Mirabella Portland

Resident 1 was admitted to the facility in 8/2022 with a diagnosis of heart disease.-á -á The facility Abuse and Incident Reporting Policy and Procedure revised on 5/2024 revealed an investigation was to be completed within five working days after an incident was reported.-á -á a. Resident 1's 10/8/25 Unwitnessed Fall investigation revealed on 10/8/25 she/he tried to move a swivel chair, lost balance, and fell. The investigation indicated at the time of the fall Resident 1's care plan was followed and abuse and neglect were ruled out two hours after the incident occurred. The investigation was not completed until 11/1/25. -á On 3/26/26 at 10:07 AM and 12:55 PM Staff 2 (DNS) stated investigations were to be completed and submitted to her and Staff 1 (Administrator) five days after an investigation was initiated. Staff 2 stated at the time of Resident 1's fall there was no resident care manager and the paperwork was not completed timely.-á -á On 3/27/26 at 8:28 AM Staff 1 stated if a resident fell, the nurses were to initiate an investigation, start obtaining interviews with witnesses, implement new interventions if indicated, and notify Staff 2 of the incident. Staff 1 stated the investigation was to be completed within five days, including the root cause analysis, and then submitted to him for a final review. b. Resident 1's 11/21/25 Witnessed Fall investigation revealed she/he fell while being assisted to bed. Staff 2 (DNS) completed the fall investigation on 12/2/25. Staff 1 (Administrator) signed off on the completed investigation on 12/16/25.-á -á On 3/26/26 at 10:07 AM and 12:55 PM Staff 2 (DNS) stated investigations were to be completed and submitted to her and Staff 1 (Administrator) five days after an investigation was initiated. Staff 2 stated at the time of Resident 1's fall there was no resident care manager and the paperwork was not completed timely, but the staff ensured Resident 1 needs were met.-á On 3/27/26 at 8:28 AM Staff 1 stated if a resident fell, the nurses were to initiate an investigation, start obtaining interviews with witnesses, implement new interventions if indicated, and notify Staff 2 of the incident. Staff 1 stated the investigation was to be completed within five days, including the root cause analysis, and then submitted to him for a final review.

Resident 1 investigation not completed within 5 working days. Residents previous incident reports reviewed and assessed for completion. All resident’s at risk for reoccurring incidents without a proper investigation completed and interventions implemented. Systemic changes to ensure deficient practice does not reoccur: In-service with LN’s, CNA’s and RCM’s regarding investigation policy and procedures RCM or designee will complete incident reports within 5 days of incident. Sustainability/monitoring: Open IRs to be completed will be reviewed in our morning stand up meeting DNS or designee will audit investigation completion timeliness x4 weeks, then monthly x3 months until substantial compliance is met. DNS will report incident report completion to monthly QAPI committee to ensure POC is achieved and sustained.

2. Resident 27 was admitted to the facility in 12/2025 with a diagnosis of left hip replacement.-á -á Resident 27's 1/21/26 Progress Note revealed she/he was transported to the hospital.-á -á Resident 27's clinical record revealed she/he did not return to the facility and there was no documentation to indicate the State Longterm Care Ombudsman office was notified of her/his discharge.-á -á On 3/26/26 at 10:52 AM and 3/27/26 at 8:33 AM Staff 1 (Administrator) stated Staff 3 (Social Services Director) was responsible for notifying the State Longterm Care Ombudsman office when residents were discharged from the facility. Staff 1 also stated the facility did not notify the ombudsman unless a resident was discharged involuntarily.-á -á On 3/26/26 at 10:53 AM Staff 3 stated she did not notify the State Longterm Care Ombudsman office when residents were discharged from the facility, including Resident 27. , 1. Resident 4 was admitted to the facility in 5/2024 with diagnoses including pulmonary embolism without acute cor pulmonale (a blood clot in the lung artery that does not cause immediate right-sided heart failure) and vascular dementia (a decline in cognitive function caused by conditions that block or reduce blood flow to the brain). Resident 4GÇÖs 1/21/26 Annual MDS revealed she/he had moderate cognitive impairment. A review of Resident 4GÇÖs health record revealed she/he was admitted to the hospital on 1/25/26 due to pain in her/his left flank (side of the torso between the lower ribs and the top of the hip) and decreased blood oxygen saturation. No evidence was found in Resident 4GÇÖs health record to indicate the facility notified the State Longterm Care Ombudsman of her/his discharge or provided Resident 4 or her/his representative with a copy of the facilityGÇÖs bed hold policy. On 3/26/26 at 3:17 PM Staff 9 (RN) stated she made the decision to send Resident 4 to the hospital because of her pain and low oxygen levels after speaking with her/his provider and family representative. Staff 9 stated she did not provide the resident or her/his family with a copy of the facilityGÇÖs bed hold policy and she did not contact the office of the State Longterm Care Ombudsman. On 3/30/26 at 1:02 PM Witness 1 (family member) stated the facility did not provide him or Resident 4 with a notification of the bed hold policy when she/he was discharged to the hospital. On 3/27/26 at 9:46 AM Staff 1 (Administrator) stated staff did not notify the State Longterm Care Ombudsman of Resident 4GÇÖs discharge to the hospital nor did they provide Resident 4 or her/his representative with a copy of the facilityGÇÖs bed hold policy when she/he was discharged to the hospital on 1/25/26 because he was unaware this was a requirement.

Resident #4 and #27 were discharged to the hospital without facility providing copy of bed hold agreement, and not notifying Ombudsman of transfer. All resident’s need to be provided bed hold agreement upon discharge to hospital, and Ombudsman and resident need to receive Acute Care transfer form upon transfer. Systematic changes to ensure deficient practice does not reoccur: Educated Social services regarding ombudsman notification requirement. Social services to provide Ombudsman notification of transfers to residents and maintain proof of notification in facility records. In-serviced nurses regarding bed hold agreement process upon transfer. In-serviced nurses regarding providing and reviewing the notice of transfer to Acute Care form from DHS, to the transferring resident. Medical records or designee will upload signed copies of transfer forms into medical record. Sustainability/monitoring Administrator or designee to audit resident files of transferred residents weekly x4 weeks, then monthly x3 months until substantial compliance is met. Administrator or designee will report results of audits to monthly QAPI committee to ensure POC is achieved and sustained.

Resident 13 was admitted to the facility in 6/2018 with diagnoses including intracranial injury with loss of consciousness (traumatic brain injury) and aphasia (a language disorder caused by brain damage and resulting in impaired communication and comprehension). Resident 13GÇÖs care plan dated 1/2/20 indicated staff were to ensure her/his glasses were available to support her/his participation in activities and staff were to provide assistance to place and remove them. Resident 13GÇÖs 1/21/26 annual MDS revealed she/he had severe cognitive impairment, was dependent on staff for assistance with ADLs including dressing and completing personal hygiene tasks and had adequate vision with the use of glasses. Random observations on 3/23/26 through 3/26/26, between 8:30 AM and 4:03 PM Resident 13 was observed not wearing her/his glasses when she/he was in the living room with other residents, or during group activities or while sitting in her/his room. Resident 13's glasses were observed in their case on the shelf above her/his dresser. On 3/25/26 at 12:21 PM Staff 4 (CNA) stated he referred to Resident 13's care plan to know how much assistance to provide her/him. Staff 4 stated Resident 13 was not able to ask for assistance and was completely dependent on staff assistance for completion of her/his ADLs. Staff 4 stated he never saw Resident 13 wear glasses and he was not sure if she/he had glasses. On 3/25/26 at 3:40 PM Staff 5 (CNA) stated she referred to Resident 13's care plan whenever she worked with the resident because she/he was not able to communicate verbally and was not able to complete any personal care tasks for herself/himself. Staff 5 stated she didnGÇÖt think Resident 13 wore glasses. On 3/26/26 at 10:08 AM Staff 6 (CNA) stated Resident 13 was completely dependent on staff to provide assistance and was unable to ask for help. Staff 6 stated she referred to Resident 13's care plan to know what assistance to provide for her/him. Staff 6 stated she was not aware Resident 13 needed to wear glasses. On 3/26/26 at 10:33 AM staff 7 (RN) stated Resident 13 was, GÇ£Totally dependentGÇ¥ and did not do anything on her/his own. Staff 7 stated Resident 13 had glasses and he saw her/him wear them occasionally. Staff 7 stated it was important for staff to assist Resident 13 with her/his glasses because she/he needed them and she/he could not ask for anyone to help her/him put them on or take them off. On 3/26/26 at 11:53 AM Staff 2 (DNS) stated Resident 13's spouse wanted her/him to wear her/his glasses. Staff 2 stated she expected staff to assist Resident 13 to use her/his glasses because she/he was not able to place and remove them herself/himself and she/he was not able to communicate requests to her/his caregivers.

All residents vision and hearing care plans reviewed and updated as needed. Systemic changes to ensure deficient practice does not reoccur: Resident’s vision and hearing care plans will be discussed during LNs monthly meeting and CNAs monthly meeting Resident’s vision and hearing care plans will be reviewed and updated by RCM at least quarterly and when changes noted Sustainability and monitoring: Resident care review competency will be completed by DNS or designee for 3 staff members per month to ensure care plan interventions are followed. DNS or designee will report audit results to monthly QAPI committee to ensure POC is achieved and sustained.  Continued frequency of audits will be determined by QAPI committee. Monthly QAPI meeting to review any incidents and training compliance issues.

Based on observation, interview and record review it was determined the facility failed to follow fall prevention techniques for 1 of 4 residents (# 16) reviewed for accidents. This placed residents at risk for falls. Findings include: Resident 16 was admitted to the facility in 7/2020 with diagnoses including dementia. A 10/23/24 Fall Risk Evaluation determined Resident 16 to be at high risk for falls. A 11/18/24 CNA Pocket Guide regarding transfers stated Resident 16 required the assistance of one person with the use of a front wheel walker (FWW) and gait belt with a focus on turning clockwise when available. On 11/19/24 at 12:13 PM Resident 16 was observed being assisted by Staff 4 (CNA) with a standing transfer with the use of a FWW. Resident 16 was observed without a gait belt turning counter-clockwise when she/he was observed falling backwards onto the ground. On 11/19/24 at 12:36 PM Staff 4 stated Resident 16 experienced a fall during a standing transfer. Staff 4 confirmed Resident 16 was not wearing a gait belt and "probably should have been wearing one." Staff 4 stated she was not aware of specific instructions regarding fall prevention techniques for Resident 16. On 11/19/24 at 12:38 PM Staff 2 (DNS) confirmed the CNA Pocket Guide was updated daily and was provided to nursing staff at the start of their shifts to provide care need information to staff. Staff 2 stated Resident 16 did not experience a significant injury as result of the fall. Staff 2 stated Resident 16 should have been wearing a gait belt and assisted with turning clockwise to reduce the risk of falls.

-Current Resident -resident 16 care plan reviewed and interventions updated -Potential Resident -all residents functional status: transfers care plans reviewed and updated as needed -systemic changes to ensure deficient practice does not reoccur: -Resident’s care plans were discussed during LNs monthly meeting on 12/11/24 and will be discussed during CNAs monthly meeting on 12/18/24. -Resident care plans will be reviewed and updated by RCM at least quarterly and when changes noted -sustainability/monitoring: -Resident care review competency will be completed by DNS or designee for 3 staff members per month to ensure care plan interventions are followed -DNS or designee will audit training records, pre service training and ongoing training for completion compliance -DNS or designee will report audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee -Monthly QAPI meeting to review any incidents and training compliance issues

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

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#76) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 76 was admitted to the facility in 2020 with diagnoses including dementia. A Nursing Facility Reported Incident Form dated 3/13/23 indicated Resident 76 was physically abused by Staff 13 (Former contracted radiology technician). The incident was witnessed by Staff 10 (CNA), Staff 11 (CNA) and Staff 12 (agency CNA). A facility incident investigation report dated 3/13/23 indicated Resident 76 was in pain and confused on 3/13/23. Staff 13 hit the resident's forearm four times, restrained the resident's right arm and was verbally abusive toward the resident. Staff 10, Staff 11 and Staff 12 notified Staff 4 (LPN) who assessed the resident and no injuries were noted. A handwritten signed witness statement by Staff 10 dated 3/13/23 indicated she, Staff 11 and Staff 12 were assisting Staff 13 to position Resident 76 for x-rays. The resident was "in a lot of pain, very agitated, confused and scared" and the resident was "flailing" her/his arms. Staff 13 held the resident's arms down, hit the resident's forearm and told the resident "your mother is here and she's not going to like this." Staff 13 seemed flustered and frustrated throughout the process because Resident 76 was not cooperating perfectly even though it was clear the resident was confused and in an immense amount of pain. A handwritten signed witness statement by Staff 11 dated 3/13/23 indicated she, Staff 10 and Staff 12 were helping position Resident 76 for an x-ray. The resident was positioned but would move out of position several times. Staff 13 became more irritated and physical, pinned the resident's arms down, slapped the resident's forearm and said "stop or your mom will be mad at you." A handwritten signed witness statement by Staff 12 dated 3/13/23 indicated she, Staff 10 and Staff 11 were trying to position and calm Resident 76. The resident was very confused, agitated and in a lot of pain. Staff 13 was frustrated, annoyed and impatient because the resident would not stop moving. Staff 13 tightly held the resident's arm down by the wrist which did not work and the resident touched the x-ray equipment. Staff 13 "snapped" and said "something along the lines of 'you better not break that it's a $100,000'" and then started swatting the resident's forearm about four times. Staff 13 then said "you better stop moving or your mom will be mad at you!!!" Staff 4 entered the room and moved between Staff 13 and the resident. Staff 11 reported the incident immediately. Progress Notes dated 3/14/23 and 3/16/23 indicated Resident 76 was on hospice and died at 5:30 AM on 3/16/23. A written statement by Staff 13 dated 3/14/23 was received for review on 8/25/23 from Witness 2 (Senior Human Resources Business Partner for the contracted diagnostic company). In the statement Staff 13 wrote "...due to pain the CNAs and I did have to restrain [the resident's] hands at different times and hold [the resident's] ankles to obtain the exams." and "Earlier in the exam the patient started talking to their Mother and Grandmother making them happy they cooperated in completing the exams. (Since my training is to "join their world" I went along with that line of talk) to get the patient to cooperate and it did work for a bit." On 8/22/23 at 1:27 PM Staff 10 stated [on 3/13/23] around dinner time they were attempting to position and calm Resident 76 for x-rays. The resident was confused and moving around. The resident grabbed at the x-ray equipment and Staff 13 hit the resident's hand out of the way. Staff 13 told the resident to behave or her/his mom would be mad. Staff 11 was crying and Staff 4 entered the room and helped to calm the resident. On 8/23/23 at 9:56 AM Staff 11 stated the incident occurred [on 3/13/23] around dinner time. Staff 4 told her someone needed to go into Resident 76's room with Staff 13. The resident was confused and moving around. Staff 13 held the resident's wrist down, slapped her/his wrist and told the resident to stay still or her/his mom would be mad. Staff 13 slapped the resident's wrist three to four times loud enough to hear the impact. Staff 11 stated Staff 4 entered the room, she left the room, started to cry and called Staff 1 (Administrator) to report the incident. On 8/23/23 at 10:04 AM the facility's staffing agency was requested to have Staff 12 contact the Surveyor. As of 8/25/23 Staff 12 had not contacted the Surveyor. On 8/23/23 at 1:19 PM Staff 4 stated when she came to Resident 76's room it was reported to her the x-ray process was not going well. She entered the room and attempted to calm the resident. Staff 13 was pushing to complete the x-rays but she stopped the process because she was not going to allow the resident to become more distressed. Staff 4 stated she assessed the resident, no injury was noted and the resident was not in additional distress. Staff 4 stated she immediately started an incident report and notified Staff 1. On 8/24/23 at 9:17 AM Staff 1 (Administrator) confirmed Resident 76 was abused by Staff 13. On 8/25/23 at 2:05 PM a request was made to Witness 2 for Staff 13 to call the surveyor. No return call was received as of 8/28/23. ,

-Current resident: -Resident 76 no longer with us -Potential resident: -Any future potential allegations of potential abuse will be reported within reporting time frames -Any resident receiving mobile imaging services, 1 staff member will remain in the room for the entirety of the imaging visit -All residents with behavior and psychosocial/mood care plans reviewed and updated as needed -Systemic changes to ensure deficient practice does not reoccur: -Abuse/Neglect will be discussed during LN monthly meeting on 9/13 and CNA monthly meeting on 9/20. 1:1 training will be held with DNS for all staff that were unable to attend meeting. -Nursing staff (nursing assistants, CNAs, CMA, LPNs, RNs) will have pre hire Relias training prior to working with residents -Ongoing annual Abuse trainings via Relias, DNS will audit staff completion monthly -Halcyon certification within 90 days of hire, training will be coordinated and completed by memory support coordinator -resident care plans will be reviewed and updated by RCM at least quarterly and when changes noted -Sustainability/monitoring: -Abuse recognizing and reporting competency will be completed for 3 staff members per month -DNS will audit training records, pre service training and ongoing training for completion compliance -DNS will report audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee. -Monthly QAPI meeting to review any incidents and training compliance issues. Completion date: 10/12/23

Based on interview and record review it was determined the facility failed to complete an Admission or Annual MDS (Minimum Data Set) assessment in the required time frame for 4 of 14 sampled residents (#s 6, 8, 16 and 77) reviewed for resident assessments. This placed residents at risk for unassessed needs. Findings include: The facility's 6/2022 MDS policy and procedure specified the following: -The facility would complete and maintain MDS assessments on every resident admitted to the facility in accordance with the current Centers for Medicare and Medicaid Services Resident Assessment Instrument manual, Version 3.0. -The purpose of the MDS was to assess residents using a comprehensive process in order to identify care needs and to develop an interdisciplinary care plan. On 8/23/23, Staff 2 (RNCM) provided a list of the following residents with overdue Admission or Annual MDS assessments: -Resident 6's Admission MDS was due 6/23/23 and was 61 days overdue; -Resident 8's Annual MDS was due 6/23/23 and was 61 days overdue; -Resident 16's Annual MDS was due 6/30/23 and was 54 days overdue; -Resident 77's Admission MDS was due 7/13/23 and was 41 days overdue. On 8/23/23 at 11:44 AM Staff 3 stated he was responsible for ensuring each resident's MDS assessment was completed. Staff 2 stated there were multiple residents whose Admission or Annual MDS assessments were not yet completed and he was working towards getting all of the overdue MDS assessments completed and transmitted. On 8/24/23 at 8:45 AM Staff 2 (DNS) confirmed there were many residents with overdue Admission and Annual MDS assessments and the nursing staff were working on getting them caught up.

Current resident: -Resident 6, 8, 16 and 77 MDSs have been completed -Potential resident: -All residents Comprehensive Assessments and MDSs will be completed in required time frame -Systemic changes to ensure deficient practice does not reoccur: -IDT will be in-serviced on Comprehensive Assessment and MDS schedule within required time frame on 9/19/23. -IDT will complete Comprehensive Assessments and MDSs within required time frame -Sustainability/monitoring: -MDS ARDs and due date will be reviewed in our morning stand up meeting -DNS or designee will audit completion of Comprehensive assessments and MDSs -DNS will report audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee Completion date: 10/12/23

Based on interview and record review it was determined the facility failed to complete a Quarterly MDS (Minimum Data Set) assessment in the required time frame for 10 of 14 sampled residents (#s 1, 4, 5, 10, 13, 15, 18, 20, 22, and 23) reviewed for resident assessments. This placed residents at risk for unassessed needs. Findings include: The facility's 6/2022 MDS policy and procedure specified the following: -The facility would complete and maintain MDS assessments on every resident admitted to the facility in accordance with the current Centers for Medicare and Medicaid Services Resident Assessment Instrument manual, Version 3.0. -The purpose of the MDS was to assess residents using a comprehensive process in order to identify care needs and to develop an interdisciplinary care plan. On 8/23/23, Staff 2 (RNCM) provided a list of the following residents with overdue Quarterly MDS assessments: -Resident 4's Quarterly 3 MDS was due 6/15/23 and was 69 days overdue; -Resident 1's Quarterly 3 MDS was due 6/16/23 and was 68 days overdue; -Resident 22's Quarterly 2 MDS was due 6/27/23 and was 56 days overdue; -Resident 20's Quarterly 3 MDS was due 7/5/23 and was 49 days overdue; -Resident 18's Quarterly 2 MDS was due 7/7/23 and was 47 days overdue; -Resident 15's Quarterly 2 MDS was due 7/17/23 and was 37 days overdue; -Resident 23's Quarterly 1 MDS was due 7/19/23 and was 35 days overdue; -Resident 10's Quarterly 1 MDS was due 7/27/23 and was 27 days overdue; -Resident 13's Quarterly 2 MDS was due 8/3/23 and was 20 days overdue; -Resident 5's Quarterly 1 MDS was due 8/10/23 and was 13 days overdue. On 8/23/23 at 11:44 AM Staff 3 stated he was responsible for ensuring each resident's MDS assessment was completed. Staff 2 stated there were multiple residents whose Quarterly MDS assessments were not yet completed and he was working towards getting all of the overdue MDS assessments completed and transmitted. On 8/24/23 at 8:45 AM Staff 2 (DNS) confirmed there were many residents with overdue Quarterly MDS assessments and the nursing staff were working on getting them caught up.

-Current resident: -Resident 1,4,5,10,13,15,18,20,22, and 23 MDSs have been completed -Potential resident: -All residents Quarterly Assessments and MDSs will be completed in required time frame -Systemic changes to ensure deficient practice does not reoccur: -IDT will be in-serviced on Quarterly Assessment and MDS schedule within required time frame on 9/19/23. -IDT will complete Quarterly Assessments and MDSs within required time frame -Sustainability/monitoring: -MDS ARDs and due date will be reviewed in our morning stand up meeting -DNS or designee will audit completion of Quarterly assessments and MDSs -DNS will report audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee Completion date: 10/12/23

Based on observation, interview and record review it was determined the facility failed to store drugs and biologicals in locked compartments for 1 of 1 medication carts and 1 of 1 treatment carts observed during this survey. This placed residents at risk for medication diversion and accidents. Findings include: The facility's Medication and Accounting Policy and Procedure dated 7/21 indicated: -It was the policy of the facility to store medications in a safe and locked place that was not accessible to persons other than employees responsible for the supervision of medications. 1. On 8/22/23 at 10:15 AM a treatment cart was observed to be unlocked near the nurses' station. The nurse was not in view of the cart. Staff 9 (RN) verified the cart was unlocked. 2. On 8/24/23 at 8:16 AM a medication cart was observed to be unlocked across from the spa room. The nurse was not in view of the cart. Staff 8 (LPN) verified the cart was unlocked. On 8/24/23 at 10:50 AM Staff 1 (Administrator) stated it was her expectation the carts remained locked when not in use. , 3. On 8/24/23 at 11:32 AM a medication cart near the conference room was observed unlocked and unattended by staff. Staff 8 (LPN) exited a nearby resident room and approached the cart. Staff 8 acknowledged the cart was unlocked and it should have been locked.

-Potential residents: -All residents at potential safety risk if medication and/or treatment cart left unlocked -Systemic changes to ensure deficient practice does not reoccur: -CMA/LNs will be in serviced on locking the medication and treatment carts at the LN meeting on 9/13/23. 1:1 training will be held with DNS for all staff that were unable to attend meeting. -Sustainability/monitoring: -Medication and Treatment cart audit will be completed by DNS or designee twice weekly on different shifts -DNS will report audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee -Monthly QAPI meeting to review any incidents and training compliance issues Completion date: 10/12/23

******************** OAR 411-085-0360 Abuse Refer to F600 ******************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F636 and F638 ******************** OAR 411-086-0260 Pharmacy Sevices: Phamaceutical Services Refer to F761 ********************

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/25/2022 and 07/31/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to obtain and maintain an advance directive for 2 of 2 sampled residents (# 8 and 23) reviewed for advance directives. This placed residents at risk for not having their health care wishes followed. Findings include: 1. Resident 23 was admitted to the facility in 2019 with diagnoses including depression. The resident's 6/2022 MDS indicated the resident was cognitively impaired. Resident 23's record did not include an advance directive or legal documentation for a responsible person to make medical decisions for the resident. A 10/5/21 Care Conference form indicated the resident had an advance directive. The resident's medical record did not indicate the family or responsible party was provided advance directive information. On 7/28/22 at 9:19 AM Staff 9 (Social Service Director) acknowledged Resident 23 did not have an advance directive and there was no documentation to indicate the resident or responsible party was provided advance directive information. , 2. Resident 8 was admitted to the facility in 2018 with diagnoses including a brain injury. Resident 8's care conference notes from 6/1/20 through 6/13/22 included seven notes indicating Resident 8 had an advance directive and one note indicating she/he did not. No evidence was found in the facility's electronic health record to indicate Resident 8 had a current advance directive. On 7/27/22 at 2:41 PM Staff 9 (Social Services Director) confirmed the facility did not have a copy of Resident 8's advance directive in the resident's record.

Social Service Director has added a blank copy of the Advanced Directive to the Agreement packet to offer to all residents on admission. Social Service Director has also added a section in the care conference review to document if resident has an Advanced Directive and if Advanced Directive was offered, if resident does not have an Advance Directive one will be offered and responses will be documented in the medical record- progress note, care conference assessments and 72 hour care conference review form. This remedy has been completed. We have received a copy of the Advanced Directive for resident #8, that was noted and it has been added to their medical record. Resident #23's family has not responded to emails or phone calls left by Social Service Director in regards to Advanced Directive. Social Service Director emailed a blank copy of the Advance Directive to family and documented it in the residents record. All resident records were reviewed to ensure that an advanced directive was either offered or on file and documented correctly.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for for 1 of 1 sampled resident (#27) randomly observed. This placed residents at risk for an un-homelike environment. Findings include: Resident 27 was admitted to the facility in 2018 with diagnoses including dementia. On 7/26/22 at 9:19 AM a large brown irregular shaped stained area approximately 12 inches in diameter was observed on the carpet between the foot of Resident 27's bed and bathroom. There was no odor noted in the room. On 7/26/22 at 10:31 AM Witness 3 (Spouse) stated the carpet in the resident's room was dirty and she/he was not sure what caused the stain. On 7/27/22 at 10:18 AM Staff 13 (Housekeeping) stated when carpets were dirty they called maintenance and the maintenance staff cleaned the carpets. On 7/27/22 at 10:20 AM Staff 14 (Housekeeping) stated Resident 27's carpet was dirty for approximately one month and she told Staff 15 (Maintenance) the carpet needed to be cleaned about 15 days ago. On 7/29/22 at 11:09 AM Staff 15 stated housekeeping staff notified him when there was a carpet stain that needed to be cleaned. He was not aware of a stain in Resident 27's room and acknowledged the carpet was stained.

Resident #27's carpet stain was resolved during the survey. HCA walked every room with facility services on 8/8/2022 and ensured all carpets were properly clean and free of stains. All main lobby and hallway carpets were cleaned on 8/30/2022. Facility will add carpet checks to the housekeeper checklist each day, if they notice spots that need cleaned, they will notify maintenance. Maintenance will schedule a carpet spot clean in maintenance connection to ensure it gets done timely. The carpets in general will remain on a routine cleaning schedule  that will be tracked for completion through Maintenance Connection We will also include rooms in the monthly healthcare walkthrough with the Administrator and Facility Services Director The Healthcare team will also work with C.N.As and Nurses to ensure new spills/stains are addressed promptly. This will be addressed in the upcoming monthly meetings

Based on interview and record review it was determined the facility failed to provide snacks for 1 of 1 sampled resident (#80) reviewed for meal choices. This placed residents at risk for unintended change in nutritional status. Findings include: Resident 80 was admitted to the facility in 2021 with diagnoses including dementia. Resident 80's functional nutritional Care Plan included the resident was to be offered snacks three times a day initiated on 10/27/21. A review of daily snack pass sheets, many of which were undated and only went back as far as 1/27/22 through 6/13/22, revealed Resident 80 was not offered three snacks per day. On 8/2/22 Staff 19 (Dietary Manager) confirmed the snack pass sheets indicated Resident 80 was generally only offered one to two snacks daily.

Resident #80 is no longer with us. All current resident care plans will be reviewed with the team and appropriate changes made to snack pass offerings and documentation. Residents will be offered snacks 3 times daily. These offerings will be documented. More thorough records will be taken and kept for a longer period of time of daily snack passes. In-services will be provided by the Registered Dietitian on the standards for snack pass offerings and recording the offers. The Registered Dietitian or designee will conduct weekly rounds to monitor compliance in these areas and additional training and follow up will be completed as indicated. Findings from the weekly audits will be compiled by the RD and brought to the QAPI committee on a quarterly basis. The QAPI committee will monitor compliance of this protocol.

Based on interview and record review it was determined the facility failed to provide bathing for 1 of 2 sampled residents (#80) reviewed for ADLs. This placed residents at risk for lack of person hygiene and infections. Findings include: Resident 80 was admitted to the facility in 2021 with diagnoses including dementia. Resident 80's functional mobility Care Plan initiated on 10/18/21 indicated the resident required staff assistance with bathing. A review of Resident 80's bathing record from 10/2021 through 6/2022 revealed the following: - In 10/2021 no baths were provided. - In 11/2021 two baths were provided. - In 12/2021 one bath was provided. - In 1/2022 no baths were provided. - In 2/2022 two baths were provided. - In 3/2022 four baths were provided from 3/3/22 through 3/7/22. - In 4/2022 seven baths were provided from 4/11/22 through 4/27/22. - In 5/2022 nine baths were provided from 5/8/22 through 5/29/22. - In 6/2022 four baths were provided from 6/1/22 though 6/15/22. On 7/29/22 Staff 8 (RNCM) stated Resident 80 was not resistive to bathing and there was no evidence to support the resident received routine bathing cares.

-Current Resident -Resident 80 no longer with us -Potential Residents -All residents bathing care plans reviewed and updated as needed -All residents task tab for bathing reviewed and updated as needed -Systemic changes to ensure deficient practice does not reoccur -Licensed Nurses (LN) will be in-serviced on showers at the LN meeting 9/14/22, Certified Nursing Assistants (CNAs) will be in-serviced on showers at the CNA meeting 9/7/22 -All residents will have a TAR item for LNs to acknowledge on scheduled shower days -Sustainability/Monitoring: -All new admissions will be audited by RCM or designee for bathing care plan and scheduled bathing task item -Shower completion will be reviewed in morning stand up meetings -DNS will report audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee. -Monthly QAPI meeting to review any audit issues Completion date: 9/20/22

Based on interview and record review it was determined the facility failed to ensure a resident was provided an activity program to meet a resident's needs for 1 of 2 sampled residents (#11) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include: Resident 11 was admitted to the facility in 2022 with diagnoses including Parkinson's disease. Resident 11 resided in the Health Center. Resident 11's 2/2/22 Activity History and Personal Preference form indicated it was very important to do things with groups of people. The July 2022 Daily Activity Lists revealed multiple activities in the Memory Care Unit including group exercises. There were no group exercises offered in the Health Center. On 7/29/22 at 1:36 PM group exercise was observed in the Memory Care Unit. Staff 10 (RN) stated all the residents who participated in the activity resided in the Memory Care Unit. On 7/29/22 at 10:47 AM Resident 11 stated she/he would attend most exercise group activities on a daily basis if they were not located in the Memory Care Unit. On 7/28/22 at 9:43 AM Staff 16 (Activity Director) stated there were group activities on the Health Center side a couple times a week but most of the activities were on the Memory Care Unit. Staff 16 stated he was not aware residents, including Resident 11, did not want to go the Memory care unit. Staff 16 acknowledged there were no group exercise programs offered to the residents on the Health Center side of the facility.

Resident #11 is currently being invited to activities of interest that are now provided on the skilled nursing side of the unit. In assessing the availability of exercise programming in the Health Center location, our twice weekly visits by Jamie the Wellness/exercise instructor will now be split evenly, occurring once weekly in the memory care (Tuesdays) and in the HC Living Room (Fridays). Restorative Aide Tammy will add on a once per week exercise class in the Health Care Living Room. Additionally, the Eldergrow Indoor Garden and Horticultural Therapy program will be scheduled and conducted evenly distributed between the HC and MC unit. The first lesson of the month will take place in the Memory Care unit and the second class/group activity of the month will occur in the Health Care Living Room. There is already an existing book club reading group evenly split on both sides, we will continue as currently planned due to ongoing success/involvement. Larger Live Music performances typically are situated in the larger HC living room monthly, we will alternate location between HC and MC every other month. When occasionally Terry or other Independent Living Residents play music, well alternate venue. We just finished our relationship with a student Art Therapist from Lewis & Clark College. With our next student Art Therapist we will be alternating location every other week between MC Activity Room and HC Living Room. All changes to location (and added events) will clearly identify location on the Monthly Activity Calendar. Daily Activity sheet and newsletter will reflect these changes and announce the location for events (as is already practice). Activities will encourage and build interest for HC groups and exercise, invite and encourage HC residents to try the additional options and location. We will interview and ask residents how they feel about the new offerings and elicit feedback for improvements or suggestions for making these options more engaging. Residents, and Family will be engaged in this process during the Resident Family Council. We will investigate and trial if color coding specified locations on calendars and Daily Activities sheets is easier for residents and staff to understand and increases engagement and/or team coordination.

Based on interview and record review it was determined the facility failed to ensure a resident was monitored after first developing signs of a UTI for 1 of 2 sampled residents (#19) reviewed for UTIs and failed to follow physician orders for medications for 2 of 11 sampled residents (#s 17 and 18) reviewed for medications. This placed residents at risk for delayed care and adverse medication reactions. Findings include: 1. Resident 19 was admitted to the facility in 2018 with diagnoses including dementia. A Progress Note by Staff 6 (LPN) dated 7/19/22 indicated Resident 19 had increased urination and the symptoms started on 7/16/22. There was no documentation prior to 7/19/22 to indicate the resident was monitored for signs of a UTI. On 8/1/22 at 8:52 AM Staff 6 stated Resident 19 had mixed incontinence. Staff assisted the resident every two hours during the day, every four hours at night and upon the resident's request. Staff 6 stated he worked on 7/16/22 and Resident 19 had increased urination which indicated a possible UTI and staff were going to monitor the resident. Staff 6 stated on 7/16/22 he notified the oncoming shift to monitor the resident. Staff 6 indicated he did not work from 7/16/22 until 7/19/22. Staff 6 reviewed the progress notes and acknowledged there were no notes to indicate the staff assessed the resident for signs of a UTI. On 8/1/22 at 10:19 AM Staff 2 (DNS) stated when a resident had a change in condition, staff were to put the resident on alert charting, monitor and assess the resident and document in the resident's record. Staff 2 acknowledged Resident 6 first developed symptoms on 7/16/22 but there were no assessments until 7/19/22. , 2. Resident 18 was admitted to the facility in 2022 with diagnoses including pain. Resident 18's 7/2022 MAR revealed a physician's order for diclofenac sodium gel 1% (topical cream to treat pain) apply two grams three times a day to both knees, left hip and right shoulder. Maximum daily dose 16 grams to all joints. The MAR indicated the medication was administered three times a day for 24 of 28 days reviewed. On 7/29/22 at 9:40 AM Staff 6 (LPN) confirmed two grams of diclofenac administered to all four sites equaled 24 grams per day which was in excess of the maximum 16 grams per day as ordered. 3. Resident 17 was admitted to the facility in 2018 with diagnoses including macular degeneration (eye disease which causes blurred vision) and cataract (cloudy lens of the eye). A physician's order dated 11/23/20 indicated Resident 17 was ordered Systane Ultra (for dry eyes) eye drops, one drop in each eye, once daily in the morning and PRN for eye irritation and burning, and Systane gel one drop in each eye at bedtime. Resident 17's 7/2022 MAR revealed Systane eye drops were scheduled and administered at 3:00 PM, 8:00 PM and 12:00 AM (midnight) daily. The MAR also indicated Systane gel drops were administered daily at 11:00 PM. (There was only a one hour separation from the administration of the gel at 11:00 PM and the regular drops at midnight.) On 7/29/22 at 11:38 AM Staff 8 (RNCM) was asked why there were two different orders for Systane eye drops. and why they were ordered to be administered one hour apart at 11 PM and 12 AM. Staff 8 stated it was an error but did not clarify which order was in error.

-Current Resident -Resident 19 treated for UTI -Resident 18 order for Diclofenac updated -Potential Residents -All residents with a noted change of condition, will be put on alert charting, change of condition note entered and MD notified on day of noted change in condition -All residents with Medication orders with max daily dose will be checked upon order transcription, then double checked the next business day by RCM or designee -Systemic changes to ensure deficient practice does not reoccur -Licensed nurses (LN) will be in-serviced on change of condition process and Medication orders with max daily dose during LN meeting on 9/14/22 -LNs to document amount administered when there is a max daily dose with the medication order -Sustainability/Monitoring: -All change of condition notes, alert charting and Medication order double checks will be audited by RCM or designee the next business day -DNS will report audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee. -Monthly QAPI meeting to review any audit issues Completion date: 9/20/22 -Current Resident -Resident 17 orders for Systane eye drops and Systane eye gel -Potential Residents -All residents with orders for eye drops or eye gel will be checked upon order transcription, then double checked the next business day by RCM or designee -Systemic changes to ensure deficient practice does not reoccur -All Medication order double checks will be audited by RCM or designee the next business day -DNS will report audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee.

Based on observation, interview and record review it was determined the facility failed to ensure a safe environment free from toxic flowers and plants in 1 of 1 facility and failed to identify the root cause of a resident's fall and implement fall interventions for 1 of 1 sampled resident (#80) reviewed for accidents. This placed residents at risk for injury. Findings include: 1. Resident 80 was admitted to the facility in 2021 with diagnoses including dementia. Resident 80's fall Care Plan initiated on 10/18/21 indicated the resident was a high risk for falls. Interventions included every 15 minute safety checks initiated on 11/1/21. A Progress Note dated 12/5/21 indicated the resident was a high fall risk and was checked on by staff every 25 to 30 minutes. A review of facility incident reports revealed Resident 80 fell eight times between 1/9/22 and 5/3/2022. None of the eight incident reports included an evaluation or analysis to identify specific hazards, risks and trends, or the development of targeted interventions to reduce the potential for additional falls. None of the reports included an analysis and rationale to demonstrate abuse and neglect had been ruled out. The reports included the following: - On 1/9/22 the resident fell with a family member present and incurred abrasions to her/his head and hand. - On 1/9/22 the resident was found crawling on the floor next to her/his wheelchair. No injuries were noted but the report did not indicate when the resident was last assisted or checked on by staff. - On 2/16/22 the resident was found on the floor near her/his bed with a 1 cm by 2 cm laceration to the left brow. The report did not indicate when the resident was last assisted or checked on by staff, however, a Progress Note dated 2/16/22 indicated staff had last assisted the resident 10 minutes prior to the fall. - On 2/26/22 the resident was heard screaming and was found on her/his knees on the floor. The report did not indicate when the resident was last assisted or checked on by staff. - On 3/27/22 the resident was witnessed by staff as she/he slid out of her/his wheelchair onto the floor. - On 4/13/22 the resident was found on the floor near her/his wheelchair. The report did not indicate when the resident was last assisted or checked on by staff. - On 4/30/22 the resident was heard to fall out of bed as staff were entering the resident's room. Staff last assisted the resident 19 minutes prior to the fall. - On 5/3/22 the resident had an assisted fall to the floor. On 8/1/22 at 11:14 AM Resident 80's fall incident reports were discussed with Staff 2 (DNS). Staff 2 acknowledged the lack of root cause analysis and care plan changes related to the resident's falls. She stated they were behind on charting. Staff 2 stated Staff 1 (Administrator) had not signed off on any of the incident reports yet. On 8/1/22 at 11:32 AM Staff 1 stated she had not signed off on any of the incident reports because they were not closed yet and stated they were behind on their documentation. On 8/2/22 at 12:59 Staff 2 (DNS) stated there was no documentation of the care planned 15 minute safety checks. , 2. Multiple random observations from 7/25/22 through 8/2/22 between the hours of 8:30 AM and 4:00 PM revealed living plants in numerous resident rooms and common areas of the Health Center and Memory Care Unit of the facility. Residents were frequently observed unsupervised in the Memory Care Unit common living area near plants and residents self-ambulated in the hallways and sat at the nursing station where flowers and plants were readily accessible. On 7/27/22 at 3:11 PM Staff 12 (Memory Care Coordinator) provided a list of living plants accessible to residents in the following areas of the Memory Care Unit: living room, front table, nursing station, dining room, plant table, resident rooms, indoor therapy garden and outdoor therapy garden. There were approximately 38 living plants listed including hydrangea and anthurium. According to the University of California: Safe and Poisonous Garden Plants, Division of Agriculture and Natural Resources, dated 2022 (https://ucanr.edu/sites/poisonous_safe_plants/), two living plants located on the Memory Care Unit were identified as toxic to humans. These included hydrangeas located at the nursing station and resident room 228 and an anthurium plant located in resident room 225. On 7/27/22 at 2:45 PM Staff 12 stated the facility contracted with an organization that provided plants for the facility's indoor therapy garden and those plants were non-toxic; however, the facility did not have a system in place to identify toxic flowers and plants brought into the facility by staff or family members. Staff 12 was unable to state if any flowers and plants in the common areas or resident rooms on the Memory Care Unit were considered toxic to humans. On 7/29/22 at 11:30 AM Staff 1 (Administrator) confirmed the facility did not have a system in place to identify potentially toxic flowers and plants brought into the facility and understood this was a safety concern, especially in the Memory Care Unit. On 7/29/22 at 2:13 PM Staff 12 confirmed hydrangeas and anthurium were toxic to humans.

Plants: A policy to address toxic plants/flowers in memory care is in draft mode and being finalized by Pacific Retirement Services. Once it is finalized, it will be reviewed at the upcoming monthly meetings. Activities coordinators will abide by the facilitys new guidance for communicating safety issues regarding hazardous plants in facility. HCA will inform families of the new standards and the activities team will oversee the safety verification process through the policy identified means. Activities will remove any unsafe plant materials and communicate with families to comply with facility safety standards. Activities will work with families to suggest different plants or safe materials for gifts to replace dangerous ones and maintain a safe environment. Activities will help ensure understanding of this new policy and educate staff, working to confirm diligence and adherence to safety protocol regarding plant safety. Activities will inform Elaine and Eldergrow of the new policy and ensure compliance, verifying Eldergrow plants for safety. The plants in room 225 and 228 were removed and locked in the medication room. Families were contacted and the plants were given to them. Alternative/safe plant options were offered in place of the plants that were removed. Falls: -Current resident -Resident 80 no longer with us -Potential resident -All residents incident reports will be completed within 5 days of incident -All residents with care planned 15 minute checks has written documentation in place -systemic changes to ensure deficient practice does not reoccur: - Licensed Nurses (LN) will be in-serviced on 15 minute check process at the LN meeting 9/14/22, Certified Nursing Assistants (CNAs) will be in-serviced on 15 minute check process at the CNA meeting 9/7/22 -PIP in place for IR process, will be reviewed in monthly QAPI meeting -RCM or designee will complete incident reports within 5 days of incident -sustainability/monitoring: -Open IRs to be completed will be reviewed in our morning stand up meeting -DNS or designee will audit completion of documented 15 minute checks -DNS will report incident report completion and audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee

Based on observation and interview it was determined the facility kitchen staff failed to handle and prepare food in a sanitary manner for 1 of 3 kitchens reviewed. This placed residents at risk for foodborne illness. Findings include: On 7/28/22 at 11:34 AM Staff 18 (Cook) was observed to wear gloves and plate lunch meals for residents in the 2nd-floor kitchen. She opened the refrigerator, removed containers of meat, cheese, spread, and bread, and placed them on the counter while she wore the same gloves. Staff 18 did not change her gloves before she assembled grilled beef and cheese sandwiches. With the same gloves she returned the bread, cheese, and spread to the refrigerator. Staff 18 then changed her gloves without performing hand hygiene, opened a different refrigerator wearing the new gloves, retrieved a salad container to the counter, and used her gloved hands to scoop portions of roasted potato wedges onto plates. She did not use the utensils that were readily available to scoop the potatoes. Throughout this process Staff 18 was observed to place plated meals in the insulated tray carts and returned to handle food without changing gloves and performing appropriate hand hygiene after touching potentially contaminated surfaces. On 7/28/22 at 11:40 AM Staff 18 reported, "I can use my gloved hands to pull food out of the fridge and containers and place it on the flat top but then I change gloves when I turn around to the steam table to work with food that has already been cooked." On 8/2/22 at 2:45 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of hand hygiene and appropriate glove use by Staff 18.

How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Residents safety and chances of Food Borne Illness will be greatly reduced. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice. The employee was coached on proper hand hygiene, sanitation, and the use of the proper tools. An in-service on hand hygiene was held with all employees. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: In-services will be provided by the Registered Dietitian and Executive Chef on the standards for use of gloves, tools, and appropriate hand hygiene. The Registered Dietitian or designee will conduct weekly rounds to monitor compliance in these areas and additional training and follow up will be completed as indicated. How the facility plans to monitor its performance to make sure that solutions are sustained: Findings from the weekly audits will be compiled by the RD and brought to the QAPI committee on a quarterly basis. The QAPI committee will monitor compliance of this protocol. Completion Dates: In-service has been completed.

Based on observation and interview it was determined the facility failed to ensure hand hygiene was performed between tasks for 2 of 2 staff (#s 10 and 17) who were randomly observed for hand hygiene. This placed residents at risk for cross contamination. Findings include: 1. On 7/28/22 at 10:35 AM Staff 17 (Server) was observed to deliver food to Room 231, left the room, did not perform hand hygiene and then delivered food to Room 232. Staff 17 stated she did not usually do hand hygiene when passing snacks. On 8/1/22 at 10:03 AM Staff 2 (DNS) indicated hand hygiene was to be performed upon leaving each resident room. 2. On 8/2/22 at 10:29 AM Staff 10 (LPN) was observed to remove gloves and walk to the medication cart. Staff 10 then made contact with a computer keyboard, opened the medication cart and then started to prepare a resident's medications. Staff 10 did not wash her hands. Staff 10 acknowledged she did not wash her hands after removing the gloves and before starting to prepare a resident's medications.

-Potential residents -All residents at potential risk of cross contamination and infection -Systemic changes to ensure deficient practice does not reoccur -LNs will be in serviced on hand hygiene at the LN meeting on 9/14/22, CNAs will be in serviced on hand hygiene at the CNA meeting on 9/7/22 -Sustainability/Monitoring: -Hand hygiene audit will be completed by Dining Manager and DNS or designee for a total of 6 staff members per month -DNS will report audit results to monthly QAPI committee to ensure POC is achieved and sustained. Continued frequency of audits will be determined by QAPI committee -Monthly QAPI meeting to review any incidents and training compliance issues Completion date: 9/20/22

Based on interview and record review it was determined the facility failed to ensure a resident's prophylactic use of an antibiotic was reviewed and a rationale for continued use was documented for 1 of 2 sampled residents (#23) reviewed for antibiotic usage. This placed residents at risk for adverse medication consequences and drug resistant infections. Findings include: Resident 23 was admitted to the facility in 2019 with diagnoses including UTIs. Resident 23's 6/4/21 CAA indicated she/he was incontinent of urine and was at risk for infection. Staff were to monitor the resident for UTIs. There was no information related to the resident's prophylactic use of an antibiotic. A Progress Note dated 7/25/22 indicated Resident 23 was not on antibiotics. A 7/25/22 Physician Visit note indicated the resident had recurrent UTIs, functional incontinence with a decline in mobility and was on prophylactic nitrofurantoin (antibiotic). The note indicated the resident's last UTI was 10/2021 which was resistant to nitrofurantoin. The plan was to continue the nitrofurantoin. On 8/1/22 at 12:02 PM Witness 4 (Pharmacist) stated there was a risk with any long-term use of antibiotics for the development of bacteria which were resistant to antibiotics. The facility needed to weigh the overall health of the resident and the risk factors which could develop and the benefits of the resident acquiring fewer UTIs. Witness 4 also stated on 5/29/19 the pharmacist consultant's review regarding the nitrofurantoin indicated the resident's kidney function should be monitored and nitrofurantoin was not recommended per Beers list (Potentially Harmful Drugs in the Elderly). The pharmacist recommended an alternative medication, trimethoprim (antibiotic), to administer in place of the nitrofurantoin. The physician did not accept the recommendation. Resident 23's 3/7/22 Laboratory results revealed the resident's current creatinine (kidney function) level was 0.79 (normal 0.60-1.10). The resident's records did not have current pharmacy reviews specific to the use of the nitrofurantoin. On 7/29/22 at 12:00 PM Staff 8 (RNCM) stated Resident 23 had a history of frequent UTIs and was on nitrofurantoin since 2018. Staff 8 reviewed the resident's record and did not find a rationale with risk versus benefits for the continued use of the nitrofurantoin to ensure it was still the best medication for the resident. On 8/1/22 at 10:03 AM Staff 2 (DNS) stated they did not review the residents on prophylactic antibiotic as part of the antibiotic stewardship program. On 8/2/22 at 11:18 AM Staff 1 (Administrator) stated the review of residents on prophylactic antibiotics will be added to the antibiotic stewardship program.

-Current resident -resident 18 continues on Prophylactic antibiotics, MD rationale provided and documented -Potential resident -MD documented rationale are in resident charts for those on Prophylactic antibiotics -systemic changes to ensure deficient practice does not reoccur: -For all newly started Prophylactic antibiotics, will request documented rationale for continued Prophylactic antibiotics -MD will provide documented rationale for all residents continuing Prophylactic antibiotics -sustainability/monitoring: -Monthly QAPI meeting to review all Prophylactic Antibiotic use -Pharmacist Consultant review of Prophylactic Antibiotics will occur Annually Completion date: 9/20/22

OAR 411-086-0040 Admission of Residents (Advanced Directive)

Refer to F578 *************** OAR 411-087-0100 Physical Environment: Generally Refer to F584 *************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 *************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677 and F684 *************** OAR 411-086-0230 Activity Services Refer to F-679 *************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F689 and F757 *************** OAR 411-086-0250 Dietary Services F812 *************** OAR 411-086-0330 Infection Control and Universal Precautions F880 and F881 ***************

The findings of the state licensure and memory care unit health survey conducted on 7/25/22 to 8/2/22 are documented in this report. It was determined the facility was in compliance with OAR 411 Division 57.