care list was generated. The bowel care list was provided to the day shift charge nurses to follow up.

In an interview on 8/12/22 at 10:10 AM Staff 7 (LPN) stated Resident 17 was on the bowel list frequently. Staff 7 indicated the senna usually worked for her/him and she/he sometimes refused the PRN bowel medications. Staff 7 stated they also tried prune juice or apple juice along with the Miralax or senna.

On 8/12/22 at 1:24 PM Staff 2 (DNS) and this surveyor reviewed Resident 17's bowel care and staff failure to follow her/his physician-order protocol. Staff 2 confirmed the resident's BMs were tracked in their system and alerted staff when PRN interventions were required. Staff 2 voiced understanding regarding Resident 17's frequent periods without BMs and the need to ensure the bowel care protocol was administered and monitored appropriately.

Based on interview and record review it was determined the facility failed to provide sufficient staffing to timely address care needs for 1 of 1 sampled residents (#8) reviewed for dental services. This placed residents at risk for unmet needs.

Resident 8 was admitted to the facility in 2020 with diagnoses including heart failure and spinal stenosis (narrowing of the spinal canal).

The 5/21/22 Quarterly MDS indicated Resident 8 was totally dependent on staff for locomotion in her/his room and required two person assistance for transfers.

The 7/2022 updated care plan revealed to observe Resident 8 for signs of fatigue when sitting in the chair.

On 8/10/22 at 10:58 AM Resident 8 stated on 6/21/22 she/he returned to the facility after an appointment during the day and a long time in her/his wheelchair. Resident 8 requested assistance to be transferred from her/his wheelchair to the bed and remained in her/his wheelchair for a total of three hours. Resident 8 stated staff informed her/him they were "short-handed" when she/he returned from the appointment and became more uncomfortable during the wait for care.

On 8/10/22 at 11:13 AM Staff 9 (CNA) recalled the event on 6/21/22 and stated Resident 8 did not like to remain in her/his wheelchair for more than 30 minutes due to pain. Staff 9 stated she was aware Resident 8 was left in her/his chair and Staff 9 worked overtime to eventually assist the CNA assigned to Resident 8's care. Staff 9 commented that residents who required two person transfers may remain for extended periods of time without timely transfers due to lack of staff or time management.

On 8/12/22 at 11:04 AM Staff 1 (Administrator) stated she expected Resident 8 should be transferred into her/his bed when she/he requested. Staff 1 also stated the CNA assigned to Resident 8's care should have sought assistance to timely transfer Resident 8 even if the CNA needed to ask the RN for the day. The Direct Care Staff Daily Report and Daily Staffing Assignment by Zone for 6/21/22 were reviewed with Staff 1 which indicated there was no RN coverage for the day and one CNA worked the designated COVID-19 unit and unavailable to assist in other units. No additional comments were provided.

Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight hours a day, seven days a week. This placed residents at risk for unmet assessment needs. Findings include:

Direct Care Staff Daily Reports on 6/21/22 and from 7/1/22 through 8/8/22 were reviewed. A RN did not provide direct resident care for seven out of the 40 days reviewed: 6/21/22, 7/4/22, 7/19/22, 7/20/22, 7/21/22, 7/26/22 and 8/7/22.

On 8/11/22 at 1:37 PM Staff 10 (Staffing Coordinator) stated he was aware there were multiple days when there was no RN coverage and policy changes to cover those shifts were in process.

On 8/12/22 at 11:04 AM Staff 1 (Administrator) acknowledged the requirement to have a RN each day.

Based on observation and interview it was determined the facility failed ensure facial hair was restrained by staff preparing food in 1 of 1 kitchen surveyed. This placed residents at risk for contaminated foods. Findings include:

On 8/8/22 at 1:09 PM Staff 16 (Dietary Manager) and Staff 15 (Cook) were observed working directly with food preparing lunches for resdents. Both staff members had beards and were not wearing beard restraints. Staff 16 confirmed he and Staff 15 should have been wearing beard restraints while working in the kitchen.

On 8/11/22 at 9:58 AM Staff 15 was observed emptying cans of beans into holding trays and did not wear a beard restraint.

On 8/11/22 at 10:04 AM Staff 16 (Dietary Manager) reported beard restraints were available to all dietary employees and confirmed Staff 15 should wear a beard restraint while working in the kitchen.

Based on interview and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing: This placed residents at risk for incomplete and inaccurate staffing information. Findings include:

A review of the Direct Care Staff Daily Reports on 6/21/22 and from 7/1/22 through 8/8/22 revealed all 120 shifts with either no or incomplete full time equivalent (FTE) number of hours worked recorded for nursing staff.

Further review of the Direct Care Staff Daily Report and Daily Staffing Assignment by Zone revealed on 6/21/22, six CNAs worked the day shift and only five CNAs were reported.

On 8/12/22 at 11:04 AM Staff 1 (Administrator) acknowledged nursing hours were not calculated and posted on the Director Care Staff Daily Reports as expected and nursing staff needed additional training to ensure the information was accurate.

OAR-411-086-0040 Admission of Residents

Refer to F578
*****
OAR-411-087-0100 Physical Environment: Generally

Refer to F584
*****
OAR-411-086-0110 Nursing Services: Resident Care

Refer to F684
*****
OAR-411-086-0100 Nursing Services: Staffing

Refer to F725 and F727
*****
OAR-411-086-0250 Dietary Services

Refer to F812
*****

Based on observation, interview, and record review it was determined the facility failed to ensure residents who chose to self-administer medications were assessed for 2 of 3 sampled residents (#s 1 and 9) reviewed for medication administration. This placed residents at risk for lack of dignity and safe medication administration. Findings include:

1. Resident 1 was admitted to the facility in 2021 with diagnoses including spinal fractures.

The 7/27/21 Care Area Assessments indicated Resident 1 was alert, oriented and able to make needs known.

A 7/31/21 Progress Note indicated Resident 1 and her/his family was upset because the resident reported Staff 11(LPN) performed a genital test on her/him. The note indicated the resident did not have an order for self-administration of medication and Staff 11 administered the prescribed medication.

The 8/2/21 Investigation indicated Resident 1 reported Staff 11 (LPN) administered her/his genital medication and she/he was tearful when describing the events.

On 9/3/21 at 12:44 PM Staff 11 indicated a CNA accompanied him when he administered Resident 1 her/his genital medication. The resident was informed prior to the administration and the resident did not request to self-administer the medication.

On 9/3/21 at 12:40 PM Staff 7 (RN) indicated she administered Resident 1 her/his genital medication on one occasion. The resident indicated she/he was able to administer the medication. The resident did not have an order to self-administer, therefore, Staff 7 observed the resident administer the medication and Staff 7 did not have concerns with the resident's ability to administer the medication.

On 9/1/21 at 1:01 PM Resident 1, with Witness 5 (Complainant) present, stated she/he administered the genital mediation without issues for multiple years. Witness 5 stated on 7/31/21 Resident 1 was very upset when Staff 11 administered the genital medication. The next day Staff 13 (Agency LPN) entered the room to administer the same medication. The resident was able to stop Staff 13 from administering the medication.

On 9/8/21 at 9:08 AM Staff 14 (RNCM) indicated Resident 1 was admitted to the facility on multiple occasions and he was familiar with her/him. In previous admissions the resident requested to self-administer the genital medication and was assessed to do so. Staff 14 acknowledged the resident reported an incident when Staff 11 administered her/his medication and it upset the resident. Staff 14 indicated he should have assessed the resident to allow her/him to administer the medication to ensure the resident did not feel compromised.

2. Resident 9 was admitted to the facility in 2021 with diagnoses including a spinal fracture.

The resident's 8/11/21 MDS indicated the resident was cognitively intact.

The 8/2020 and 9/2020 MARs revealed the resident was to be administered saline nasal spray PRN. There was no documentation to indicate the resident or staff administered the spray.

On 9/2/21 at 11:00 AM Resident 9 was observed to have a bottle of saline nasal spray on her/his bedside table. Resident 9 indicated she/he used it every night.

On 9/2/21 Staff 7 (RN) indicated if a resident was to self-administer medications the RNCM was to assess the resident to ensure the resident had the ability to administer the medications safely and the medications were stored in the resident's room in a safe manner. Staff 7 indicated the MAR did not indicate Resident 9 self administered the nasal spray and did not notice the nasal spray was in the resident's room.

On 9/2/21 at 12:55 PM Staff 14 (RNCM) indicated if a resident requested to self administer medications the resident was assessed. Resident 14 was not aware the resident had the spray at her/his bedside.

Based on interview and record review it was determined the facility failed to report an allegation of abuse within two hours for 1 of 2 sampled residents (#1) reviewed for abuse. This placed residents at risk for continued abuse. Findings include:

Resident 1 was admitted to the facility in 2021 with diagnoses including spinal fractures.

A facility Abuse Investigations policy revised on 10/15/20 revealed if an allegation involved abuse or had resulted in serious bodily injury, the facility designee in charge of the investigation would notify the state appointed reporting authority and/or ombudsman that an investigation was being conducted. This would be done no less than two (2) hours after the allegation was made, as applicable by state and federal regulations.

The 7/27/21 Care Area Assessments indicated Resident 1 was alert, oriented and able to make needs known.

A Progress Note dated 7/31/21 at 6:26 PM by Staff 11 (Agency LPN) indicated Resident 1's family came to the nurses' station and stated someone put something in the resident's genitalia, the resident's knees were up in the air and photos were taken of the resident "down there". The nurse informed the family photos were not taken and a CNA was with the nurse during the interaction with the resident. The 7/31/21 at 10:14 PM Progress Note by Staff 21 (Agency LPN) also indicated Resident 1's family voiced concern related to a genitalia procedure and photos. The 10:14 PM note further indicated Staff 15 (DNS) and Staff 16 (Administrator) were notified of "the claims" from the resident and family.

A FRI dated 8/2/21 indicated Resident 1 and Resident 1's family reported the resident was "sexually mistreated" at the facility.

The facility reported the incident two days after the allegations were made.

On 9/2/21 at 12:04 PM and 12:11 PM with Staff 15 and Staff 16, Staff 16 indicated allegations of abuse were to be reported to the state survey agency within two hours including allegations of sexual abuse. Staff 16 indicated photos of the genital region could be sexual abuse. Staff 15 acknowledged she was aware of Resident 1's 7/31/21 incident. Staff 15 felt the nursing staff communicated with the resident and family and clarified with the family the resident had a genital medication administration and the resident did not have photos taken. Staff 15 acknowledged the resident alleged photos of the genital region were reported on 7/31/21 and she did not open an investigation until 8/2/21. Staff 15 indicated on 8/2/21, two days after the incident, she spoke with Resident 1 and realized the resident was very upset. The incident was then reported to the state survey agency.

Refer to F610 for additional information.

Based on interview and record review it was determined the facility failed to ensure resident safety was maintained after an allegation of abuse was made until the investigation was completed for 1 of 2 sampled residents (#1) reviewed for abuse. This placed residents at risk for ongoing abuse. Findings include:

A facility Abuse Investigation policy last updated 8/2017 revealed if an allegation involved abuse, while the investigation was being conducted, the accused employees would be reassigned to nonresident care duties or suspended from duty until the results of the investigation were reviewed by the administrator.

Resident 1 was admitted to the facility in 2021 with diagnoses including spinal fractures.

The 7/27/21 Care Area Assessments indicated Resident 1 was alert, oriented and able to make needs known.

A Progress Notes dated 7/31/21 at 6:26 PM by Staff 11 (Agency LPN) indicated Resident 1's family came to the nurses' station and stated that someone put something in the resident's genitalia, the resident's knees were up in the air and photos were taken of the resident "down there." The nurse informed the family photos were not taken, a CNA was with the nurse during the interaction with the resident. The 7/31/21 at 10:14 PM by Staff 21 (Agency LPN) also indicated the Resident 1's family voiced concern related to a genitalia procedure and photos. The 10:14 PM also note indicated Staff 15 (DNS) and Staff 16 (Administrator) were notified of "the claims" from the resident and family.

A FRI dated 8/2/21 indicated Staff 11 (Agency LPN) and Staff 12 (CNA) were with the resident at the time of the 7/31/21 allegation of abuse. The investigation was completed on 8/2/21 at 1:00 PM.

The work schedule for Staff 12 indicated she worked the day shift on 8/2/21. Staff 12's shift started at 6:00 AM. This was seven hours before the investigation was completed.

The work schedule for Staff 11 indicated he worked 8/1/21 from 10:00 PM until 7:00 AM. This was more than 12 hours before the investigation was completed.

On 9/1/21 at 6:08 PM Staff 12 stated she immediately left the facility after she assisted Staff 11 with a genital medication administration on 7/31/21, had a few days off and then returned to work on 8/2/21.

On 9/3/21 at 12:44 PM Staff 11 stated after the 7/31/21 allegation he continued to finish his shift but was assigned to other residents and worked the next day.

On 9/2/21 at 12:04 PM and 12:11 PM with Staff 15 (DNS) with Staff 16 (Administrator) present, Staff 15 stated staff were generally removed from resident care until the investigation was completed. Staff 15 acknowledged both staff 11 and 12 worked before the investigation was completed.

Based on interview and record review it was determined the facility failed to follow physician orders timely for 1 of 3 sampled residents (#3) reviewed for labs. This placed residents at risk for undiagnosed infectious disease and delayed treatment. Findings include:

Resident 3 was admitted to the facility in 2020 with diagnoses including blood infection and surgery.

A physician order dated 9/11/20 directed staff to test Resident 3 for C-diff (a bowel infection). The order was 'noted' on 9/13/20.

A review of Resident 3's physician's orders revealed a C-diff lab order was added to the resident's TAR/orders on 9/13/20 to start on 9/14/20.

On 9/10/21 at 2:10 PM Staff 25 (LPN) stated orders that came in after she left on Friday's did not always get processed until the following Monday. Staff 25 stated the nurses on the weekend did not always look at new orders.

On 9/14/21 at 1:05 PM Staff 15 (DNS) stated the facility had a resource nurse who processed new orders and the RNCM double checked the orders. If the facility received an order when the resource nurse did not working, then the floor nurse knew to process the order right away. Staff 15 stated the facility did not call doctor's offices after resident appointments to ask if there were orders unless the facility believed there were known concerns. Staff 15 aknowledged the delay in implimentation.

Based on interview and record review it was determined the facility failed to assess a new skin injury and implement new interventions to prevent worsening of spinal pressure ulcers for 1 of 3 sampled residents (#6) reviewed for pressure ulcers. This placed residents at risk for delayed healing. Findings include:

Resident 6 was admitted to the facility 3/13/20 with diagnoses including right leg localized infection.

The 3/19/20 CAAs indicated Resident 6 was assessed to have cognitive loss and limitations in ROM. The resident had "severe" kyphosis (hunchback) and it was difficult for the resident to straighten her/his neck for a prolonged period of time. The resident required assistance with mobility. The CAAs also revealed the resident was admitted to the facility with bruises and abrasions but otherwise the skin was intact. The resident was assessed to be at mild risk for pressure injury but was at risk for delayed healing related to multiple health issues.

The Care Plan revised on 7/13/20 indicated Resident 6 required the use of bed canes and one to two staff for bed mobility. The resident was identified to be at risk for skin impairment/pressure ulcer and interventions included a pressure reduction mattress and a cushion in her/his wheelchair. Staff were also to complete weekly skin at risk assessments.

A Progress Note dated 3/17/20 indicated the resident's spine had a skin injury. The 3/18/20 note indicated the resident's spine was red.

There were no additional assessments in the resident's record on 3/17/20 and 3/18/20 to indicate if the redness or injury identified to the spine were pressure ulcers, the size of the impairment or how to prevent continued pressure or impairment to the spine.

The care plan did not include new interventions to prevent pressure to Resident 6's spine after the identification of the injury on 3/17/20 or the reddened area on 3/18/20.

The Skin Event form dated 3/22/20 indicated the resident was identified to have four Stage two pressure injuries (shallow partial thickness skin loss) to the spine. There was also one deep tissue injury (purple or maroon localized area of discolored skin due to damage of underlying soft tissue from pressure or shear) to the right hip. The impairment was identified to be deterioration of an existing impairment. The form indicated the resident had a curved spine and the skin breakdown was from constantly leaning against the bony spine and hip while in bed and the wheelchair. There were no interventions to direct staff how to ensure there was decreased pressure to the resident's spine.

The 3/22/20 photos of the spine included one pressure injury with eschar (dry dark scab). The eschar made the pressure injury unstageable (depth not able to be determined due to eschar). The eschar was not noted on the 3/22/20 Skin Event form.

The 3/22/20 right hip ulcer photo revealed a deep tissue injury with eschar to the center of the injury. The 3/22/20 Skin Event Form did not identify the right hip pressure injury to have eschar and was also unstageable.

On 9/3/21 at 10:03 AM and 9/9/21 at 3:26 PM Staff 15 (DNS) stated a skin injury would require a skin event and this was not done on 3/17/20 for Resident 6. Staff 15 acknowledged the abrasion and redness to the spine were over a bony prominence and this would indicate a pressure injury. A request was made to Staff 15 for additional assessments for the 3/17/20 and 3/18/20 skin injuries and what additional interventions were implemented to keep pressure off the resident's spine. No additional information was provided.





Based on observation, interview and record review, it was determined the facility failed to ensure a resident was assisted to turn to prevent a pressure ulcer for 1 of 3 sampled residents (#20) reviewed for pressure ulcers. This placed residents at risk for skin impairment. Findings include:

1. Resident 20 was admitted to the facility 11/9/21 after spinal neck surgery.

An 11/9/21 Nursing Admission Assessment indicated Resident 20 was alert, oriented but at times forgetful. The resident was assessed to have increased weakness to the left arm and leg and did not have full control of the left side. The resident had a Foley catheter (drains urine from the bladder) and was identified to be incontinent of bowel movements. The resident was assessed to be at risk for skin breakdown but did not have any pressure ulcers.

A care plan initiated 11/9/21 indicated the resident was at risk for skin impairment and required two staff for bed mobility, wore an incontinent brief and staff were to offer the resident a bed pan for bowel movements.

An 11/2021 Bed Mobility documentation revealed on 11/12/21 and 11/13/21, night shift, Staff 36 (CNA) documented bed mobility did not occur for Resident 20. On 11/15/21 and 11/16/21, night shift, Staff 35 (CNA) documented bed mobility for Resident 20 did not occur.

The 11/16/21 and 11/22/21 Skin and Wound Event forms revealed Resident 20 had a facility acquired incontinence associated dermatitis to the right buttock. The area was reassessed on 11/22/21 and the resident's skin condition was changed to include a stage two pressure ulcer (partial thickness skin loss) to the right buttock which was 2.3 cm by 4.4 cm and the area was also assessed to have deep tissue injury (injury to the underlying tissue below the skin's surface that results from prolonged pressure) which was 7.9 cm by 6.7 cm.

A 11/18/21 FRI with an attached investigation revealed on 11/18/21 Resident 20's family was notified the resident developed skin impairment and the family alleged the facility did not assist Resident 20 to turn. An investigation was initiated and staff interviews were conducted. The investigation revealed Staff 35 cared for the resident on the night shift from 11/14/21 through 11/16/21, the nights prior to the identification of the pressure ulcers. The morning of 11/16/21 Resident 20 was found to have dried bowel movement on her/his skin and was also identified to have skin new impairment. The investigation revealed Staff 35 reported she was not informed by the previous shift that Resident 20 required assistance to be turned, thought the resident was independent with mobility and she allowed the resident to sleep through the night. The investigation also indicated the resident was not able to tell when she/he was incontinent of bowel and Staff 35 reported she was not aware the resident could not report to staff when she/he was incontinent. The facility determined the resident was not provided repositioning or incontinence care prior to the skin impairment. A wound specialist reassessed the resident on 11/22/21.

On 11/30/21 at 11:20 AM Staff 35 acknowledged she worked with Resident 20 on 11/15/21 and 11/16/21. The resident slept during the night shift. On 11/16/21 at approximately 3:00 AM Staff 35 stated she checked on the resident with Staff 37 (CNA) and the resident was not incontinent. Staff 35 stated she placed pillows around the resident but did not turn the resident. The resident did not report pain and did not make any requests to be repositioned. Staff 35 stated if a resident was turned it was documented in the resident's electronic record. Staff 35 also stated she was not aware the resident had impaired sensation and was not cognizant when she/he had a bowel movement. Staff 35 also indicated she was not aware of all the resident's specific needs because it was not documented on the Kardex (CNA guide to resident specific care based on the care plan).

On 11/30/21 at 1:29 PM Staff 37 stated she did not work with Resident 20 and did not remember assisting Staff 35 with the resident's care.

On 11/30/21 and 12/1/21 telephone calls were placed to Staff 36 who documented Resident 20 was not reposition on 11/12/21 and 11/13/21. A return call was not received.

A 11/29/21 wound specialist report of the resident's right buttock revealed the resident's deep tissue injury on the right buttock improved with decreased area and more healthy tissue in place. The pressure ulcer was 100 % eipthelialized (new cell growth), had a scant amount of drainage, no pain and there was no sign of infection. Staff were to continue to assist the resident to reposition and offload pressure to the area.

On 11/29/21 at 10:12 AM the resident was observed in bed on an air mattress. The resident stated she/he did not have concerns with her/his care. Resident 20's dressing was changed by the wound specialist prior to this surveyor's arrival to the facility and wound observations were not able to be completed.

On 11/29/21 at 12:21 PM and 12/1/21 at 10:10 AM Staff 15 (DNS) stated after Resident 20 developed a pressure ulcer and family alleged the staff did not turn the resident, the facility initiated an investigation. Staff 35 admitted she did not assist the resident to turn during the night. Staff 15 acknowledged the residents record also indicated Staff 36 documented bed mobility did not occur on the 11/12/21 and 11/13/21 night shifts.

2. Resident 11 was admitted to the facility in 2019 with diagnoses including spinal fractures.

The 8/9/21 CAAs indicated Resident 11 had impaired cognition and had difficulty if presented with too many options. The resident had decreased safety awareness, poor judgement and was unable to follow precautions. The resident required one person for transfers and was at risk for falls.

An 8/20/21 Fall/Post Fall assessment indicated Resident 11 was found on the floor in the fetal position under her/his television on her/his right side. The resident had a baseball size blood stain on the carpet near the resident's head. The resident was not able to state how she/he fell and became aggressive when staff tried to assist the resident. The resident had a scalp laceration and reported neck pain. Contributing factors to the fall included the resident self transferred. The plan to prevent falls included the resident was to be seated in an area of high visibility for supervision and staff were to ensure the resident wore nonskid footwear.

The Care Plan was updated on 8/24/21 and indicated the resident was to sit in a highly visible area for supervision.

On 9/2/21 at 11:00 AM Resident 11 was observed to be in a wheelchair in her/his room. The resident was not visible from the doorway. A bedside table was in front of the resident with a breakfast tray. The resident wore shoes and the call light was within reach.

On 9/2/21 at 11:00 AM Staff 22 (LPN) stated when a resident was to be in a high visibility area the resident should be in the dining area or in an area in the room in which staff can visualize the resident when they walk by the room.

On 9/2/21 at 11:00 AM Staff 4 (CNA) reviewed the care plan and she indicated the resident was to be in a high visibility area when seated. Staff 4 verified the resident was not visible from the door way and repositioned the resident to where the resident's legs were visible from the doorway.

On 9/2/21 at 1:02 PM Staff 2 (RNCM) acknowledged the care plan directed staff to assist the resident to an area with high visibility when the resident sat in a chair.






, Based on observation, interview, and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety for 2 of 3 sampled residents (#s 4 and 11) reviewed for falls. Resident 4 was left unattended in the bathroom, fell off the toilet and sustained significant cranial trauma. Findings include:

1. Resident 4 admitted to the facility in 2020 with diagnoses including a neck fracture and repeated falls.

A comprehensive care plan dated 9/15/20 indicated Resident 4 required one-person constant supervision and physical assistance during toileting.

A Post Fall Assessment initiated on 9/21/20 at 11:45 AM revealed the following:

-Resident 4 had an unwitnessed fall in her/his bathroom. The resident was found lying face down on the floor, legs twisted under her/him, a hematoma (a pooling of blood under the skin) was noted to the upper left portion of the head and Resident 4 was noted to be bleeding from her/his head. Resident 4 was assisted to a seated position at which time it was noted her/his pulse was barely palpable, she/he had a rapid respiratory rate, could not support her/his own weight in a seated position and was unable to verbally respond to questions from the nurse. Resident 4 was evaluated by the house doctor and immediately sent to the hospital for evaluation.
-In the "Prevention Plan Details" it was documented that the resident was being treated in the hospital for "brain hemorrhage" (bleeding inside the brain) and it was unlikely the resident would return to this facility.

On 9/8/21 and 9/9/21 attempts were made to contact Staff 24 (Former CNA), and Staff 30 (Former CNA) who were responsible for transferring and attending Resident 4 while she/he was on the toilet. Neither staff responded to repeated attempts for an interview.

On 9/6/21 through 9/13/21, between 10:00AM and 4:00 PM Staff 27 (LPN), Staff 28 (LPN), Staff 23 (CNA), Staff 26 (clinical support RN), Staff 25 (RN), Staff 10 (CNA), and Staff 31 (CNA), confirmed continuous monitoring was a common care plan intervention and meant you did not leave a resident alone for any reason. The staff stated if something else happened while a resident was being monitored, staff could call for assistance and someone else could respond to the new situation that needed to be addressed.

On 9/13/21 at 2:07 PM Staff 14 (RNCM) stated he was in the room when the resident was found and participated in the assessment and the investigation. Staff 14 confirmed the information in the investigation was correct. Staff 14 further stated he was aware resident 4 was treated for "some type of hemorrhage in her/his head" in the hospital due to the fall. Staff 14 confirmed the care plan was not followed and Resident 4 should not have been left alone for any reason while on the toilet.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary narcotic medication for 1 of 3 sampled residents (# 3) reviewed for medication misuse. This placed residents at risk for adverse medication consequences of narcotic medication. Findings include:

Resident 3 admitted to the facility in 2020 with diagnoses including blood infection and chemical imbalance in the brain causing brain disfunction.

The 8/28/20 hospital discharge record indicated Resident 3 was allergic to morphine(narcotic pain medication) with side effects including nausea, vomiting, increased confusion and slurred speech.

Resident 3's 9/2020 MAR indicated Resident 3 was administered morphine 18 times.

Resident 3's 9/2020 PRN MAR indicated Resident 3 was administered Zofran (anti-nausea medication) 3 times for nausea and vomiting.

On 9/11/20 a Progress note indicated Resident 3 complained of nausea following a dose of morphine. The Progress notes further stated Zofran was given with good effect.

On 8/31/21 at 10:14 AM Witness 8 (Complainant) stated facility staff provided morphine to Resident 3 when the resident was allergic to morphine and it made Resident 3 sick.

On 9/13/21 at 2:07 PM Staff 14 (RNCM) acknowledged morphine was ordered and administered to Resident 3. Staff 14 was not aware of any conversation between the facility, the physician, Resident 3, or the family discussing Resident 3's allergy to morphine.

On 9/14/21 at 1:05 PM Staff 15 (DNS) confirmed the hospital discharge to facility record indicated Resident 3 had an allergy to morphine.

Based on observation and interview it was determined the facility failed to ensure visitors were screened in the evenings on weekends for 1 of 2 weekend days (Saturday) observed for visitor screening. This placed residents at risk for exposure to Covid-19. Findings include:

On 9/4/21, Saturday, at 6:22 PM the facility front entrance was locked. The sign on the door indicated all visitors and residents were required to wear a mask no matter their vaccination status. There was no sign on the door to inform visitors of the screening process.

On 9/4/21 from 6:22 PM through 6:59 PM this surveyor rang the doorbell located to the left of the entrance doors. At 6:59 PM Staff 6 (RN) unlocked the door and screened this surveyor for signs of Covid -19 symptoms as well as any possible Covid 19 exposure. Staff 6 documented contact information of this surveyor and provided a sticker to be worn which indicated this surveyor was screened.

On 9/4/21 at 7:02 PM two visitors were observed to come from the B hall. Both visitors wore a mask but did not have a sticker on their shirts to indicate they were screened by staff prior to entrance to the facility. Witness 6 (Visitor) and 7 (Visitor) indicated a male visitor at the front entrance unlocked the door and allowed Witness 6 and 7 in to the facility and staff did not screen them. Witness 6 and 7 indicated they did not have recent exposure to Covid-19 and did not have symptoms including a fever. Witness 6 and 7 voluntarily disclosed they were vaccinated.

On 9/4/21 at 7:17 PM Staff 32 (CNA) indicated Witness 6 and Witness 7 visited a resident who resided in the B hall.

On 9/4/21 at 8:05 PM the front lobby was observed to not have a sign to notify visitors to not open the door for other visitors. The Covid-19 screening log book page for 9/4/21 did not have the names of Witness 6 and Witness 7.

On 9/4/21 at 8:02 PM Staff 6 (RN) indicated when visitors rang the door bell staff were to unlock the door, screen the visitors, document the visitor screening was completed and provide a sticker. Staff 6 was not aware the visitors were not screened.

OAR 411-085-0310 Residents ' Rights: Generally

Refer to F554
***************
OAR 411-085-0360 Abuse

Refer to F609 and F610
***************
OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
***************
OAR 411-086-0140 Nursing Services: Problem Resolution &
Preventive Care

Refer to F686, F689 and F757
***************
OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880
***************




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

Refer to F686

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 09/06/2021 and 09/12/2021, 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.